Podiatry Review November/December 2013

Podiatry Review

ISSN 1756-3291

Volume 70 No.6. Published by the Institute of Chiropodists and Podiatrists as a Peer Review Journal November/December 2013

• All about Polymyalgia Rheumatica (PMR) • Primary and Secondary Raynauds • Learning and Sharing in Thailand

The Institute of Chiropodists and Podiatrists

NATIONAL OFFICERS

National Officers President

Mr R Henry F.Inst.Ch.P, DChM

Chairman Executive Committee Mrs C Johnston MInstChP BSc(Hons)

Vice-Chairman Executive Committee Mr A. Reid M.Inst.Ch.P

Chairman Board of Ethics Mrs J. Dillon MInstChP

Chairman Board of Education

Mr R Sullivan BSc.(Hons) Podiatry, MSc. Pod Surg,.

PgDip Mio.Acu,.FIChPA. M.Inst.Ch.P.

Vice-Chairman Board of Education

National Officers Area Council Executive Delegates Branch Secretaries

Branch Secretaries Birmingham

Mrs J Cowley

01905 454116

Miss Joanne Casey MInstChP BSc

Cheshire North Wales

Mrs D Willis

0151 327 6113

Honorary Treasurer

Devon & Cornwall

Mr M. Smith

01803 520788

East Anglia

Mrs J Sadler

01992 589063

Essex

Mrs B Wright

01702460890

Hants and Dorset

Mrs J Doble

01202 425568

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Mr N Hodge

01924 475338

Leicester & Northants

Mrs S J Foster

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London

Mrs F Tenywa

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North East

Mr A Thurkettle

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North of Scotland

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North West

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Midland Area Council

Northern Ireland

Mrs P McDonnell

028 9062 7414

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Mrs V Dunsworth

0115 931 3492

North West Area Council

Republic of Ireland

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Surrey and Berkshire

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Scottish Area Council

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Western

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Mrs J Drane MInstChP

Standing Orders Committee

Mr M. Hogarth MInstChP Mrs L. Pearson MInstChP BSc Pod Med

Secretary

Area Council Executive Delegates Miss A. J. Burnett-Hurst

Mr S. Miah BSc. (Pod M), M.Inst.Ch.P

Mrs M Allison MInstChP

Republic of Ireland Area Council Mrs J Casey MInstChP BSc

Mr A Reid MInstChP

Mr D Crew OStJ, FInstChP, DChM, CertEd

Yorkshire Area Council Mrs J Dillon MInstChP

N O V E M B E R / D E C E M B E R 2013 V O L 70 N o.6

Editor Ms B. Hawthorn H.M.Inst.Ch.P.

Academic Editor Robert Sullivan BSc.(Hons) Podiatry, MSc. Pod Surg,.

PgDip Mio.Acu,.FIChPA. M.Inst.Ch.P.

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PODIATRY REVIEW

The Institute of Chiropodists and Podiatrists

Contents

Editorial .............................................................................2 Polymyalgia Rheumatica (PMR) Denise Willis M.Inst.Ch.P., BSc..........................................4 Primary and Secondary Raynauds Loreto Sime M.Inst.Ch.P ...................................................6 Peripheral Vascular Disease and the Drugs used in Treatment Malcolm Holmes M.Inst.Ch.P BSc(Pod Med) ..................10 BPA and You, Your Family and Your Patient’s Health Beverley Wright MSc, BSc (Hons) PGCE, PGDip, MInst.Ch.P ...........................................................12 Cognitive Function Test explained Food for the Brain ...........................................................14 Learning and Sharing in Thailand Henry Lee BSc – Cosyfeet Award Winner 2013...............16

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ISSN 1756-3291

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© The Institute of Chiropodists and Podiatrists.

The Editor and the Institute of Chiropodists and Podiatrists accept no responsibility for any opinions expressed in the articles published in the Journal; and they do not accept responsibility for any discrepancies in the information published. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying or otherwise, without the prior written permission of the publishers.

Product Review – Bodyblock Stephen Willey M.Inst.Ch.P., DChM................................21 The role of the Geko Tom Wainwright PgDip PgCert BSc(Hons) MCSP SRP .....22 International day for the Abolition of Slavery and ACPU Award information ................................................23 Arthritis news ..................................................................26 NICE news........................................................................27 Branch News ...................................................................28 Diabetes News.................................................................32 Classified Adverts ............................................................35 Diary of Events ................................................................36

page | 01

EDITORIAL Dear Readers, Whilst writing this it is hard to believe that it is the last Podiatry Review of 2013 – the flowers in the garden are still flourishing, the grass is still growing and we were walking about in sunshine eating ice creams last weekend! Thank you to those of you who have taken the time to contact to let us know how much you have enjoyed reading Podiatry Review this year. It is much appreciated! You have requested it; so commencing with the January-February 2014 issue we will be resuming the CPD pullout section. Remember this is YOUR journal and if anybody would like to contribute, as is often said ….send it in!

In this issue we thank Denise Willis of Cheshire North Wales branch who has sent a very interesting article on Polymyalgia Rheumatica (page 4) and Loreto Sime of Western branch who has sent us an article on Raynauds; Primary and Secondary (page 6). Both of these ladies have taken up the plea for more articles from our membership. Malcolm Holmes has submitted an article on Peripheral Vascular Disease and the Drugs used in Treatment (page 10). The signs and symptoms of PVD commonly present in the lower extremity which means podiatrists are often the first

to identify the condition. Whilst most, at the moment, will not be prescribing drugs it is essential to know what the patient may be prescribed by their GP and why. We would also like to thank Beverley Wright from Essex branch who has submitted the findings of the effects of BPA. If you haven’t a clue what BPA means then turn to page 12 now! The findings are quite worrying! Just to cheer you up even more there is information on ways to detect early memory decline and alzheimers. You can also log on-line to do a test! Do it – the editor has done (results will remain secret!) Seriously though, you will be contacted in a year’s time and be offered another test to see if there are any noticeable changes. We also have lots of other interesting features, including branch news and current diabetes information which we hope will interest you too.

That just leaves me to say Happy Christmas to one and all from the staff and directors. I hope you all have an enjoyable, funfilled or peaceful break whatever you do or whatever your beliefs.

See you all in 2014!

Bernadette Hawthorn, Editor

From your President

Roger Henry F.Inst.Ch.P., D.Ch.M First of all I would like to thank all the people who voted for me as President. I have been with the Institute of Chiropodists and Podiatrists since 1967 after initially training at the London Foot Hospital. I worked for Scholl for five years, primarily in Wimbledon but also in Richmond, Surrey. I then decided to go into private practice but could not afford to rent a clinic as London was and still is too expensive! I decided to move – as you do! – to Blackpool!! I had a very successful practice in Blackpool which I ran for 15 years. My wife, however, is Cornish and after 15 years in Blackpool we sold up and bought a house and practice in Falmouth, Cornwall which became equally as busy and successful.

I have every sympathy for chiropodists just starting out. Believe me, I know how hard it can be.

secretary/host on four occasions. In addition I was editor of Podiatry Review from 1995 – 2009.

My work didn’t stop ‘ in house’ though as previously I was asked to be a member of the Parliamentary liaison committee and an IOCP representative for the Department of Health. I am a member of the American Podiatry Medical Association APMA (USA) and have been to three international conferences in Boston, Las Vegas and Toronto, Canada.

During my time with the Institute I have been branch auditor, branch chairman, branch delegate to area council and I was area council chairman for twelve years. I have been a member of the Board of Education for twenty years. This was in addition to being honorary treasurer for twenty years. I was also conference

I shall bring all that chiropodial experience to the office of President of the Institute of Chiropodists and Podiatrists and look forward to serving.

02 | page

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TECHNICAL ARTICLE

Polymyalgia Rheumatica (PMR) Denise Willis B.Sc. M.Inst.Ch.P What is Polymyalgia Rheumatica It is an inflammatory condition that causes many painful muscles ( poly meaning many, Myalgia meaning muscles.) The cause of PMR is not known. It tends to affect the muscles of the shoulders and thighs. PMR strikes suddenly, appearing over a week or two and sometimes just after a flu-like illness. PMR can start at any age from 50 onwards but the overall average age for it to start is 70. It affects 1 in 2000 people. 1 in 1000 people over the age of 50 develop PMR each year. Women are three times more likely to be affected than men. (Arthritis Research Campaign ).It is the most common reason for commencing older people on steroids (Nichol et al 2008). Stiffness may be so severe that getting dressed, reaching for things, climbing stairs or even getting out of bed may be difficult.

The symptoms are quite different from the ache you may feel after exercise. The pain and stiffness is often widespread and is made worse by movement. The stiffness may be so bad that there is great difficulty turning over in bed, rising from a bed or a chair, or raising arms above shoulder height (like combing hair).

Most common symptoms • Stiffness • Pain

• Aching and tenderness of large muscles around the shoulders and upper arms. The muscles around the neck and hips may also be affected • Inflammation and swelling sometimes occurs in other soft tissues of the body

Other general symptoms include tiredness, depression, night sweats, fever, loss of appetite and weight loss. Some or all of the above symptoms typically develop over a few days or weeks.

However they develop more slowly in some cases, causing the patient to confuse them with pains of getting older. PMR are sometimes similar to other conditions such as frozen shoulder, arthritis or other muscle diseases.

How is it diagnosed

At present there is no single specific test to diagnose PMR and sufferers may not be diagnosed straight away. A blood test is usually done to make the correct diagnosis. No blood test is 100% reliable. However, there are three tests that may be used: 04 | page

• erythrocyte sedimentation rate (ESR) The ESR test measures the rate at which the red blood cells at the

bottom of a test tube ( as a sediment), leaving a layer of plasma above it. The sedimentation rate is usually

quicker in blood from a patient with PMR. However the ESR measures inflammation in the body generally and may also be increased in patients with PMR the ESR may be normal. The ESR is just one way of measuring inflammation.

• C-reactive protein (CRP) test can detect if there is inflammation present from other diseases. Other method include the plasma viscosity (PV) test.

Treatment for PMR

Steroids work by reducing inflammation. The most common steroid is Prednisolone. Treatment usually works very quickly and within a few days patients feel much better. The improvement in symptoms over 2-3 days is often dramatic. If symptoms don’t improve within the week after taking steroids, the diagnosis for PMR may not be correct. The treatment is usually started with a medium dose usually 15mg per day. This is gradually reduced to a lower maintenance dose. It can take several months to get to this point, and each patient is different. The usual lower dose is between 5 and 8 mg per day. This can then go on for 2 to 3 years until the patient is able to stop medication. If the treatment is stopped too early the symptoms will return. If a relapse occurs, steroids can be restarted.

Side effects of steroids.

By taking higher doses of steroids, the risk of developing side effects can increase. A lower dose is used to keep symptoms of PMR away. A maintenance dose below 7-10mg per day is the best. Osteoporosis - Steroids increase the chance of starting with Osteoporosis. Treatments can be given to help protect against this if you are at risk.

Alendronic Acid (Fosamax) may be prescribed If you are aged 65 or over or have a history of fractures. If you are below 65 and do not have a history of fractures, a bone density scan (DEXA scan) will be offered.

Infections An increase chance of infections in particular chicken pox (shingles) or measles can be one of the side effects. If you have

TECHNICAL ARTICLE had these already most people are immune to it. If not it is best to avoid anyone who has these conditions.

Changes in mood or behaviour

Most people feel better in themselves when they take steroids.

However steroids may aggravate depression and other mental health problems and may occasionally cause mental health problems. This could be caused within a few weeks of starting treatment and is more likely with higher doses.

The other important side effects to note are weight gain and high blood sugar – this is important to diabetics as increased insulin doses need to be taken to offset the side effect. It can also cause diabetes to develop. It is important that patient to discusses any family history of diabetes to check this as the treatment progresses. Skin problems may occur such as poor healing after injuries, thinning skin and easy bruising.

Complications of Polymyalgia Rheumatica If left untreated it can lead to:-

• Chronic disability

• Normochromic anaemia (associated with all forms of inflammatory diseases)

• Hepatitis with raised alkaline phosphatase

• The patient may become immobile

Progression to giant-cell arteritis with major vessel occlusion, leading to blindness, stroke or myocardial infarction.

Giant Cell Arteritis

Between 1 and 2 in every 10 people with PMR also develop a related condition called Giant Cell Arteritis (GCA) also known as temporal arteritis. This may be at the same time or some time earlier or later than when PMR develops. GCA can be much more serious than PMR. The risk of Giant Cell Arteritis occurring while Polymyalgia Rheumatica is being treated is 10-20%.(Hunder GG(1997)).The cause of Giant Cell Arteritis is unclear. It is thought that a combination of genetic and environmental factors – such as infection may be responsible.

page | 05

TECHNICAL ARTICLE

Primary and secondary Raynauds, and how to help improve the symptoms of both with acupuncture, and auricular acupuncture Loreto Sime M.Inst.Ch.P BSc

This medical condition was first diagnosed by the French Physician Maurice Raynaud (1834-1881). It is a condition characterised by a recurrence of episodes of discolouration of the fingers and / or toes as a result of over sensitivity to the cold.1 There are two different types of this disease namely: a) Primary which is a condition that develops by itself. b) Secondary which develops in association with another pre-existing health condition.2 Raynaud’s Phenomenon is an exaggeration of Vasomotor Responses to cold or emotional stress. It is a hyper activation of the Sympathetic Nervous System causing extreme vasoconstriction of the Peripheral Blood Vessels leading to Tissue Hypoxia. It is usually apparent on the fingers and toes, but can also affect the tongue, earlobes, nose, and in very rare cases the nipples or penis.3 These areas are supplied by small blood vessels.

This condition is often described as an “allergy to coldness”.

The affected areas usually change colour as a result of the exposure to cold temperatures. This causes the affected area to lose heat. The toes are affected in 50 per cent of cases with the digits becoming white and numb due to the sever reduction in blood flow. The same may also occur in the fingers, but the hands and feet are not affected.4 Between attacks digits appear normal.

When the arteries fully reopen the digits become red from reactive hyperaemia accompanies by a dull throbbing pain.

The pathophysiology of Raynaud’s phenomenon is not fully understood, but it is believed to be related to increased plasma viscosity, making blood flow more difficult, and also to the over activity of the sympathetic nervous system which causes them be become too restrictive too quickly. Hence it is usually only the digits and body extremities which are affected.5 This is illustrated in the pictures which show the change of colour and effect of Raynaud’s Disease in the hands.6 The diagnostic criteria for Primary Raynaud’s Disease are as follows: (a) Vasospastic attacks precipitated by exposure to cold and or emotional stimuli. (b) Bilateral involvement of the extremities. (c) Absence of gangrene or if it is present it will be limited only to the skin on the toes or fingertips. (d) No evidence of any underlying disease that could be responsible for these vasospatic attacks. (e) The patient will have a history of these symptoms for at least two years.7 If somebody suffering from Raynaud’s phenomenon is placed in a very cold climate it could be potentially dangerous. The symptoms of Raynaud’s Phenomenon usually subsides during pregnancy due to an increase in blood flow. If it occurs in breast feeding mothers it causes the nipples to turn white and becomes extremely painful.8 Treatment with Nifedipine, which is a calcium 06 | page

channel blocker and vasodilator, has been found in some cases to be effective.9 Primary Raynaud’s Disease is believed to be partly hereditary although the genes responsible have not yet been identified.10 “The reported prevalence of Reynaud’s Phenomenon ranges from 3 per cent to 21 per cent with women being more frequently affected than men at a ratio of approximately 4 to 1”.11 This depends on the criteria used. It is a common condition occurring in 5 to 10 per cent of the whole population, and is especially common in women aged 20 to 40 years.12 Also there is a hormonal influence.

This condition may also cause the nails to become brittle with longitudinal ridges since smoking affects the circulation especially the lower limbs. It is to be responsible for an increase in the frequency and worsening of attacks. Caffeine is also responsible for these adverse effects. Sufferers are more likely also to suffer more from migraine and angina.13 A careful and full medical history needs to be taken to ascertain which type of Raynaud’s Disease is present. The following factors therefore need to be considered: (a)Testing digital artery pressure before and after the hands has been cooled. A drop of 15 millimeters of mercury tests positive. (b)Test blood flow using a Doppler.

The following will show if it is caused by something else. (c) Full blood counts to detect anaemia, or renal failure. (d) Full blood test for urea and electrolytes shows renal failure. (e) Thyroid function. (f) An autoantibody screen test to detect the rheumatoid factor, the erythrocyte sedimentation rate. A corrective protein should reveal a specific cause or a generalised inflammatory process. (g)Nail fold vasculature using a microscope.

These tests can be undertaken by the G.P. If Primary Raynaud’s Disease is diagnosed then the G.P. can take care of the treatment.14 Secondary Raynaud’s Disease tends to have a large number of pre-existing causes, and therefore people suspected of having it are usually referred to a specialist. It is most frequently caused by any one of the following connective tissue conditions: (a)Scleroderma which is the hardening of the skin resulting in stiffening of joints and gradual wasting of muscles.15 (b)Systemic Lupus Erythematous which is a disease that can affect every organ in the body. It is up to 9 times more common in

TECHNICAL ARTICLE women than men, and affects black women 3 times more than white women. (c) Rheumatoid Arthritis which is the chronic inflammation of the synovial lining of several joints, and tendon sheaths. It tends to be symmetrical and involves a large number of peripheral joints.16 In America 71 per cent of Rheumatoid Arthritis are women. (d)Sjogren’s Syndrome involves the lack of ability to produce tears or saliva with 9 out of 10 cases occurring in women in midlife.17 (e)Polmyositis usually affects the muscles of the shoulders or the hips. It causes them to weaken and become tender to touch.18 These five conditions are listed by Menz.19 (f) Dermatomyositis which is an auto-immune disease characterised by erythema of the skin, and wasting of the muscles. (g)Mixed Connective Tissue Disease, also known as Sharp’s Syndrome,20 commonly abbreviated as MCTD is an autoimmune disease in which the body’s defence system attacks itself. (h)Cold Agglutinin Disease (CAD) is an autoimmune disease characterised by the presence of high concentrations of circulating antibodies, usually IgM, dirested against red blood cells.21 The disease can be either Primary or Secondary.

Primary CAD is associated with monoclonal cold reaction autoantibodies, is chronic and occurs after the age of 50 years.

It peaks when the patent reaches 70 to 80 years of age.

Secondary CAD is caused by polycional cold reacting auto antibodies. It is caused by infection and Lymphoproliferative disorders. In children this condition is usually transient.22 (i) Ehlers-Danlos Syndrome (EDS), also known as Cutis Hyperelastica,23 is a group of inherited connective tissue disorders, caused by a defect in the synthesis of collagen (Type I, III, or V).24 (j) Thoracic Outlet Syndrome (TOS) causes the nerves on blood vessels, just below the neck, to become compressed or squeezed. It can be between the muscles of the neck and shoulder or between the first rib and the collar bone. This causes a burning, tingling feelings combined with numbness in the arm, hand and fingers. It may also cause weakness in the hand. The arm may swell, and tire easily. If the vein is compressed this may result in excessive sensitivity to cold and result in it turning pale and / or blue.25 (k)Reflex Sympathetic Dystrophy (RSD) is now called Complex Regional Pain Syndrome (CRPS). It is defined as an excessive or exaggerated response to an injury of an extremity. It is manifested by 4 constant characteristics: 1. Intense and prolonged pain.

2. Vasomotor disturbances.

3. Delayed functional recovery.

4. Various trophic changes.26 (l) Cryoglobulinemia is a condition in which the blood contains large amounts of cryoglobulins which are proteins that become insoluble at reduced temperatures. This should be contrasted with cold agglutinins which cause agglutination

of RBCs. Cryoglobulinemia can be associated with various diseases such as multiple myeloma, and hepatitis C infection.27 Raynaud’s Disease also affects the internal organs, and small blood vessels. It is 3 times more prevalent in women than in men, and 15 times in women of child bearing age. It is also more common amongst black women.28 There are a number of other instigating factors resulting in Secondary Raynaud’s Disease and they include: 1. Anorexia Nervosa which is an eating disorder that can in extreme cases if left untreated result in death.29 2. Obstructive Disorders including Atherosclerosis which is due to the disposition of cholesterol onto the walls of the arteries.30 3. Buerger’s Disease affects more Jews than gentiles, and it can result in gangrene and ulceration in hands and feet. This is an inflammatory disease involving the blood vessels.The disease may be caused by smoking, and is almost entirely confined to men. Currently there is no known cure for it.

4. Aneurysm which is a weakness in the arteries wall. If it bursts then haemorrhaging may occur, which in some cases can cause death.31 5. Lyme Disease comprises arthritis associated with skin rashes, fever and sometimes encephalitis or carditis (inflammation of the heart). It is caused by a spirochaete which is transmitted by tick bite. It can be treated with antibiotics.32 6. Hypothyroidism is caused by a defective thyroid function resulting growth retardation, hoarse voice, course or thin hair. If left untreated will lead to learning difficulties. It is easily diagnosed, and can be treated with throxine.33 7. Magnesium Deficiency leads to muscular weakness, and interferes with the efficient functioning of the heart.34 8. Carpal Tunnel Syndrome involves pressure on the nerve as it passes under the ligament which lies across the front of the wrist. It can affect the first, third or fourth fingers resulting in pain and tingling in the affected fingers.35 9. Multiple Sclerosis is a disease of the brain and spinal cord which results in paralysis and tremors. This is believed to be the result of the breakup of the fatty matter in the nervesheaths which leaves the nerve-fibre bare.36 Other causes of Secondary Raynaud’s Disease are occupation, using vibrating machinery, very cold working conditions, and exposure to vinyl chloride or mercury. The list is a long one and also includes Repetitive Strain Injury, Computer Operatives or Musicians Physical Trauma, Magliancy, Magnesium Deficiency, and Multiple Sclerosis.

Long standing cases of Secondary Raynaud’s Disease may also develop Chronic Paronychia which results in redness and inflammation of the tissue around the nail.37 Some cancers, usually those affecting the blood, can be included to the list including: (a) Lymphoma in the Lymphatic glands. (b) Acute Lymphoblastic Leukaemia which is a cancer of the blood cells which usually affects children. (c) Multiple Myelong is a bone marrow cancer caused by page | 07

TECHNICAL ARTICLE the use of illegal drugs such as cocaine or amphetamines. Prescribed medication for this includes:1. Beta Blockers. These block the beta-andrenoceptors in the heart, and peripheral vasculature. Oxprenolol, pindolol, acebutolol, and celiprolol may be the best choice of medication since they tend to facilitate less coldness in the bodies extremities.38 2. Ergot Derivatives. These are used to treat migraine, but need to be used with caution as they may cause an increase in the symptoms of Raynaud’s Syndrome.39 3. Vinblastine is an alkaloid derived from the periwinkle plant. It is used in the treatment of certain forms of malignant disease, particularly choriocarcinoma and Hodgkin’s disease.40 4. Bleomycin is an antibiotic used successfully in the treatment of cancer of the upper part of the gut, the genital tract and lymphomas.41 5. Cyclosporin is a drug used to prevent the rejection of transplanted organs such as heart and kidneys. It is also used in the treatment of severe rheumatoid arthritis.42 6. Sulfasalazine is often found to be better tolerated than many other disease modifying Rheumatic drugs.43 In treating Rheumatoid Arthritis there is a great danger of exacerbating the symptoms of Raynaud’s Syndrome. Raynaud’s Disease can exist for up to 20 years before the true picture is seen.

The treatment of one disease might worsen the state of the other.

This possible interrelation needs therefore to be considered when formulating a course of treatment.

When Raynaud’s phenomenon is limited to one hand or foot it is known as Unilateral Raynaud’s. It is uncommon, and usually progresses over several years to affect other limbs. It is always secondary to a local or regional vascular disease.

Treatment Recommended: - Exercise, reduce stress. stop smoking, reduce stimulants. In cases of surgery then use lumber sypathectomy.44 Topical Treatment: - Nitro- glycerine ointment.

Vasodilation: - Is the treatment of choice in 75 per cent of cases.45 Treatment of Raynaud’s Disease46 1. Treatment options depend on the type of Raynaud’s present.

2. Address the underlying cause, but also consider other options.

3. Primary Raynaud’s treatment focuses on avoiding triggers.

General Care 1. Environmental triggers should be avoided e.g. cold, vibration.

2. Emotional stress is another trigger.

3. Extremities should be kept warm.

4. Consumption of caffeine and other stimulants, and vasoconstrictors must be prevented.

5. If triggered by exposure to a cold environment, and no warm water available, place the affected digits in a body cavity. Keep the affected area warm until normal body 08 | page

colouring returns. Also get out of the cold and into a warm environment as soon as possible.

Some Alternative Treatments 1. The extract of the Ginkgo biloba leaves may reduce the frequency of the attacks.47 2. Arginine is a precursor for the synthesis of nitric oxide which is a strong vasodilator.

3. Fish oil supplements which contain long-chain omega-3 fatty acids may help to control symptoms of Primary Raynaud’s Disease.48 4. Vitamin D is also shown to be very helpful in treating Raynaud’s.

A recent study indicates that acupuncture is more effective than drugs in the treatment of Raynaud’s Disease.

Treatment of Primary Raynaud’s Syndrome with Traditional Chinese Acupuncture.49 This research was undertaken at Medizinische Hochschule Hannover Department of Angiology in Germany.

Objective: Evaluation of the effects of a standardized acupuncture treatment in Primary Raynaud’s Syndrome Design: A controlled randomised prospective study.

Setting: A winter period of 23 weeks at Angiological Clinic in Hannover Medical School.

Subjects: 33 patients with Primary Raynaud’s Syndrome. 16 controls and 17 treatments.

Interventions: The patients of the treatment group were given 7 acupuncture treatments during the weeks 10 and 11 of the observation period.

Main Outcome Measures: All patients kept a diary throughout all the observation period daily capillaroscopy was performed for all patients at baseline (Week 1), and in weeks 12 and 23 recording flow stop reactions of the nail fold capillaries.

Results: The treated patients showed a significant decrease in the frequency of attacks from 1.4 per day to 0.6 per day. P<0.01 (control 1.6 to 1.2 p=o.08). The overall reduction of attacks was 63 per cent (control 27 per cent p=0.03). The mean duration of the flow stop reaction from 71 – 24’s (week 1vs week 12. P=0.001) + 38s (week1 vs. week 23 p=0.02) respectively. In the control group the changes were not significant.

Conclusions: These findings suggested that traditional Chinese acupuncture is a reasonable alternative in treating patients with Primary Raynaud’s Syndrome.

Vasodilation induced by transcutaeous nerve stimulation in peripheral ischemia (Raynaud’s phenomenon and diabetic polyneuropathy)50 Results: Electrical stimulation at acupoints at 2 Hz produced marked vasodilation in 6 patients.

Peripheral effects of sensory nerve stimulation (acupuncture) in inflammation and ischemia51 Results: For chronic diabetic ulcers 40-60 minutes daily treatment 5-7 days weekly may be the minimum needed to produce a clinical response.

Microcirculation52 Results: Subjects with Primary Raynaud’s Syndrome who

TECHNICAL ARTICLE receive acupuncture treatment recorded significant reduction in the attack rate, and an increase in blood flow.

Raynaud’s phenomenon, cytokines and acupuncture: a case report53 Abstract: A 30 year old African-American woman diagnosed in 2006 with Primary Raynaud’s Phenomenon (RP) was seen in the clinic in 2010 and the diagnosis confirmed excluding underlying disorders. Acupuncture was administered twice weekly bilaterally to L14 Hegu for 5 hours for 2 months. This resulted in improvement in pain severity, joint stiffness, and colour of her fingers and toes. The literature shows that acupuncture is effective in improving pain severity, and joint stiffness in RP. The patient’s cytokines were compared with those from an on-going study in the institution and the results indicate that acupuncture therapy might be anti-inflammatory. Therefore it should be considered as an alternative treatment for pain associated RP. Articular Acupuncture: A Potential Treatment for Anxiety54 Raynaud’s disease is exacerbated by stress. Needling all nervous tension points, and the accompanying nervous depression point will aid the release enkephalins which have the same pharmacological effect as morphine. The Articular Acupuncture point which stimulates the auricular vagus nerve results in an increase of vagus nerve activity which results in a decrease in heart rate and suppresses sympathetic nerve activity.

This is very useful in treating situational anxiety. Useful auricular points which affect the circulation are: 1. Sypathetic 2. Shenmen 3. Liver 4. Upper and lower lung Secondary Raynaud’s Disease can be aided by treating the associated underlying conditions i.e. Rheumatoid Arthritis, Scleroderma, or Sjogren’s Syndrome. These conditions can be aided by either auricular or full body acupuncture.

Acupuncture therefore has many different applications in dealing with Primary and Secondary Raynaud’s Disease. Research is thus on going in this area of medicine where the potential benefits to patients are great.

References 1. Raynaud M. On local asphyxia and symmetrical gangrene of the extremities. The Sydenham Society; 1888.

2. Allen EV, Brown GE. Raynaud’s disease: a critical review of minimal requisites for diagnosis. American Journal of Medical Science 1932; 183: 187-200.

3;5;7;11;19;37;44;45 Menz HB. Foot problems in older people: Assessment and Management. Churchill Livingstone Elsevier; 2008.

4. Brash PD, Tooke JE. Circulatory disorders. In: Lorimer D, French G, West S, editors. Neale’s Common Foot Disorders: Diagnosis and Management. 5th ed.

6. Wikipedia. Raynaud’s Phenomenon [Online]. 2013 June 5 8. Holmen OL, Backe B. An underdiagnosed cause of nipple pain presented on a camera phone. BMJ 2009; 339: b2553.

9. Anderson JE, Held N, Wright K. Raynaud’s phenomenon of the nipple: a treatable cause of painful breast feeding. Pediatrics 2004 Apr; 113(4): e360-4.

10. Wikipedia. Raynaud’s Phenomenon [Online]. 2013 March 5 12. Randell GC, Thompson CE, Boyd PM. Disorders of the adult foot.

In: Lorimer D, French G, West S, editors. Neale’s Common Foot

Disorders: Diagnosis and Management. 5th ed. London: Churchill Livingstone Elsevier; 1997. P.110.

13;14. Wikipedia. Raynaud’s Phenomenon [Online]. 2013 March 5 [cited 2013 March 9]; 15. Gayraud M. Raynaud’s Phenomenon. Joint, Bone, Spine 2007 Jan; 74 (1): e1-8.

16 - 18. Macpherson G, editor. Black’s Medical Dictionary. 38th ed.

London: A and C Black; 1995.

20. Naveau B, Dryll A, Peltier AP, et al. Evolutive aspects of Sharp’s mixed connective tissue disease. Nouv Presse Med 1981 Sep 19; 10 (33): 2731-3.

21. Gertz MA. Cold Agglutinin Disease. Haematologica 2006 Apr; 91 (4): 439-41.

22. Berentsen S, Beiske K, Tjonnfjord GE. Primary Chronic Cold Agglutinin Disease: An update on Pathogenesis, clinical features and Therapy. Hematology. 2007 Oct; 12 (5): 361-70.

23. Milhorat TH, Bologese PA, Nishikawa M, et al. Syndrome of occipitoatlantoaxial hypermobility, cranial setting, and chiairi malformation type I in patients with hereditary disorders of connective tissue. Journal of Neurosurgery, Spine. 2007 Dec; 7(6): 601-9.

24. Parapia LA, Jackson C. Ehlers- Danlos Sydrome – A historical review.

British Journal of Haematology. 2008 Apr; 141 (1): 132-35.

25. Foley JM, Finlayson H, Travlos A. A Review of Thoracic Outlet Syndrome and the Possible Role of Botulinim Toxin in the Treatment of the Syndrome. Toxins. 2012; 4: 1223-1235.

26. Veldman PH, Reynen HM, Amtz IE, et al. Signs and Symptoms of Reflex Sympathetic Dystrophy: Prospective Study of 829 Patients.

Lancet. 1993; 342 (8878): 1012-16.

27. Brouet JC, Clauvel JP, Danon F, et al. Biological and Clinical Significance of Cryoglobulins. A Report of 86 Cases. Am. J. Med.. 1974; 57 (5): 775-88.

28. Wikipedia. Raynaud’s Phenomenon [Online]. 2013 March 5 29-33 Macpherson G, editor. Black’s Medical Dictionary. 38th ed.

London: A and C Black; 1995.

34. Vierling W, Liebscher DH, Micke O, et al. Magnesium deficiency and therapy. Dtsch Med Wochenschr. 2013 May; 138 (22): 1165-71.

35. Durkan JA. A new diagnostic test for carpal tunnel syndrome. J Bone Joint Surg Am. 1991; 73: 535-38.

36. Macpherson G, editor. Black’s Medical Dictionary. 38th ed. London: A and C Black; 1995.

38 - 43. Martin J, editor. British National Formulary. Sep 2009 ed.

London: BMJ Group; 2009 46. Wikipedia. Raynaud’s Phenomenon [Online]. 2013 March 5 47. Muir AH, Robb R, McLaren M, et al. The use of Ginkgo biloba in Raynaud’s disease: a double-blind placebo-controlled trial. Vascular Medicine. 2002; 7 (4): 265-7.

48. DiGiacomo RA, Kremer JM, Shah DM. Fish-oil dietary supplementation in patients with Raynaud’s phenomenon. The American Journal of Medicine. 1989; 86 (2): 158-64.

49. Appiah R, Hiller S, Caspsry L, Alexander K, Creutzig A. Treatment of Primary Raynaud’s Syndrome with Traditional Chinese Acupuncture. J Intern Med. 1997; 241(2): Feb 119-124.

50, Kaada B. Vasodilation induced by transcutaneous nerve stimulation in peripheral ischemia (Raynaud’s phenomenon and diabetic poly neuropathy). Eur Heart J. 1982; 3(4): 303-314.

51. Lundeberg T. Peripheral effects of nerve stimulation (acupuncture) in inflammation and ischemia. Scandinavian Journal of Rehabilitation Medicine. 1993; 29(suppl): 61-86.

52. Moehre M, Blum A, Lorenz F, Roesch G, Steins A, Juenger M, et al.

1995. Proceedings of the 2nd Asian Congress for Microcirculation, Beijing 53. Omole FS, Lin JS, Chu T, Sow CM, Flood A, Powell MD. Raynaud’s phenomenon, cytokines and acupuncture: a case report.

Acupunct Med. 2012; 30: 139-141.

54. Wang S, Kain ZN. Auricular Acupuncture: A Potential Treatment for Anxiety. Anesth Analg. 2001; 92: 548-53

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TECHNICAL ARTICLE

Peripheral Vascular Disease and the Drugs used in Treatment Malcolm Holmes M.Inst Ch P, BSc(Pod Med), DCHM, LCH Intermittent claudication (IC) is one of the many manifestations of peripheral vascular disease (PVD).

Approximately 5% of the male population over 50 years of age have some degree of intermittent claudication (University of Oxford, 2000). Claudication comes from the Latin word "to limp”.

Sufferers feel pain on walking, typically after a constant claudication distance; this subsides rapidly at cessation of walking and returns after the same distance on resumption. The pain can be felt in the foot, calf, thigh and, or buttock, depending on the blood vessels affected. Narrowing (or spasm) of the superficial femoral artery causes pain in the calf, whereas that of the iliac arteries causes pain in the buttocks. Life style changes are the most important measures in the conservative treatment of Intermittent Claudication. Sufferers should not smoke, as this will worsen the problem. An exercise regime is usually suggested with advice given to walk on after the pain begins, continuing until the pain is unbearable, and then rest before walking again. The object of this is to develop collateral circulation, which will improve or may even, in time resolve the problem. Increased exercise has been shown to increase walking distance by between 28% and 210% (unweighted mean of 105%) in nine study groups (Moore, McQuay and Gray, 1998).

Medications used for intermittent claudication usually aim to relieve the pain, improve functioning, and prevent progression that might lead to gangrene and amputation, and also to prevent heart disease and stroke, reduce artery damage and improve cholesterol and lipid levels.

ASPIRIN: is useful in low doses – 75mg. daily for mild conditions, particularly for those who are also at risk of heart attack or stroke. It inhibits COX 1, preventing platelet aggregation and thus the release of vasoconstricting agents. It will improve leg circulation, and if used early it can prevent blood clots developing in the veins, however it is uncertain whether it will prevent or delay atherosclerosis (Harvey, S., 2002). It is inexpensive and generally well tolerated, but has a high incidence of gastro-intestinal disturbances. It should not be taken by children, during breastfeeding, or by anyone with a history of peptic ulcers or haemophilia.

CLOPIDOGREL (PLAVIX): is a more powerful aniplatelet drug, useful where aspirin is insufficiently effective. It should not be taken if pregnant, breastfeeding, or if any active bleeding is present, and it must be discontinued 7 days prior to surgery if antiplatelet effect is not wanted. It can cause gastro-intestinal disorders and bleeding disorders. The dosage is 75mg daily but it is much more expensive than aspirin.

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PENTOXIFYLLINE (TRENTAL): Reduces the ‘stickiness’ of blood, improving flow. Most studies suggest that it is not a very effective treatment, increasing walking distances only slightly, or, not at all against a placebo (Harvey, S., 2002). It should not be taken by those with cerebral or retinal haemorrhage, acute myocardial infarction, or while pregnant or breast-feeding. Common side effects are gastro-intestinal disturbances, dizziness, agitation, sleep disturbance and headaches. It is cheaper than CLOPIDOGREL, but less effective.

CILOSTAZOL (PLETAL): is an antiplatelet drug with vasodilatation properties; it is approved for use in intermittent claudication where there is no pain at rest and no tissue necrosis.

It is useful where aspirin and clopidogrel have not been effective, it is thought to suppress cyclic adenosine monophosphate degradation, leading to inhibition of platelet activation and aggregation, and preventing the release of prothrombotic, inflammatory and vasoactive substances. Studies have shown that patients using this drug have increased walking distances by 106 metres over a placebo, with time to initial pain also extended (Doctors Guide 1999). It should not be taken by those with bleeding problems (peptic ulcer, haemorrhagic stroke in previous 6 months, surgery in previous 3 months, diabetic retinopathy or uncontrolled hypertension), those with heart, liver or renal disease, or during pregnancy or breast-feeding. It should be noted that smoking decreases the effect of this drug and should therefore be discouraged. It often causes diarrhoea, abnormal stools and headaches, and less commonly, irregular heartbeat, dizziness, gastro-intestinal problems and flu like symptoms. The dosage is 100mg twice daily; its price is comparable to CLOPIDOGREL. NAFTIDROFURYL: is an antiplatelet drug which also blocks serotonin, improving oxygen absorption (Harvey, S., 2002) It may alleviate symptoms and increase pain free walking distance in moderate cases (Mehta, D. et al, 2006, p115). Side effects are nausea, epigastric pain, kidney failure and hepatitis.

CINNIRZINE and NICOTINATE: are also licensed for use in IC, but have been found generally ineffective.

STATINS: are now the most important agents for people who require low density lipoproteins/cholesterol lowering therapy.

They may have additional advantages for patients with PVD, regardless of cholesterol levels, as some evidence suggests that they might promote growth of new blood vessels and might help prevent IC (Harvey, S., 2002). They should not be used where there is active liver disease, or during pregnancy or breastfeeding.

Hypothyroidism must be controlled before using STATINS. These

TECHNICAL ARTICLE drugs should be used with caution in anyone who has high alcohol consumption. Liver function tests are recommended for anyone starting to take STATINS, 1 to 3 months after, then every 6 – 12 months. The most common side effects are headache, nausea, vomiting, constipation, diarrhoea, headache, rash, weakness, and muscle pain. The most serious side effects are liver failure and rhabdomyolysis. Rhabdomyolysis is a serious side effect in which there is damage to muscles, patients should therefore be advised to report any unexplained pain, soreness or tenderness (Mehta, D., 2006, p136). The cost and dosage varies considerably between the available drugs.

FIBRATES and NICOTINATE ACID: are agents that lower triglycerides and increase high density lipoproteins. There is some evidence that lipid imbalance may be a more important factor in PVD than high levels of low density lipoproteins (Harvey, S., 2002).

FIBRATES should not be taken by anyone with severe hepatic or renal impairment, gall bladder disease, while pregnant or breastfeeding. They should not generally be taken with STATINS as the risk of muscle problems is increased. Common side effects include gastro-intestinal disturbances, rashes, pruritis, headache and fatigue. The price varies, depending on the drug chosen.

NICOTINATE ACID should not be taken by anyone with arterial bleeding, active peptic ulcer or who is pregnant or breast-feeding.

Side effects are similar to FIBRATES, and the cost is comparable.

ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS: can be used as part of the overall treatment, where high blood pressure is also a factor. As they decrease vasoconstriction there is some belief that they have a beneficial effect on PVD. They should not be used by anyone with renovascular disease or who is pregnant. Caution is advised if breast-feeding. They can cause renal impairment, a persistent dry cough, and angioedema. They are generally inexpensive.

NIFEDIPINE: is a calcium-channel blocker, which has the additional effect of dilating the peripheral arteries. This can be useful in the treatment of intermittent claudication. It should not be taken by anyone with unstable angina, heart block or who is pregnant, it should not be used for I month after a heart attack.

Side effects may be headaches, flushing, sweating, palpitations, lethargy, hypotension and gastro-intestinal disturbances. An inexpensive treatment.

VERAPAMIL: also a calcium-channel blocker, its vasodilatory effect works on the smooth muscle of the blood vessels, it has little effect on cardiac arteries. It has also been shown to increase oxygen extraction in ischemic tissue. Trails have shown no effect ABPI or leg temperature, which would suggest that improvements in the condition might be due to improved oxygen metabolism (Bagger, J. et al, 1997). It showed significant benefit in moderate IC. Its contra-indications and side effects are similar to NIFEDIPINE, but are even less expensive.

ETHYLENEDIAMINE ETRA ACETIC ACID (EDTA): is used in chelation therapy and is usually given as an intravenous infusion.

It removes excess minerals from the blood. Some studies have claimed that it may slow or even reverse atherosclerosis in PVD, however the majority of studies do not support this.

CONCLUSION

Drug therapy for IC is limited and the outcome variable, with many of the drugs having little effect. The cost of treatment is also extremely variable and the more expensive drugs are not necessarily the most effective. In addition many of the drugs have unpleasant side effects, which may weigh against the, sometimes limited, improvements. Cessation of smoking and an exercise regime seem to have equally well, or even better results than do drugs – provided that patient compliance is good.

Surgical intervention is indicated for some patients, but the risk must be weighed against the severity of the problem. Surgery is also unsuitable where there is multi-segmental involvement (Doctors Guild 1999). There are a number of drugs being tested that may be of future use in the treatment of IC. For example, Beraprost, an oral prostaglandin is proving helpful in extending exercise limits (Harvey, S., 2002). Some possibly helpful research is being done using an extract from ginkgo biloba (Levy, S., 2006), which appears to increase peripheral blood flow and affect platelet aggregation. This is particularly interesting as it has mostly mild, infrequent side effects and no drug interactions. A number of other drugs are also being evaluated for their effect on IC, so more effective treatments may be in the pipeline.

REFERENCE LIST

BAGGER, J. et al, 1997. Effect of Verapamil in Intermittent Claudication. [online] American Heart Association Inc. http://circ.ahajournals.org/cgi/content/full/95/2/411 DOCTORS GUILD GLOBAL EDITION, 1999. FDA Approves Pletal for Intermittent Claudication. [online] psl group. http://www.pslgroup.com/dg/dc5f6.htm HARVEY, S., 2002. What are the Medications used for Peripheral Artery Disease and Intermittent Claudication?. [online] University of Maryland Medical Center. http://www.umm.edu/patiented/articles/medications_used_peripheral_artery _disease_intermittent_claudication_000102_7.htm LEVY, S., 2006. Herbal Medicine. [online] Buffalo University Center for Integrative Medicine. http://www.acsu.buffalo.edu/~shlevy/herbal.htm MEHTA, D. et al (eds), 2006. British National Formulary 51. London: BMJ Publishing Group and RPS Publishing. p 115, p 136.

MOORE, A., MCQUAY, H. and GRAY, J., 1998. Exercise and Intermittent Claudication. [online] Bandolier p 6. http://www.jr2.ox.ac.uk/bandolier/painres/download/bando052.pdf UNIVERSITY OF OXFORD/OXFORD RADCLIFFE HOSPITAL, 2000. Intermittent Claudication Treatments. [online] Bandolier http://www.jr2.ox.ac.uk/Bandolier/band74/b74-3.html

BIBLIOGRAPHY

MEHTA, D. et al (eds), 2006. British National Formulary 51. London: BMJ Publishing Group and RPS Publishing.

WALKER,G. 1993. ABPI Datasheet Compendium. London: Datapharm Publications Limited.

REYNOLDS,J. et al (eds), 1989. Martindale The Extra Pharmacopoeia. 29th ed.

London : The Pharmaceutical Press

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HEALTH ARTICLE

BPA and You, Your Family and Your Patient’s Health Beverley Wright MSc, BSc (Hons), PGCE,PGDip,MInstChP We have been hearing more and more about BPA in the last few years, but what is BPA?

Well, BPA is the acronym for Bisphenal A, which is a waterinsoluble organic compound discovered in the late 19th Century. In the 1930s concerns were being raised regarding the estrogen-like activity of BPA and by the late 1990s BPA in vivo testing indicated toxic effects at doses, which were previously thought to be “safe” (Environ Health Perspect. 2011 Dec;119(12):1788-93 & Endocrine Rev 2009; 30:75-95). But, why is it after over a hundred years of use we are coming to terms with the realization that BPA is not good for us, and does in fact contribute to anatomical and physiological dysfunction, ill health, major diseases, or worse, an early grave?

Research from the Harvard School of Public Health have recently discovered that with just one serving of canned soup can dramatically increase the levels of this now known dangerous chemical – BPA in the body by as much as 20 times (JAMA 2011; 306:2218-20). BPA is not only found in cans of soups, but in cans of ravioli, noodles, as well as over 700 canned goods and beverages (J Food Prot 2010; 73:1085-9 & J Agric Food Chem 2009; 57:1307-11).

It is in plastic bottles and containers, such as those containing water and soft drinks, which is why manufacturers of these plastic products have now put warnings on their labels not to re-use or re-fill bottles.

Furthermore, it is also advisable not to leave food or drink containers in a hot place or car. The heat helps to leach more BPA into the food or drink within, which is then passed directly into the body when consumed.

BPA has already been banned by some regulatory bodies around the world. Products such as reusable plastic food and drinks containers, toddler’s ‘sippy’ cups and baby drinking bottles have already been banned that contain the BPA chemical. BPA is also found in hard and clear plastic, food wrappings i.e. Cling Film and sandwich bags, bags of frozen foods and vegetables, bin liners, canned food and drink linings, and the print on most receipts, so handle with care.

Canned food and drink linings have been used to create a barrier between the food and the metal can from any likelihood of bacterial contamination. There is no regulation at the present time to ban the lining from canned foods and drinks, despite the research revealing that BPA does indeed leach from the can lining into the food inside.

(J Agric Food Chem, 2011; 59:7178-85 & Food Addit Contam, 2002; 19: 796-802).

Manufacturers and health regulatory agencies have defended the use of BPA, because they say it is quickly eliminated from the body.

However, research from the University of Missouri has discovered that ‘…continuous external BPA exposure appears to lead to sustained concentrations that are detectable in serum or plasma of humans who have not been knowingly exposed to this endocrine-

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disrupting chemical’ (Environ Health Perspect, 2011;119:1260-5).

Furthermore, a single serving from canned goods eaten regularly could lead to accumulated high levels of BPA that have become associated with certain health effects such as abnormal breast and reproductive development, certain cancers and aggressive behaviours (www.breastcancerfund.org/assets/pdfs/publications/ bpa-in-kids-canned-foods.pdf ). The Environmental Protection Agency (EPA) suggests that safe exposure levels of BPA are about 50 parts per billion (ppb), but data from the most recent study of food and beverage cans tested by the Breast Cancer Fund (BCF) range from 10 to 148 ppb with soups averaging 77.5 ppb, while average meals are about 21 ppb. So the levels of BPA found in canned foods are of great concern (www.breastcancerfund.org/assets/pdfs/ publications/what-labels-dont-tell-us-1.pdf).

In the Vandenberg et al study (Endocrine Rev 2009; 30:75-95) they state that the maximum tolerated dose of 1,000 mg/kg body weight was put in place in 1987, which is 40,000 times greater than the daily dose of 25 mcg/kg body weight set by Health Canada Food Directorate. This was to support the growing body in reducing the incidence of high toxicity levels of BPA, which have become associated with many health conditions and diseases.

Several studies have linked high levels of BPA to endocrine disruption due to estrogenic properties (Endocrine Rev 2009; 30:7595), endometrial hyperplasia (Endocr J, 2004; 51: 595-600); heart disease (PLoSOne, 2010; 5 (1): e8973 & Melzer et al, 2012); thyroid hormone antagonism; neurotoxicity; and carcinogenesis (Endocrine Rev 2009; 30:75-95); obesity (Environ. Res. (2011), doi:10.1016/ j.envres.2011.05.014); increased body fat in rats (Environ Health Perspect 2009; 117:1549-55); women’s infertility (JAMA 2011; 306:2218-20); Polycystic Ovarian Syndrome (Endocr J, 2004; 51: 1659); recurrent miscarriages (Hum Reprod, 2005; 20: 2325-9), and poor sperm quality (Zhonghua Lao Dong Wei Sheng Zhi Ye Bing Za Zhi, 2009; 27: 741-3).

It is however, foetuses, infants and young children that are vulnerable, as their developing brains and organs are sensitive to chemical exposures such as BPA. One study found that Chinese women having maternal BPA exposure in the workplace, delivered sons with anogenital distance (AGD), which is a shorter distance between their genitals and anus; when compared to pregnant women not exposed to BPA in the workplace (PloSOne, 2011; 6: e18973). In addition, the greater the dose of BPA during pregnancy, the shorter the AGD in boys, which has been linked to infertility, abnormal testosterone function and low sperm count (Birth DefectsRes A Clin Mol Teratol. 2011; 91: 867-72).

Prenatal exposure to BPA has also been linked to early childhood abnormal behaviours (Environ Health Perspect, 2009; 117: 1945-52).

Women with high concentrations of BPA in their urine during

HEALTH ARTICLE pregnancy were found to be more likely to have hyperactive and aggressive two year olds (Pediatrics 2011; 128:873-82). Children in their early years may also have eďŹ&#x20AC;ects on their developing immune system if exposed to BPA and have high BPA urinary levels, where it could cause asthma (Pediatrics 2011; 128:873-82).

So what is the alternative to canned foods? Well in 1999 food manufactures did start to move away from BPA infused linings and introduced food linings made from oleoresinous c-enamel, which comes from a natural source of oil and resin extracted from pine and balsam ďŹ r trees. Although, a natural product it is unknown and untested, and could be just as harmful as the chemicals they are replacing.

Manufacturers of plastic bottles and containers have begun eliminating BPA from their products, but it was only a few years ago that BPA free products, such as drinking containers, were quite expensive to purchase.

Fortunately, these products are much cheaper now, in respect of growing information surrounding BPA and the demand for BPA free plastic products.

Although there has been a move toward BPA free drinking containers, purchasing your favourite soft drink or water, in a can or plastic bottle still means you are not immune from BPA. If you prefer

a can of soda they contain 4.5 mcg/L; therefore, drinking two cans of soda per day means consuming 3 mcg of BPA (J Food Prot 2010; 73:1085-9).

Canned foods still contain the highest BPA content. It is canned soups, condensed soups in particular that are the main culprits of BPA consumption, over the ready to serve canned soups, which if eaten daily have been found to increase urinary BPA excretion by 1,000%, in comparison with eating fresh soups (JAMA 2011; 306:2218-20). Canned tuna (J Agric Food Chem 2009; 57:1307-11 & J Food Prot 2010; 73:1085-9), has a BPA content of 16.44 mcg in a 120 g can, or 1% of BPA provisionally for a 65 kg woman.

The best alternative of all it must be said and by far the safest solution to reduce any risk of serious health issues, is to use BPA free containers, and of course to eat fresh foods and produce. In addition, consider using glass bottles and containers, especially for microwaving and heating food.

Further references:

Lakind JS, Levesque J, Dumas P, Bryan S, Clarke J, Naiman DQ. Comparing United States and Canadian population exposures from National Biomonitoring Surveys: bisphenol A intake as a case study. J Expo Sci Environ Epidemiol 2012 [epub ahead of print].

Melzer D et al. Urinary bisphenol A concentration and risk of future coronary artery disease in apparently healthy men and women. Circulation 2012 [epub ahead of print].

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HEALTH ARTICLE

What’s the best test for early detection of memory decline?

Food For The Brain’s online Cognitive Function Test comes up trumps in comparison with current best ‘paper and pencil’ tests, says leading international psychiatry journal.

A study just published in the International Journal of Geriatric Psychiatry1, confirms that Food for the Brain’s free online Cognitive Function Test (CFT) accurately measures the most sensitive memory functions that are the first indicators of increasing risk of Alzheimer’s Disease. Brain changes that affect memory often start 30 years before diagnosis, in people in their 50s.

In the study our CFT, which measures the three aspects of memory and cognition that decline in Alzheimer’s (episodic memory, executive function and processing speed) was compared to the best paper and pencil tests currently used to diagnose mild cognitive impairment, the forerunner of dementia/Alzheimer’s. There was

almost perfect correlation showing the CFT test to be highly sensitive.

However, the advantage of the CFT is that it is digital, and free, so anyone can screen themselves at home. This means that many more people will come forward for early screening, as opposed to having to visit a very busy GP who may not have the time or expertise on hand to run an early screening test. Since we released it in 2011 over 150,000 people have taken the test.

The disadvantage of a digital test is variable computer skills. The CFT takes this into account by starting with a ‘mouse click speed test’.

This then adjusts how long someone has to complete. The CFT is validated for people aged 50 to 70. It is probably valid for a wider age group but it has yet to be tested. It also needs to be validated for its use for computers and tablets that use a touchpad, not a mouse. Most people under age 70 have some keyboard skills and this is becoming even more common so, in the future, current paper and pencil tests are likely to become obsolete.

The Cognitive Function Test is part of our Alzheimer’s Prevention Project and takes around 15 minutes to complete.

According to Professor David Smith from the University of Oxford: “Early screening is the key to Alzheimer’s prevention. Half of all cases of Alzheimer’s could probably be prevented right now if everyone over 50 were screened and then took the right prevention steps. I am very impressed with this test.”

His ground-breaking research has already established that, in people with a high blood level of homocysteine, taking B vitamins 14 | page

Six Steps to Prevent Alzheimer’s and Protect Your Memory

Eat fish - Eat fish three to four times a week, with at least two servings of oily fish (salmon, mackerel, herrings, kippers, sardines or tuna). Eat more nuts and seeds, preferably raw.

Up antioxidants - Eat at least six servings of brightly coloured vegetables and berries.

Cut sugar and refined carbs - Follow a low GL diet, with slow-releasing ‘whole’ carbohydrates. Minimise sugar, sugary drinks and juices.

Supplement B vitamins – Supplement vitamin B6 (20mg), B12 (10mcg) and folic acid (200mcg) as a sensible precaution. But do check your homocysteine level to find out how much you need. If above 10mcmol/l, supplement high dose B6 (20mg), folic acid (800mcg) and B12 (500mcg).

Limit coffee and stop smoking – Limit coffee and choose herbal or green tea instead.

Be active – Keep physically, socially and mentally active by learning new things. Crosswords, sudoku and knitting all help!

virtually stops memory loss and the brain shrinkage associated with developing Alzheimer’s. 2 Around one in two people over 65 do have high homocysteine levels (above 10mcmol/l), which Professor Smith thinks GPs should test for if a patient’s Cognitive Function Test results are negative.

The test, which is designed for people aged 50 to 70, now includes guidance on six Alzheimer’s prevention steps to reduce your risk and provides a letter for your GP to test your homocysteine level if you are at risk.

Ray Hodgson is a case in point. He did the test some 18 months ago, which indicated risk, and as a result his GP measured his homocysteine level, which was 13 – above the level of 10 associated with increased rate of brain shrinkage. He took the recommended B

HEALTH ARTICLE vitamins and has also improved his diet, eating more fish, vegetables, and wholefoods, and cutting back on sugar. “The effect has been remarkable. Whereas I had been forgetting names and finding it hard to take on new skills, my memory and concentration are definitely better". Ray has recently taken the test again and he is out of the ‘at risk’ category, giving him peace of mind as well as the desire to share his experience and help others.

“One of the advantages of the test is that you can do it at home, and monitor your cognitive function every year”, says Dr Celeste de Jager from the University of Cape Town’s School of Public Health, who helped develop and test the test. “There’s considerable evidence that cognitive decline can be slowed and that Alzheimer’s is preventable but the key is to find out early who is at risk and do something about it.”

A recent review confirms that half of all risk for Alzheimer’s can be attributed to seven factors including smoking, physical inactivity, depression, midlife obesity, diabetes, high blood pressure and lack of cognitive activity 3 – if you don’t use it you lose it.

References 1 C.Trustram Eve and C.de Jager ‘Piloting and validation of a novel self-administered online cognitive screening tool in normal older persons: the Cognitive Function test’ 2013 International Journal of Geriatric Psychiatry 2 See www.foodforthebrain.org/hcyevidence for summary of key research on homocysteine and the effects of B vitamins, brain shrinkage and memory loss including G. Douaud et al., ‘Preventing Alzheimer's disease-related gray matter atrophy by B-vitamin treatment.’ Proceedings of the National Academy of Sciences 2013 May 20.

3D. Barnes and K.Yaffe ‘The projected effect of risk factor reduction on Alzheimer’s disease prevalence’ 2011 Lancet Neurology, 10(9); 819-828

The only treatment to date that has been shown to slow down memory loss and brain shrinkage in those at risk, with high homocysteine levels, is supplementing vitamins B6, folic acid and B12. However, there is growing evidence that the following diet and lifestyle actions may also reduce your risk of age-related memory decline: Please tell all your friends over 50 to take the Cognitive Function Test at http://cft3.foodforthebrain.org/ We are seeking funding to develop this test for tablets such as ipads and test its validity across a broader age range, as well as analysing current results to find out who is at risk and what can be done to minimise it. If you would like to help us, please become a Friend of Food for the Brain or email us at info@foodforthebrain.org

About ‘Food for the Brain’

Food for the Brain is a non-profit educational charity, created by a group of nutritional therapists, doctors, psychiatrists, psychologists, teachers and scientists to promote the link between nutrition and mental health.

The foundation is governed by the Board of Trustees and supported by an panel of experts on our Scientific Advisory Board - See more at: http://www.foodforthebrain.org/ page | 15

FEATURE ARTICLE

Learning and Sharing in Thailand

Henry Lee, winner of the Cosyfeet Podiatry Award 2012, participated in a learning and skills sharing visit to Theptarin Hospital in Bangkok. Here he reports on his experiences.

As a podiatrist I want to keep people walking for life.

This can be achieved if we address vascular, neurological, dermatological, and musculoskeletal risk factors that pre-dispose people to lower limb problems. In my podiatry role at Khoo Teck Puat Hospital in Singapore, I am constantly striving to improve limb protection and salvation practices.

During my final year at Southampton University, I started to wonder how lower limb conditions are managed in different parts of the world, particularly in those countries where podiatry is not an established profession. I wondered whether there were effective and inexpensive practices that we could learn from in order to create limb protection and salvation strategies which are simple, effective, affordable and can be made widely available. With this in mind I entered for the Cosyfeet Podiatry Award and planned to join an international team on a learning journey to a leading hospital in Southeast Asia in the field of diabetes care, limb protection and limb salvation. My aim was to explore local approaches to healthcare and limb care by: •

Learning from their practice

•

Engaging in the constructive exchange of ideas

•

•

Sharing skills and experiences

Growing together, so that our combined knowledge and skills could benefit the patients under our care indefinitely

About Theptarin Hospital

In June 2013 my learning visit to Theptarin Hospital in Bangkok began. I felt excited and privileged to be visiting such a renowned hospital. Founded in 1985 as “Theptarin Diabetes and Endocrine Centre” by Professor Thep Himathongkam, this was the first diabetes care team model in Thailand. More importantly, it sets a standard for diabetes care throughout Thailand, focusing on clinical service, education, research and social responsibility.

Picture References from top to bottom

Theptarin Hospital subsequently became Thailand’s first diabetes and thyroid centre, heavily engaged in health promotion and patient empowerment through a team care approach and patient education. In the field of limb salvation, it is a pioneer in distal bypass surgery and hyperbaric medicine in Thailand, and also

opened the country’s first foot clinic.

In 2005, when research from an overwhelming number of studies revealed that type 2 diabetes is a preventable condition, Theptarin Hospital opened its “Lifestyle Building” to promote wellness through healthy living, and to prevent diabetes and related chronic diseases. Clinical services expanded accordingly from managing diabetes, to the prevention of pre-diabetes through healthy living and behavioural modification, especially in exercise and dietary habits. Such commitment to health promotion is evident from its opening of a fitness club featuring a swimming pool, gym, weight management clinic and a spa sanctuary – all in the hospital itself.

Theptarin Hospital’s commitment to excellence in diabetes care was further affirmed when, in 2011, the World Diabetes Foundation appointed the hospital as a centre of excellence, providing training for medical personnel all over the world.

On day one of my visit, I was fortunate to receive an official welcome by Professor Thep Himathongkam, who Theptarin Hospital is named after. I was subsequently introduced to the team of international visitors (see top photo left). We all shared a common vision of improving diabetes care in our respective countries and hoped to learn from each other to maximize the benefit of this month-long exchange program.

Staff as Health Ambassadors

We were given a tour of the state-of-the art facilities at Theptarin Hospital, and were impressed to see that the health supporting ethos of the hospital also extends to the staff themselves. They are encouraged to be ambassadors for healthy living and can benefit from free fitness classes and discounts for fitness services and exercise equipment. There are also staff sports competitions, and nutritional information is provided on the canteen menu.

People can often be seen using the fitness facilities until closing time at 9pm, and can join aerobics, yoga, and hydrotherapy classes at specified times.

Dr. Pande Dwipayana (Endocrinologist, Bali – Indonesia), Ms. Deeki Zangmo (Diabetes Nurse Educator, Bhutan), Ms. Tanya Vannapruegs (Dep. Director of Corp. Comm. – Theptarin Hospital), Professor (Dr) Thep Himathongkam (Founder and CEO Theptarin Hospital),Mr. Henry Lee (me) (Podiatrist, Singapore), Ms. Dahlia Brown (Senior Foot Health Specialist, Jamaica), Dr. Octo Indradjaja (Endocrinologist - Bandung, Indonesia), Dr. AAG Budhitresna (Endocrinologist - Bali, Picture 2 – All of us performing a ‘Wai – a traditional Thai gesture of greeting)

Picture 3: The Theptarin Lifestyle Building features a swimming pool, fitness centre and Spa Sanctuary, offering visitors and staff health and fitness programs to improve their overall wellness.

Picture 4: To promote a more active lifestyle, staff are encouraged to use the stairs. Staircases are lined with motivational posters and educational material to make the climb meaningful.

Picture 5:Fitza Delivery! Inspired by the concept of Pizza delivery, patients and staff routinely receive a surprise workout by a trained physiotherapist.

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FEATURE ARTICLE The fitness area feels more like a real fitness club than a conventional, sterile hospital.

In addition there is strong encouragement for the staff to use the stairs instead of the lifts. The staircases are lined with motivational posters. Each storey provides a different reason why the climb is worth it. In addition, staff can accumulate ‘ink stamps’ at several levels, and by using the entire staircase over a period of time, can earn an attractive reward token.

Health Promotion in the Diabetes Centre

Everyone knows about pizza delivery, but ever heard of ‘fitness delivery’? Affectionately known as Fitza (Fitness Pizza), patients and staff routinely receive a surprise visit by a trained physiotherapist leading a group fitness workout during their wait to see their healthcare professional in the Diabetes Centre.

Educational posters regarding diabetes and its prevention are also on display. These measures mean that the patients always have something constructive to do and learn during waiting times.

As part of our visit, we were honoured to have a presentation by Dr. Panya (orthopaedic surgeon with an interest in health promotion) titled “Exercise is Medicine” and “The 2nd prescription”. In the presentation we learned about the importance of exercise, about the latest research on the different types of body fat and their effects, and also about how an active lifestyle can be achieved anytime, any day, and anywhere. Dr. Panya strongly advocates that exercise should be one of the main ‘prescriptions’ of a doctor, and not an add-on. He states persuasively that the mindset of the patient must be changed to prioritise exercise, and that the doctor must be a key figure in this process, given the benevolent authority associated with medical doctors.

Nutrition & Dietetics

The hospital’s Nutrition & Dietetics Centre provides nutritional support for patients as part of the hospital’s multidisciplinary approach. It also provides health promotion which is both educational and entertaining. Its facilities include a Lifestyle Studio, Dietetics counselling room, kitchen for demonstration purposes, a number of food models, and many other educational tools. Everyone knows about the services of dietitians, but have you ever seen a mock-up supermarket in a hospital? The one used as a teaching aid by dietitians at Theptarin Hospital is well stocked and enables them to educate patients about the importance of reading ingredients and nutritional labels.

Ms Chintana Chaturawit (Head Dietitian of the Nutrition and Dietetics Centre) gave us a detailed introduction to the food services provided in the hospital. We also attended a presentation about food science and healthy eating. The point was

driven home that as healthcare professionals, we should be living ambassadors of healthy eating and living, and that through this we would be better equipped clinicians in our daily practice.

Corporate Partnerships

Besides being a hospital for healthcare and a fitness centre for wellness, Theptarin Hospital is also a centre for education in partnership with corporate companies as allies in health promotion. We attended the ‘Nestle Hero Health’ talk, aimed at educating Nestle personnel about the importance of behavioural modification to a healthy, active lifestyle. By influencing personnel in this way, it is hoped that future marketing campaigns and product development will be positively influenced. In order to be constantly on the move physically during the session, we sat on giant exercise balls.

The power of media

Mass media allows reach to a large audience, and is a powerful tool for health promotion and education.

Theptarin Hospital punches above its weight in terms of the quality and amount of mass media material produced, and is recognized in Thailand has a leader in health promotion and education.

When I turned on the TV in my hospital guest room, I was greeted by Channel DM (Diabetes Mellitus), an in-house TV channel showing programs about healthy living, cooking, eating, and giving medical advice. The channel is a collection of TV programs that were produced by, or featured the hospital – several which were produced by the national TV station in partnership with the hospital.

How many other hospitals have a media studio? In the hospital, a dedicated media team will design, shoot, edit, and print posters and other display materials. This has allowed the hospital to enjoy economy of scale, and educational materials pepper the entire hospital including the staircase.

The power of YouTube is not overlooked either!

Theptarin Hospital has made three videos on foot care. These have been dubbed in seven languages and can be viewed on YouTube. They are also issued direct to patients on CD. Reflecting on clinical performance

Staff at the hospital constantly reflect on clinical performance and strive to improve clinical outcomes. During our visit, we were fortunate to sit in on their Medical Records Audit session. Clinical and performance indicators regarding the quality of care for patients with diabetes were stringently analysed and compared to equivalent data from hospitals abroad. The session was conducted in Thai, but we could sense the passion of the team to review these statistics, and admired their spirit of self-improvement. Such a spirit of continuous improvement should be the way forward in

From Top to Bottom

Picture 6: Mock-up supermarket in Theptarin Hospital.

Picture 7. At the Nestle Hero Health talk. All of us work-out on an Exercise Ball while listening to the session

Picture 8: Surgical reconstruction of a foot by split-tendon transfer.

Picture 9: Tenotomy was subsequently performed (3rd and 4th toe) to release the tight flexor digitorum longus.

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FEATURE ARTICLE healthcare in order to provide the best possible patient care and outcomes.

We had the pleasure of sitting-in on one of the hospital’s twice-monthly Journal Clubs, where publications of significant clinical importance are shared and discussed. I have attended many journal clubs in several institutions, but none as intense and in-depth as those in Theptarin Hospital. The session was conducted at 5pm on a Friday night over bento set dinner.

In fact, the word ‘discussed’ is an understatement. I witnessed details of study samples, methodology, analysis, and conclusions being scrutinized to the nth degree. Discussions were intense and filled with passion, showing the dedication of the team for their work. Questions were asked by many in the audience, including the junior endocrinologist, reflecting an absence of professional segregation and hierarchy when working together in team discussions. During this journal club, two papers were discussed over a period of more than 2 hours.

(Talk about dedication on a Friday night!)

Visit to Leprosy Hospital – Rat Pracha Samasai Institute

During my visit, I had the opportunity to visit a local leprosy Hospital and observe its footwear and footcare clinic. The management of peripheral neuropathy secondary to Hansen’s disease and that secondary to diabetes are largely parallel. Insights into managing the ulcers and deformities, as well as the offloading of the Leprosy-foot, can therefore be adapted for managing the diabetic foot.

From Top to Bottom

Picture 10a: Demonstration of Total Contact Casting with Metal Stirrup technique for optimum offloading of the foot. Due to the hot weather in Thailand and cost-related issues, the technique has been adapted to be cost-effective for the locals.

Picture 10b: The completed TCC with Metal Stirrup.

Picture 11: Some examples of orthotic-capable sandals designed by the footwear clinic and made by local shoemakers. Such collaborations result in a win-win situation for the local shoemaking industry and for the health service, which enjoys significant cost savings.

Picture 12: Dr Sriurai shares experience in the management of Diabetic Foot Ulcers.

18 | page

We were introduced to Mr. Somkiat Mahaudomporn, a well-respected Foot Specialist in Thailand. We were given a guided tour of the leprosy foot clinic and shown some real patient case studies as well as the surgical and offloading options offered.

In one of the cases the patient developed a spasticity of the anterior group muscles secondary to Hansen’s disease. The foot was unable to dorsiflex or to clear the ground during the gait cycle.

Surgical reconstruction was performed to convert the posterior tibia muscle and tendon into a foot dorsiflexor by splitting and inserting into the Tibialis anterior and the Peroneus brevis tendon. A rehabilitation program followed, to condition the brain to utilize the posterior tibia muscles as a foot dorsiflexor.

Another patient had bilateral clawed toes, and subsequently developed recurrent ulcerations of the apex of her 3rd and 4th toes. The high pressure on her neuropathic toes is evident on her flipflops, which showed extensive wear of the top layer. She did not respond well to conventional offloading techniques. Tenotomy was subsequently performed to release the overly taunt flexor digitorum longus

of the 3rd and 4th toes. While we did not stay in Thailand long enough to know the outcome, Mr. Somkiat highlighted that in his clinical experience, tenotomy is a safe procedure that promises better long term outcome than conventional offloading of clawed toes indefinitely. The apical ulcers often improve rapidly given that the apex are offloaded permanently.

Numerous clinical studies have verified Total Contact Casting (TCC) as the gold standard for offloading neuropathic foot ulcers. However, ulcers located on the plantar midfoot or heel have been known to be more resistant to TCC than forefoot ulcers. One novel modification is through the use of TCC combined with a metal stirrup. This technique has been found effective, and was advocated by world-renowned diabetologist Professor (Dr.) Caravaggi during his visit to my home city of Singapore several months previously.

Using this technique, a metal stirrup is added to the TCC, suspending the cast approximately 1.5 inch above the ground, and attached at the medial and lateral aspect of the upper leg, parallel to the malleoli. This allows the ground reaction force to act directly on the metal stirrup, which is in turn transferred to the calf area for weight-bearing, significantly reducing the ground reaction force acting through the foot and offloading the midfoot and heel. The foot in the TCC will hence appear to be suspended in the air. Despite being widely advocated, the practice is seldom seen in clinical practice. During the visit to the Leprosy hospital, I had the opportunity to witness the technique being used on a patient with lateral plantar midfoot ulceration.

To make the cast more comfortable, affordable for the patient, and also tolerable given the weather in Bangkok (the hottest city in the world by mean temperature), the TCC technique was carefully refined over decades by Mr. Somkiat. A total of 4 different types or brands of fibreglass cast were used on the patient below in order to fulfil its purpose as a TCC while minimizing cost. The metal stirrup is made by the clinic itself, resulting in significant cost-savings. This is definitely a technique for TCC that all podiatrists should be proficient in so as to significantly improve clinical outcomes.

Footwear and modifications

In my clinical practice, we often have to prescribe wound care shoes, offloading shoes (e.g. DARCO orthowedge, heelwedge etc.) or rocker-bottom shoes (e.g. DARCO All-purpose boot). However, such specialized footwear can be too expensive for some patients.

In Theptarin hospital (and also the Leprosy hospital), the problem of expensive imported footwear is avoided by the use of simple but effective pre-made

FEATURE ARTICLE modification devices. Simple modifications to the patient’s existing sensible shoes can easily convert them to an ‘Instant Heel Wedge, Orthowedge, or the All-purpose boots. There is even an instant Kirby skive! These modification pieces are made by the hospital’s own technicians, resulting in significant costsavings for patients.

DM Foot – Limb Protection, Wound care, and Salvation

During our first week at Theptarin Hospital, we attended a presentation by Dr. Sriurai (Endocrinologist) on the management of Diabetic foot ulcers within the hospital. The statistics that the hospital had gathered from their routine audit were impressive and included profiles of services for patients, wound healing rates, rates of major and minor amputations, limb salvation, and even statistics correlating the profile of patients and their co-morbidities with their respective prognoses for wound healing. This information allows hospital staff to monitor and reflect on clinical outcomes, and provides meaningful data for research. All wound healing techniques used in the hospital were analysed, including HBOT, Maggot Debridement Therapy and specialist wound care products (e.g. bacterial collagenase, plant-derived papainurea, fibrinolysin-dnase, skin substitutes etc.). I plan to read up on these specialist products, and import them into my clinical practice if appropriate.

Another endocrinologist, Dr. Sirinate, showed us several patients with DM foot wounds and ulcers, giving us the opportunity to observe and learn.

TCC is hailed as the gold-standing for offloading the neuropathic ulcer. Adaptations have been devised to suit individual patients based on ulcer location, body weight and climate. However, (based on my limited experience and exposure to the podiatric world) these variations are seldom seen in clinical practice, In Theptarin Hospital, I witnessed some of these variations such as TCC with Walking Heel, Removable TCC with self-adhering bandage and TCC with metal stirrup.

With regard to footwear, I was also exposed to several devices that I had not previously encountered in my clinical practice. For instance, there was a lady with an extensive gaping wound covering the entire heel and the proximal midfoot which was successfully salvaged using negativepressure wound therapy (NPWT) and Split-Skin Graft (SSG). The wound healed but the foot was essentially unsuitable for weightbearing due to the risk of the SSG site breakingdown. I was subsequently introduced to the Patellar-Tendon weight-bearing Brace (PTB Brace), which is a device that allows the transfer of ground-reaction force directly to the Patellar tendon and the calf area.

Clinical evidence shows a mean reduction of 34-

40% of heel pressure when using a PTB Brace. I realized that this is much more effective than Heel Wedge shoes or total contact inlay as an offloading device, and that there are more offloading modalities out there for me to learn about and share, for the benefit of my patients.

In my clinical practice, semi-compressed felt (SCF) padding has been routinely prescribed to offload neuropathic ulcers. In the early months of my practice, I had begun to realize how ineffective and costly this was.

While it is commonly advocated that this padding can be left up to 7 days, in my clinical experience, it tends to flatten out over 2 to 3 days, rendering it useless for offloading. New padding then has to replace the old, resulting in the significant use of SCF padding over the months of wound healing.

SCF padding does not come cheap. The cost and the irreversible flattening of SCF padding made me wonder, back in 2011, whether there was another material that could be used. Is there something cheaper that would not flatten out, and would maintain the cushioning and antishear properties of semi-compressed felt padding? I found the answer in Theptarin Hospital – the Felted Foam, and the Foam-only technique.

In the Felted Foam technique, a ‘Foam’ (either a Rubber Foam, Polyurethane Foam, or Lowdensity EVA) of more than 0.6cm thickness is used for its shock-absorption and its durability. A thin semicompressed felt is adhered to the foam for its antishearing property. This combination is an offloading padding that can be used over several weeks.

Over the years, the clinicians at Theptarin Hospital have adapted to a Foam-only technique. Given Thailand’s status as a significant footwear manufacturer, a number of varieties of foam used in shoe-making are available, making the Foam technique much cheaper compared to the SCF padding technique.

Simple, effective, affordable, durable, and easily available locally: this is the beauty of this offloading technique when used in Thailand. During our stay we had the opportunity to practice offloading techniques on each other.

From Top to Bottom

Picture 13: Learning from Dr. Sirinate on the management of wounds

Picture 14: TCC with Walking Heel at forefoot and rear foot to offload a Charcot midfoot neuropathic ulcer.

Picture 15: Rubber foam used in offloading.

Picture 16: Dr. Sirinate and nurse communicating with me. In a hyperbaric chamber.

Other simple offloading techniques include the use of their ‘instant Kirby skive’ in an alternative way – proximal to the 5th MPJ, creating an instant offloading padding. Within the foot clinic, they also have a Podoscope – a device for plantar analysis of the feet and pressure areas.

Surgical methods

During another presentation, we were introduced to several surgical techniques to prevent foot ulcers or to improve functions. Notable mentions include Achilles Tendon lengthening, complete Achilles

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FEATURE ARTICLE Tendonotomy, and split tendon transfer.

Tenotomy of the flexor digitorum longus tendons for patients with apex ulcers of the toes was particularly highlighted and practiced by the endocrinologist themselves.

We were shown how the procedure can be performed bedside within 10 seconds – no anaesthesia is required as these patients have neuropathic feet. It is reported that complications are rare – the worst so far being a case of subcutaneous hematoma.

I will consider exploring tenotomy as an option for some of my patients with apex ulcers, instead of using toe-props indefinitely.

Hyperbaric Oxygen Therapy (HBOT) is the use of oxygen delivered at several times above atmospheric pressure in order to increase the plasma oxygen saturation. It is believed that this increase in blood plasma oxygen saturation will enhance angiogenesis at micro vascular level, which in turn is essential for tissue granulation.

While HBOT is commonly discussed in literature as an adjunct to assist wound healing, I have yet to experience the therapy personally. In Theptarin Hospital there is an HBOT department offering patients with impaired microcirculation treatment to improving wound healing. I was very glad to have the opportunity to experience HBOT first-hand, including initial assessment, briefing and treatment.

Being in a hyperbaric chamber does not feel good – the claustrophobia, the gradual increase in air pressure which you can feel in your ear (vestibular pressure) added to potential concerns about whether the treatment will assist healing. Now that I have ‘been there, done that’, I will be in a better position to share my experience with patients the next time I refer them for HBOT.

International Exchange of Ideas

On numerous occasions while at Theptarin Hospital, we were able to take part in sessions to share knowledge and so learn from others.

During the first week we attended a case discussion session with Dr. Sirinate (Endocrinologist and Head of HBOT) sharing challenging cases in Theptarin Hospital, and discussing our opinions and local management plans.

This was the first of several DM foot case discussions during which challenging case studies were examined. Ideas were shared between the entire international team according to our local management style and techniques. The team consisted of the Indonesian endocrinologists, Thai endocrinologists and podiatrist, Jamaican foot care specialist, Bhutanese Nurse Educator and me – each of us sharing the practices, challenges and limitations of our own local settings.

I was honoured during part of one sharing session to present to the group on my role as a podiatrist in a hospital in Singapore. Many countries do not have a podiatry service and so lower limb problems are managed by endocrinologists, wound nurses and other healthcare professionals. In my view the most important aspect of a podiatrist’s role is in time and cost savings for a country’s health service.

During the second week I had the opportunity to share some of my challenging cases involving tendon preservation, artery preservation, freeflaps, pedicle flaps, skin grafts, bone debridement etc, and to request expert opinions from the team on optimum management.

Overall, the many opportunities I had to share with a panel of international experts and learn from their experiences were humbling and invaluable.

Many of us left with ideas on how to improve services back in our home countries. Amongst many other issues, we discussed the best way to identify those at risk of diabetes and pre-diabetes bearing in mind that BMI standards

20 | page

are less helpful for Asian populations than Caucasian ones due to genetic differences. People of Asian (especially East Asian origin) can have normal BMI but still carry very high levels of visceral fat. One of the well-researched methods for determining cardiovascular and diabetes risk factor using level of visceral fat as a proxy instead of BMI itself was discussed: 1) Measure height (e.g. 170cm)

2) Divide by 2

3) The waist should not exceed this number (i.e. 85cm)

This method will be especially helpful for Deeki, the Bhutanese nurse educator, who can now simply carry a length of rope for measuring purposes throughout mountainous villages, and need not carry scales and measuring tape.

(Deeki’s dream is to improve diabetes care in her district, and to set up services for foot protection, wound care and limb salvation. In order to help her, Dahlia and I spent time assisting her with the basics of diabetes limb care – discussing with her: anatomy, pathophysiology of diabetic limb complications and their management protocols. In addition, we assisted her with learning basic nail clipping and callus debridement. Dahlia also gave her a pocket-size monofilament to help her start the first diabetic limb care and screening program in Bhutan!)

BeMo Program

It is of limited value if we preach about the importance of health protection without actually living healthily ourselves. It is important that health professionals lead healthy and active lifestyles, ‘walk the talk’ and become living testimonials of the benefits of healthy living.

In Theptarin Hospital, all of us were put through the BeMo Program (Be Motivated/ Behavioural Modification) to help us become living testimonials!

We were shown the MEDE Lifestyle Solutions and Fitness Club – consisting of a swimming pool, gym, fitness classes, and spa sanctuary, and our physical fitness was assessment by a Physiotherapist. A full Body Composition Evaluation was also undertaken for each of us, which revealed percentage of body fat, visceral fat deposition, muscle mass etc.

These reports were then evaluated by a dietitian and the results were quite unexpected in some cases. For instance, despite having a healthy BMI, my percentage body fat was found to be above normal level and my muscle mass to be slightly low. In addition, my fats were primarily visceral fat – which is a significant risk factor for cardiovascular diseases and pre-diabetes. In order to make the fullest use of my stay in Theptarin Hospital, I decided to utilize its facilities, and kick-start my journey to a healthier me.

I began swimming, lifting weights and running in the gym. The abundance of fruits and salad everywhere in Thailand made healthy eating much easier too. I also increased my water intake to healthier level. (Distilled water is made readily available in Theptarin Hospital, which made this much easier.)

By the end of my stint at Theptarin Hospital, I was glad to have lost 2.5 kilograms, which I think is a modest success. For my long term plan, consistency is the key. To date, I have been eating healthily and exercising regularly. I am working towards a healthier me, with my physical indicators improving towards the optimum. By walking-the-talk, I hope to be a testimony to healthy living, and an ambassador for health promotion.

I would like to thank Cosyfeet for making my learning journey possible, and to dedicate this report to those who want to keep the world healthy, happy and walking.

Henry Lee

PRODUCT REVIEW

Body Block

Stephen Willey, Sheffield Branch I was asked if I would test drive the new Body Block. “Body Block?” I responded “What exactly is a Body Block? ”

I was handed a squidgy purple oblong! Hmmm……. Looked very uninspiring, I thought, but without too much pressure I promised to take it with me on any domiciliary visits and to present my findings at the Sheffield branch seminar.

My first thoughts were; it was bulky and well just another additional piece of equipment to carry about! Nonetheless, a promise is a promise and I took ‘my task’ seriously.

I could not have been more wrong. I only wish I had invented it!

Such a simple device which lifts the foot into just the right position and which is much more comfortable for the patient. My patients seemed to love it especially the colour! It was also a good talking

point. There are different heights on each of the sides too, not just a single height for every job. Another plus is that the Bodyblock is hygienic as it can be easily sprayed between visits and can be autoclaved. It is also very versatile as it can be used to support the head or arms. I know that some of you reading this will probably say that a role of Cresco will raise the foot but the block looks more professional and it’s also a big saving on the back and neck which has always been an occupational hazard for domiciliary work.

I was interested to know the price and found out that they are only £34.00 each.

I cannot think of anything negative to say about the Body Block – the only thing I can suggest is ‘try it and see’.

Don’t keep it to yourself!

We welcome any product reviews from our readers.

If you are using a product you think others may benefit from then please share. Similarly if you find something doesn’t

work as anticipated then let others know! Please send either on email to bernie@iocp.org.uk or by post to the Editor at 150 Lord Street, Southport, Merseyside PR9 0NP

The Members’ Emergency Benevolent Fund

The Board takes the opportunity to thank everyone who has made donations to our Benevolent Fund in the past and for future ones.

Without your generosity, the Institute would not be able to provide this invaluable support to its members. This year, Head Office received three applications, two of which were successful.

Anyone who encounters severe financial hardship and worry as a result of an accident or illness is eligible to apply. Please do contact, Bernie at Head Office. All applications are evaluated by our benevolent fund panel.

Michele Allison North West Area Council Delegate page | 21

INFORMATION ARTICLE

The role of the geko™, a portable electrical stimulation device, in the podiatric management of patients with diabetes Tom Wainwright PgDip PgCert BSc (Hons) MCSP SRP Tom is a Physiotherapist and works as a Clinical Researcher at The Royal Bournemouth Hospital. He is currently a coinvestigator in research to evaluate the geko device (ClinicalTrials.gov identifier: NCT01935414). In the past he has completed consultancy work for Firstkind Ltd.

People with diabetes commonly seek relief for painful feet from podiatrists. The diabetes disease process can lead to problems with circulation, nerves, muscles, joints, and also predispose patients to infections. This article will outline how diabetes can lead to circulatory problems in your lower legs and feet, and introduce the potential role for incorporating the gekoTM device into treatment pathways for these patients.

Decreased circulation in your feet can cause intense pain, even when the feet may feel numb to the touch. Pain can be caused by the effect of high blood sugars on the arteries, capillaries and veins. Blood travels away from the heart through arteries, and this oxygenated blood is delivered to the tissues. The blood enters and leaves the tissues through capillaries and returns to the heart through veins.

The arteries behind the knee and the calf are commonly affected, because the deposit of fatty deposits within these vessels is accelerated in people with diabetes. The fatty deposits thicken the walls of the arteries, and calcium deposits may develop. This inhibits oxygenated blood flow to the feet, either partially or totally. The tissues in the foot are therefore deprived of oxygen, causing ischemia, which can be extremely painful.

Patients often report this pain by describing that it feels like their feet are being strangled in a vice.

The capillaries can also become thickened and stiff from the diabetes disease process, and so microcirculation can be adversely affected, leading to the inefficient delivery of oxygen and nutrients to and from the tissues.

The veins can become swollen and painful. This occurs when the arteries become sufficiently blocked that they can no longer handle the blood flow. Small channels are created to direct the blood from the arteries over to the veins, this occurs when blood is unable to be pushed through the closed arteries. This means that sometimes there is more blood than the veins can handle.

In these cases, they become so full that the one-way valves within the veins become broken. Consequently, blood then pools in the feet and legs, causing oedema and in some cases creating 22 | page

ulcerations, which can be very painful.

Improving circulation

There are a number of options for improving circulation that a podiatrist may recommend and these traditionally include the use of compression stockings, exercises, massage, and medications. However, the gekoTM device now offers another option. Powered by OnPulse™ technology, the non-invasive geko™ device triggers the body's built in mechanisms to increase blood circulation. The device uses small electrical impulses to gently stimulate the common peroneal nerve, which in turn activates the muscle pumps of the lower leg that return blood towards the heart. It is a simple, self-adhesive device that is applied behind the head of the fibula, and is a disposable, onesize-fits-all device designed for maximum mobility and ease of wear.

The gekoTM device has previously been proven to increase blood flow and microcirculation (A.T.Tucker et al. Int. J. Angiol.

2010; 19 (1); e31-e37) within the lower limb, and it clearly has major theoretical potential for increasing the rate of ulcer healing by its ability to increase blood flow through the lower limb.

Clinical case studies in patients with diabetic ulcers have confirmed this potential; highly significant and impressive rate of ulcer healing have been described when using the gekoTM device.

Implications for practice

Podiatrists should consider the geko™ device for use

• In the treatment of lower leg and foot ulcers.

• In the treatment of oedema where the podiatrist feels there may be a therapeutic benefit in improving blood flow

AWARENESS DAY

Did you know there are 27 million slaves in the world today?

International Day for the Abolition of Slavery

2 December 2013

Living in a modern society, it's disturbing to think that slavery by the General Assembly, of the United Nations Convention for is still happening in other parts of our world. So what are the the Suppression of the Traffic in Persons and of the Exploitation reasons to abolish slavery? No one should be treated unfairly to of the Prostitution of Others (resolution 317(IV) of 2 December suit the advantages of others but slavery and capitalism go hand 1949). in hand. Forced labour, awful forms of The focus of this day is on eradicating child labour, and human trafficking take "Today, governments, civil contemporary forms of slavery, such as place in poorer parts of the world. It seems society and the private sector trafficking in persons, sexual exploitation, a million miles away from where we are but the worst forms of child labour, forced one million kids a year are pushed into must unite to eradicate all marriage, and the forced recruitment of acting as slaves, many for sexual contemporary forms of children for use in armed conflict. exploitation.

So what are people doing to help turn things around? The online and print media promote the day through news, debates and forums. Flyers and newsletters are put up in public places like universities, where students will learn about the negative impact of slavery on people and society.

slavery. ... Together, let us do our utmost for the millions of victims throughout the world who are held in slavery and deprived of their human rights and dignity."

The United Nations (UN) is committed to fighting slavery and using International Day

Secretary-General Ban Ki-moon Message for the International Day for the Abolition of Slavery 2 December 2012

for the Abolition of Slavery to raise awareness on the subject.

The International Day for the Abolition of Slavery, 2 December, marks the date of the adoption,

Today, 21 million women, men and children are trapped in slavery all over the world.

The International Labour Organization (ILO) has teamed up with prominent artists, athletes and advocates in its new campaign to End Slavery Now. In 2007 the UN marked the 200th Anniversary of the Abolition of the Transatlantic Slave Trade on 25 March. In 2008 the International Day of

Remembrance of the Victims of Slavery and the Transatlantic Slave Trade became an annual observance.

ACPU AWARD

Applications are invited in the form of

a dissertation of between 3,000 and

3,500 words on a subject connected

with chiropody/podiatry. They will be adjudged by the ACPU Award

Committee and the winner will be awarded a monetary prize at the

Awards Ceremony at the end of the

Annual Conference of the Institute

being held in Southport.

Applications must arrive no later than

31st January 2014 and must include

the name and address of the author.

page | 23

OBITUARY

Isabel Barr 1952 – 2013

I first met Isabel in 1989 when she started training at the ‘Alec Cumming School of Chiropody’ in Paisley. When she qualified in 1991, she set up a very successful practice in her home in Bothwell and a domiciliary one in the Hamilton area.

At this time, a few of us who had trained at the Paisley school were approached by the English Association of Chiropodists with a view to setting up the first Association branch in Scotland. Isabel and I were two of the six founder members of this new branch with more and more newly qualified chiropodists joining us. In the early days we met in a Stirling pub on a Sunday where the smell of stale beer and smoke from the night before was pretty overpowering! Isabel became the Association’s National Secretary for a few years and for this work she was awarded a Fellowship.

After attending a turbulent Association AGM down south with Isabel, we suggested to our then, twenty nine members, that we should consider joining the Institute of Chiropodists and Podiatrists.

On Sunday 12th October 1997, the inaugural meeting of the West of Scotland branch with Mr Robert Cleary from the Institute of Chiropodists and Podiatrists observing took place. Isabel was the first branch secretary – a job she did well and willingly for a number of years. We had great fun attending every AGM together.

In early 2001, it was noticed that all was not well with Isabel and after hospital tests she was told that she had alzeheimers; early onset dementia. In her true style she said she would fight this illness all the way – and she did. She never mentioned that word again! As time passed the illness took hold and on 16th August she sadly slipped way.

My condolences go to her husband, William; daughter, Alison; son-in-law, Stephen and her grandsons David and Jamie.

May you rest in peace Isabel

Ann Yorke West of Scotland Branch

Alzheimer’s Disease Alzheimer's disease is the most common cause of dementia, affecting around 496,000 people in the UK. The term 'dementia' describes a set of symptoms which can include loss of memory, mood changes, and problems with communication and reasoning.

These symptoms occur when the brain is damaged by certain diseases and conditions, including Alzheimer's disease

Alzheimer's disease, first described by the German neurologist Alois Alzheimer, is a physical disease affecting the brain. During the course of the disease, protein 'plaques' and 'tangles' develop in the structure of the brain, leading to the death of brain cells. People with Alzheimer's also have a shortage of some important chemicals in their brain. These chemicals are involved with the transmission of messages within the brain.

Alzheimer's is a progressive disease, which means that gradually, over time, more parts of the brain are damaged. As this happens, the symptoms become more severe.

24 | page

People in the early stages of Alzheimer's disease may experience lapses of memory and have problems finding the right words. As the disease progresses, they may:

• become confused and frequently forget the names of people, places, appointments and recent events • experience mood swings, feel sad or angry, or scared and frustrated by their increasing memory loss

• become more withdrawn, due either to a loss of confidence or to communication problems

• have difficulty carrying out everyday activities - they may get muddled checking their change at the shops or become unsure how to work the TV remote.

Further information can be obtained at www.alzheimers.org.uk Helpline 0300 222 11 22

HEALTH NEWS

Whether it’s at school, at work or in social settings, people with autism are often misunderstood.

NHS Choices

They suffer discrimination, intolerance and isolation. For many, that means a lifetime of exclusion from everyday society.

In an attempt to understand the reasons behind this, The National Autistic Society commissioned research into levels of awareness and understanding of autism among the public. It published a report on its findings in June 2007. Overall, the research shows that awareness of autism is high but there’s a lack of understanding about what it really means to live with autism. The National Autistic Society knows from experience that this has a negative effect on people with autism and their families. The research also shows that people think more positively once they know a person has autism. But there’s a significant gap between those good intentions and the reality experienced by people living with the condition.

Of those surveyed, 92% had heard of autism but far fewer had heard of Asperger syndrome (only 48%). Asperger syndrome is mostly a hidden disability. This means you can't tell that someone has the condition from their outward appearance.

While there are similarities with autism, people with Asperger syndrome have fewer problems with speaking and are often of average or above-average intelligence. They do not usually have the accompanying learning disabilities associated with autism, but they may have specific learning difficulties. These may include dyslexia, dyspraxia, attention deficit hyperactivity disorder (ADHD) or epilepsy.

Respondents were asked how many people they thought were affected by autism.

The majority (90%) didn’t know how common it is.

There are more than half a million people with autism in the UK. That's one person in every 100.

• 92% have heard of autism • 90% don’t know how common it is • Two in five know there is no cure • One in five think most people with autism have special abilities • Three-quarters don't know that Asperger syndrome is a form of autism Many people correctly identified some of the key characteristics of autism, including difficulty communicating, difficulty making friends, love of routine and obsessive behaviour.

However, some other common characteristics, such as the need for clear and unambiguous instructions, being disturbed by noise and touch, and having difficulty sleeping, were less well known. Ten per cent of people thought autism was not a disability.

More than a third of respondents (39%) thought most people with autism have special abilities, for example in maths or art. In fact, it’s estimated that only one person in every 200 with autism has special abilities.

More than a quarter (27%) of those who had heard of autism mistakenly thought that it mostly affects children. A child with autism grows up to be an adult with autism.

There was considerable confusion about whether autism can be cured. Less than half (only 39%) were aware that there is no cure. Although there is no cure, access to the right help and support can greatly enhance the lives of people with autism.

A representative sample of more than 2,000 adults aged 16 and over was surveyed across 175 sites in England, Wales, Scotland and Northern Ireland. The report can be viewed on Think differently about autism. www.autism.org.uk. Additional information www.nhs.uk

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HEALTH NEWS

Cosyfeet Award Winner is Research High Flyer

Dr Gwen Fernandes, who won the Cosyfeet Podiatry Award in 2007, will head up a new clinical research project aimed at helping professional footballers.

Based at Nottingham University, in the department of Academic Rheumatology, the project is focussed on identifying the risk factors of hip, knee, foot and ankle arthritis in current and retired professional footballers. The project is made possible by funding from Arthritis Research UK and Gwen will be working with both FIFA and the University of Oxford in the course of her research.

“Professional footballers are prone to arthritis due to the intensity of the sport they play over a prolonged period of time.

They are more likely to develop early onset osteoarthritis of their knee joints, for example, compared to the general population,’’ says Gwen. “The results of our study would establish the prevalence of osteoarthritis in a professional footballer population and identify the key risk factors involved. This would allow us to better direct and inform training, rehabilitation and overall preventative strategies in the future.”

Back in 2007, Gwen used her award funding to volunteer in wound care clinics with diabetic patients in Ghana.

“Winning the Cosyfeet Podiatry Award allowed me to do something that I’d always wanted to do,” says Gwen. “Ghana is a country of such interesting cultural diversity and I felt that building my knowledge and sharing evidence-based practice with the Ghana Diabetes Association would be integral to my training as a Podiatrist”

h Be a Volunteer at C

While completing her BSc degree, Gwen realised that she was well-suited to the systematic analysis and tenacity required of a clinical researcher. She graduated from Cardiff in 2008 and applied for PhD funding, with the Research Capacity Building Collaboration (RCBC) Wales, while working in her native Bahrain. Being only 21 at the time, she was uncertain that her application would succeed.

Gwen was delighted to be granted her PhD funding in early 2009 and went on to conduct research into the lower limb biomechanics of people with medial knee osteoarthritis. This research project included a randomised control trial to determine if modified laterally wedged orthoses could relieve pain in patients with arthritis of the knee. The results, obtained rigorously over 3 ½ years, were positive and are now being written up for publication.

For more information on the Cosyfeet Podiatry Award contact Katie House katieh@footshopltd.co.uk

ristmas

New Socks for Crisis Guests

Cosyfeet will donate 500 pairs of socks to Crisis at Christmas guests from 23rd to 30th December this year. The socks will be offered to users of the volunteer podiatry service provided over the Christmas period.

Crisis is a national charity for single homeless people. At Christmas the charity provides companionship and support to alleviate loneliness and isolation, and to help people to take their first steps out of homelessness.

“Crisis are always looking for donations of socks as well as all sorts of other food and clothing for use during the Christmas week,” says Cosyfeet’s Katie House. “We’re delighted to be able to help.”

Cosyfeet make a wide range of socks including extra-roomy and seam-free socks for those with swollen or sensitive feet, complementing the company’s range of extra-roomy footwear.

Crisis at Christmas welcomed over 3000 guests in 2012, around 350 of whom benefitted from the volunteer podiatry service.

The charity is always looking for podiatrists to volunteer over the Christmas period. For further information, contact the Crisis at Christmas volunteering team on 0844 892 8980 or visit the Crisis website www.crisis.org.uk/volunteering

26 | page

HEALTH NEWS

New standard could improve diagnosis rates of inherited cholesterol condition National Institute for Health and Care Excellence (NICE) A new quality standard for familial hypercholesterolemia (FH)

could help healthcare professionals identify more cases of a condition often dubbed a ‘silent killer', says NICE.

FH is an inherited condition caused by an alteration in a gene

which results in a high cholesterol concentration in the blood.

This can lead to the early development of atherosclerosis and coronary heart disease.

Raised cholesterol concentrations are

often unaware that they have the condition.

An audit of nearly 2,500 patients conducted by the Royal

College of Physicians in 2011 found that very few relations were being screened in the UK, especially in England.

The quality standard recommends that people with a clinical

diagnosis of FH are offered DNA testing as part of a specialist

present from birth and lead to early development of

assessment. This increases the certainty of a diagnosis of FH and

transmitted from generation to generation in such a way that

through cascade testing.

atherosclerosis and coronary heart disease. The condition is

siblings and children of a person with FH have a 1 in 2 chance (50:50 risk) of also having FH.

Most people with FH have

inherited an altered gene for FH in an autosomal dominant

pattern from only 1 parent and are therefore 'heterozygous'.

Occasionally, a person will inherit an altered gene from both parents and will have 'homozygous' FH or 'compound

allows the identification of affected and unaffected relatives A statement on cascade testing is included in the quality

standard. This recommends that relatives of people with a confirmed diagnosis of FH are offered DNA testing through a nationwide, systematic cascade process.

The quality standard also calls for healthcare professionals to

heterozygous' FH. Homozygous FH is rare, with an incidence of

ensure that all patients with FH are offered a structured review

The prevalence of heterozygous FH in the UK population is

and adjusted to achieve the recommended LDL-cholesterol

approximately one in a million.

estimated to be 1 in 500, which means that approximately

120,000 people are expected to be affected [1]. However, more

than 80% of these are currently undiagnosed and untreated. If

left untreated, more than 50% of men with heterozygous FH will

develop coronary heart disease by the age of 50 years and more

than 50% of women by the age of 60 years [2]. Life expectancy is

restored to near normal with early preventive treatment,

at least once a year, as this enables treatment to be monitored

concentration.

It also enables monitoring for the possible development of

symptoms and signs of coronary heart disease and optimising

management. Records can then be maintained of affected family

members and information can be tailored to individual circumstances. Progress with cascade testing of at risk relatives

particularly statin treatment and smoking cessation.

can also be monitored.

identifying those at risk of inherited conditions like FH in its

diagnosing children under 10, and on drug treatment in adults

The Department of Health acknowledged the importance of

Elsewhere, the quality standard makes recommendations for

cardiovascular strategy published in March this year.

and in children.

identification and management of heterozygous FH, based on the

quality standard and Group Medical and Scientific Director at

The quality standard sets out eight statements to improve the

NICE guideline on FH.

Dr Rubin Minhas, Chair of the group that developed the FH

Nuffield Health, said: “This new quality standard will help doctors

It calls for all adults with a total cholesterol above 7.5 mmol/l

to identify the hidden cases of FH. While a number of audits have

greater identification of FH and support cascade testing of their

lack of family cascade testing within families of known FH cases.

Cascade testing is important as half of all people with FH will

can receive early treatment and lifestyle changes which can help

to be assessed for the clinical diagnosis of FH. This will result in relatives.

have a first degree relative that will be similarly affected but are

shown that diagnosis rates are low for this condition, there is a

“Identifying patients with FH is crucial to ensuring that they

to lower the risk of heart disease and improve life expectancy."

page | 27

BRANCH NEWS

28| page

BRANCH NEWS

Sheffield Branch Seminar Sunday 22nd September 2013

Travelling over the Pennines on a beautiful warm sunny Sunday morning at 8 a.m. I did question my sanity! I was off to spend it ‘indoors’ at the Sheffield Works Department Sports and Social Club on Heeley Bank Road, attending Sheffield Branch’s seminar. I needn’t have queried my decision; Debbie Straw, branch secretary and Penni Hardy, branch chair had put together another amazing day of lectures and socialising. These events are never easy to organise but full marks to Sheffield Branch.

On arrival coffee tea and biscuits were provided by the venue, while Mark Lawrie from D. L. Townend, Son and Sandy provided the trade stand.

Delegates had ample opportunity to discuss products and ‘grab’ bargains; many at reduced prices.

Mandy Plant, Matron of renal services at Sheffield’s Northern hospital, kicked off the lectures with a very interesting and informative discussion regarding renal failure and the treatments available. She also touched on the very sensitive subject of organ donation.

Despite advancement in dialysis and the ability to be able to carry this out at home, transplant is still by far the most effective. Not that you will be unaware of this but…. the kidneys are located on each side of the body, just beneath the ribcage.

Their main role is to filter waste products from the blood before converting them to urine. Damaged kidneys lose this ability and waste products can build up and be potentially life threatening.

Unlike the heart and liver a person only needs one kidney to survive. Therefore, a living person can donate a kidney. It doesn’t have to be a close relative but receiving a donation from a close relative means there is less risk of the body rejecting the kidney.

Mandy stressed how important it was for anyone who is thinking of organ donation (after death) to inform their family and register their interest. Many people do not get round to ‘opting-in’ which is why a system of ‘opting-out’ may be the way forward.

and decisions of vulnerable older people in relation to keeping warm in winter.

For this they choose 50 people over 55 in Rotherham in South Yorkshire. Most chiropodists could identify patients in this category who may be ‘at risk’. I will try to include the full study in a future issue of Podiatry Review.

Following the two morning seminars there was a final opportunity to stock up supplies with Mark followed by a delicious hot and cold buffet washed down by a glass of wine or a beer as well as soft drinks and teas and coffees.

Our final lecture was by a vascular specialist nurse, Hazel Trender who explained the symptoms and diagnosis of peripheral artery disease (PAD) and the part chiropodists play in checking for and managing patients with PAD.

For those of you who feel you would not benefit from attending branch seminars, you could not be more wrong! Chiropodists in the private sector can feel very isolated. The subjects always bring something else to ponder or a different approach to what you already think you know. It is not all about learning, however, it is about socialising with your peers, picking other people’s brains, stocking up on supplies. From the HCPC perspective they are excellent opportunities to obtain CPD, at very little cost. For these three lectures plus lunch and refreshments throughout – the cost was a mere £50.

Once again I would like to thank Debbie and Penni for their efforts. Remember they do it all for your benefit, in their own time, without any monetary reward.

Bernadette Hawthorn Head Office

Our second lecture was by Professor Angela Tod of Sheffield Hallm University. Angela has been pivotal in carrying out a study connecting the elderly and cold with ill health. The objectives of Angela’s study were to understand the influences

page | 29

BRANCH NEWS

30 | page

BRANCH NEWS

Western Branch Linda Pearson

Sunday 22nd September brought another fully packed afternoon for members of the Western Branch The first presentation was by Catherine Brown, a Nurse from NHS Blood and Transplant Donation in Liverpool, which tackled difficult issues such as how consent was gained, also the strict procedures, guidelines and criteria which had to be met.

After a short break, with Trade shows from Chiropody Express and Advancis Medical in attendance we reconvened with an interactive presentation and open discussion on "Sterilisation and

good practice" from David Thomas MDS Medical.

To finish off the afternoon Gemma Glenn from Advancis Medical gave a hands on interactive session with Honey Dressings and discussed with members questions on the subject.

The next Western branch meeting is on Sunday 12th January 2014. There will be a presentation/lecture which will be confirmed soon.

‘Tales of the unexpected’ by anonymous.

Whilst undertaking our practical training, our tutors told us students of events that had happened to them. They also warned us of things that we were likely to experience and we did not believe them. How wrong we were!

On the day of my examination there were raised voices in the waiting room. A client had become agitated. She could not be consoled.

Then ‘Sods Law’ prevailed and the somewhat vocal client ended up in my chair. I thought that I could use my charm to calm the client, and bring her blood pressure down. I was very wrong. The ‘volcano’ continued to erupt. Her local bank manager had annoyed her! She had an array of letters, and bank statements in her hands which she proceeded to wave about in a frantic fashion whilst using superlatives not included in the dictionary. She would not put her papers down but held them in an iron grip, and ordered me to remove her shoes and stockings. However she refused to remove her coat and hat despite the ‘heat wave’. Then, half way through the treatment she sought to test my abilities as a contortionist. She wanted me to take her coat off, but she insisted in remaining in a sitting position and still holding the offending documents in that vice like grip. This proved to be a two woman job with the examiner assisting me. We eventually succeeded by using techniques not in the chiropody manual but conforming to Health and Safety Regulations.

In another case, involving a home visit, I received a call from a client who had a sore toe which I considered might be an ingrowing toe nail. When I arrived at the house there was nobody in and a neighbour invited me into her home. She informed me that my client had gone to Mass. The client duly arrived 15 minutes late, and then proceeded to tell me that she had gone to pray for the success of the treatment. I then started to wonder if she had any faith in my ability as a

chiropodist? However the problem continued. Having set up my equipment and sprayed her feet I was ready to start the treatment. She then asked me to wait a moment whilst she went out of the room to get a bottle of ‘Holy Water’. On her return she poured the contents over her sore toe and produced her rosary beads, whilst reciting the Hail Mary and simultaneously smoking a cigarette. I then found it difficult to see, working in a smoke cloud.

She stopped after a while to say that I was not saying very much. I replied that I did not want to disturb her prayers. I am not sure whether it was the Mass, the Holy Water, her praying or my treatment that should take the credit for a job well done. I assume it was well done since she did not contact me again. Perhaps there was another reason? However, all the asking for Gods help with the chiropody treatment did nothing for my confidence as a newly qualified.

There are numerous funny incidents that happen during chiropody treatments. One domiciliary client asked me why I did not bring a proper chiropody chair with me. Another client called me back to say that I had broken her adjustable chair when I had never used it. She called in the repair man who said that she was always doing this and for me not to worry about the chair.

Lastly the daughter of an elderly client told me off for walking across her very expensive carpet. I felt I should have explained I had left my ‘hover mode’ at home that day but this would not have been the correct response!

You will not be surprised to hear that I now have my own clinic, and do very little domiciliary visiting. Perhaps I will have more success in the clinic. Here’s hoping! page | 31

DIABETES NEWS

Revealed: the area where 10% of people have diabetes A new analysis of the highest diabetes rates in England has revealed that there is now an area, Brent in London, where over 10 per cent of people aged over 16 have diabetes.

According to the list of the 10 areas in England with the highest rates of the condition, published today (Monday) by Diabetes UK, 10.5 per cent of people in Brent have the condition. This is almost double the rate in the City of London (5.5 per cent), which has England’s lowest rate despite being just three miles from Brent.

As well as Brent, the other areas with the highest rates in England are: Newham in London (9.9 per cent); Wolverhampton (9.6 per cent); Harrow in London (9.4 per cent); Sandwell (9.4 per cent); Leicester (9.3 per cent); Walsall (8.8 per cent); Blackburn with Darwen (8.7 per cent); Redbridge in London (8.7 per cent); and Birmingham (8.7 per cent).

While Brent is currently the only area with a rate of over one in 10 people have the condition, six other areas are projected to join it by the end of the decade. Nationally, 7.4 per cent of people aged over 16 are now thought to have diabetes and this is projected to rise to 8.4 per cent by 2020. This rise is expected to comprise mainly of new cases of Type 2 diabetes, where risk factors include being overweight; having a large waist; being over 40 (or over 25 if they South Asian); or having a close relative with diabetes.

Diabetes UK has responded to the news by urging people to make sure they know the risk factors for Type 2 diabetes and have a risk assessment if any of these apply to them. People can do this at a pharmacy, their GP surgery, or online at www.diabetes.org.uk/risk and this can act as the start of people reducing their risk; 80 per cent of cases of Type 2 could be delayed or prevented through making healthy lifestyle changes.

The charity is also concerned that many people wrongly think diabetes is a relatively mild condition and so do not see the need to find out more about their own risk, whereas in fact it can lead to devastating health complications such as blindness, amputation,

stroke and heart attacks, and ultimately to early death. This is why Diabetes UK is currently running a hard-hitting advertising campaign, which it is funding through its National Charity Partnership with Tesco, to highlight the possible consequences of having Type 2 diabetes, including the devastating impact it can have on people’s families.

Barbara Young, Chief Executive of Diabetes UK, said: “It is truly alarming that there is now somewhere in England where more than one in ten of the people have diabetes and shows that we are heading at frightening speed towards a future where diabetes becomes the norm.

“Given that the increase in diabetes cases is mainly due to a sharp rise in Type 2 diabetes, the only way we will finally bring the increase under control is by getting much better at preventing cases of Type 2. A vital first step towards this is to ensure both that people realise how serious it is and also that they understand their own personal risk so that if they are at high risk they can make the simple lifestyle changes that can help prevent it.

“This is why we need to raise awareness that if people are overweight, have a large waist or are over 40, they need to get a risk assessment, as should people who have a family history of diabetes or are South Asian and over 25.

“I know that we all have busy lives and that thinking about future health can be uncomfortable, but it is only if people grasp the nettle and get their risk assessed that we can avoid a future where there are many areas where one in 10 of the population have diabetes, and the devastating health complications associated with it.”

Type 2 diabetes accounts for about 90 per cent of diagnosed diabetes cases. About 10 per cent of cases are Type 1 diabetes, which tends to occur in younger people and is not linked to lifestyle or weight at all. The estimates for the number of people with diabetes in 2012 and 2013 come from official figures produced by Yorkshire and Humber Health Intelligence.

Could Carrots Help Prevent Type 2 Diabetes From; Behind the Headlines They say

The Express reported in January that scientists found that the vegetable is packed with potent health-boosting antioxidants that seem to prevent Type 2 diabetes.

We already know that eating a healthy, balanced diet and keeping to a healthy weight are key to reducing the risk of Type 2.

32 | page

However, the new findings shed light on the interaction between our genes and the content of the foods we eat and their impact on our risk of developing this condition.

Researchers from Stanford University in California found that, in people with particular common genetic variations, high blood continued on next page

DIABETES NEWS from previous page

levels of beta carotene, which the body converts to a form of vitamin A, might lower the risk of Type 2 diabetes.

They also found that high levels of gamma tocopherol (the major form of vitamin E in the diet, found in vegetable oils, nuts, seeds and wholegrains), might increase the risk of Type 2.

The research, published in the journal Human Genetics, focused on the interactions that occur between the specific genetic variations found in different individuals and blood levels of key substances that have previously been linked to an increased risk of Type 2.

On their own, none of the genetic factors showed an impressive impact on Type 2 risk.

But when paired with the antioxidants, there were significant results. In people carrying a double dose of a specific variation (in the gene SLC30A4), which is known to increase the risk of Type 2, researchers found clear links between high blood levels of beta carotene and a reduced risk of Type 2. Whereas, the variations combined with high blood levels of gamma tocopherol were

linked to an increased risk of the condition.

These findings highlight the need for further studies to find out if beta carotene and gamma tocopherol are protective or harmful themselves, or if they are simply markers associated with the true causes of Type 2.

Diabetes UK says

Dr Richard Elliott, Diabetes UK’s Research Communications Officer, said, "This tells us more about the genetic and environmental factors that cause Type 2 diabetes, but doesn’t provide enough evidence for us to recommend changes to the vitamin content of a person’s diet.

"Large-scale research is needed to detail how external elements, such as certain foods, interact with genes to increase a person’s risk of developing the condition.

"What we already know is that following a healthy, balanced diet and taking regular physical activity is the best way of reducing Type 2 risk."

Study shows insulin pumps more effective than injections Insulin pumps are more effective at controlling blood sugar than insulin injections and cause fewer complications, according to new research by Associate Professor Elizabeth Davis and colleagues, Princess Margaret Hospital for Children, Perth, Australia.

Improvements in pump technology, the availability of insulin analogues, and the benefits offered by improved blood sugar control, have all contributed to an increase in the use of insulin pump therapy over the last 15 years, particularly in children.

However, there has been relatively little research into the long-term effects in children, with many studies too short in duration or with too few patients.

How effective are insulin pumps?

This study followed 345 young people on pump therapy over the course of seven years, matching them to controls using insulin injections. As the longest and largest study of the effectiveness of pump therapy, the study found that episodes of severe hypoglycaemia (dangerously low blood glucose) more than halved, while events in the control group increased. Admissions for diabetic ketoacidosis for pump users were also less than half than for those using injections.

Why did some children stop using their pumps?

Despite the improved control provided by the pump therapy, 38 patients stopped using the pump during the course of the study; six of these were in the first year of treatment, seven in the second

year and 10 in the third year of treatment, with the remainder

stopping after having used a pump for at least three years. The

researchers found that some children stopped because they

became tired of the extra attention needed to manage their pump, or were concerned about how it looked. Other children took a temporary ‘pump holiday’, before going back to using a pump.

The need for specialist nursing support

Bridget Turner, Director of Policy and Care Improvement for

Diabetes UK, said: “This provides further evidence that using insulin

pumps can help children with Type 1 diabetes achieve good blood

glucose control and, with the right education and specialist nursing

support, in the long term this can help reduce risk of serious complications such as amputation, blindness and kidney failure.

“This is why it is a real concern that the UK is lagging behind

comparable countries in terms of insulin pump usage. We want the

NHS to do more to ensure there are enough healthcare

professionals who are qualified to support children and adults with

Type 1 diabetes to use a pump effectively, so that everyone who

wants to use one is able to do so. This could make a real difference

to ensuring that everyone with diabetes has the best possible

chance of a long and healthy life.”

The study is published in Diabetologia, the Journal of the

European Association for the Study of Diabetes.

page | 33

MEMBER’S NEWS

Member’s News

Lydia Foley M.Inst.Ch.P North East member Lydia Foley is making quite a name for herself as an author! Writing under the name of Olivier Kerridge her first book entitled ‘The sins of the father’ is now available to download onto Kindle.

The story digs deep into the heart of some experiences from the people within her region but holds a universal appeal for readers everywhere through her candid and touching account of life that is often encountered the world over.

The story in brief:-

Locked in a battle to quench the personal demons that had tormented him since childhood. Now a man, a husband and a father, he wanted nothing more than to escape the memories of his horrendous past, spent in a convent in Southern Ireland.

But for Mike Donnigan, his escape is often found in the bottle of his beloved "Newcastle Brown Ale" bringing its own anguish with disastrous results, both for him and his family.

Arthritis Research UK

New treatment option for people with painful knee.

People with painful osteoarthritis of the knee are being recruited to take part in a brand-new clinical Arthritis Research UK trial which could reduce their pain by altering the way they walk.

Researchers at the University of Salford are looking to recruit up to 60 people from the Salford and Manchester area to test wedge insoles, which could reduce load on the knee joint by correcting the way they walk, and hopefully reduce pain.

Osteoarthritis of the knee affects around six million people in the UK and treatment is currently largely limited to painkillers, exercise and joint replacement.

The most common type, medial knee osteoarthritis, affects the inside of the knee joint between the femur and the tibia and is a painful condition that restricts daily life in those affected.

People from the Salford and Manchester areas aged between 40 and 85 who join the study will be asked to walk and climb stairs barefoot and wearing two different insoles in their shoes, and their gait and foot pressure will be analysed. If found to be eligible for the study, they will then attend three further gait analysis assessments over a 16-week period.

“When we stand, walk or climb stairs, our weight is transmitted through our knee joint,” explained Dr Richard Jones, senior lecturer in clinical biomechanics at the University of Salford, who is leading the study. ”The way this weight is transmitted and its measurement are determined as load. We aim to gain a more thorough understanding 34 | page

The Sins of Which Father? is a powerful novel set in the suburbs of Newcastle Upon Tyne that gives a clear, heartfelt insight into the effects ones upbringing can have not only on the victim, but also their loved ones.

Congratulations and very well done, Lydia from all us at the Institute. I hear you are currently working on your second novel?

Olivier Kerridge has always lived in Tyneside; past of the North East of England and is currently working on her second novel. She has worked as a chiropodist-podiatrist all her working life and from her close contact with the Geordie public, they have inspired and encouraged her to write her first novel.

of the loading on the knee that leads to osteoarthritis, and the effect that different insoles have on this load.

“Because of the way we walk, we have constant loading on the inside of the knee joint, and this is linked with the progression of disease,” added Dr Jones.

“We’re looking at how the knee moves and why it moves in a particular way, using 3D gait analysis to look at the hip, ankle and foot, as well as the knee.

A number of insoles have been designed to potentially lower the loads in the knee joint. Dr Jones and his team believe that these treatments could be extremely popular, effective and inexpensive interventions for osteoarthritis of the knee - if they can understand which one has the best results.

The trial is part of the ROAM (Research into Osteoarthritis in Manchester) project which is running a series of clinical studies at The University of Manchester in collaboration with the University of Salford. The project is led by internationally renowned osteoarthritis expert Professor David Felson from Boston, with funding of £1.8m from Arthritis Research UK. More information http://www.arthritisresearchuk.org/news/ telephone 0161 306 0545/0547/0549

CLASSIFIED

Classified Section

PRACTICES FOR SALE

LANCASTER NEAR TO LAKE DISTRICT

Excellent opportunity to acquire well established and thriving private practice in the historic town of Lancaster, close to the Lake District. Currently based at Dacrelands Clinic (centre for excellence in medicine) it boasts a highly desirable location within a Grade II Georgian townhouse with private parking for customers and recently refurbished treatment room.

With over 3000 clients, Lune Podiatry has strong repeat business and excellent customer service reputation with clients from across the country and overseas.

Currently carries out a range of treatment from routine chiropody to nail surgery and biomechanics. Holds a sizeable portion of domiciliary work across the region as well as several large nursing home contracts.

Excellent motorway, bus and rail links. Buyer can remain at Dacrelands or expand/reduce elsewhere. Would also provide perfect partnership opportunity.

Sale offered with all equipment, stock, goodwill and website and advertising are set for 2014.

Phased takeover available.

Selling due to family commitments. Current turnover in excess of £45k with capacity to expand. Serious offers in region of £30k considered.

If interested in whole or part of business please contact: Theresa (owner) 07739848171 or Jennifer (practice manager) 07921174112

ST HELENS (SUTTON) AREA

Established 3.5 years. Takings £15K plus based on 2 and a half days. Plenty of room for expansion as in busy village location. Genuine reason for sale.

Telephone 07921 762831

RETIREMENT SALE - WREXHAM.

Wrexham town centre, in ideal location very close to bus station, car parks and shops.

Ground floor, leasehold, established over 44yrs, personally owned and run for 36yrs.

Initially due to family illness, personal injury and now approaching retirement, work on average 3 days a week but huge potential to do more again if desired.

OIRO £18,000. email jones@valeriejones510.orangehome.co.uk

SOUTH WEST DUBLIN

Podiatry/Chiropody Business For Sale Business located in prime demographic area. Very modern premises and facilities well suited to medical uses and expansion. Located in area with little competition.

Excellent opportunity and huge potential evidenced by accounts.

Please call 00353 8724 82798.

RECRUITMENT LOCUM CHIROPODIST/PODIATRIST OR FOOT HEALTH PROFESSIONAL REqUIRED

Please contact Peter Hayward at Crowthorne Chiropody Clinic (Berkshire) on 01344 777105 or 07973 898594.

Email: healingvalues@yahoo.co.uk

SOUTH NOTTS

Opportunity to join a high profile private practice in South Nottinghamshire.

Podiatrist with excellent interpersonal skills, a minimum of 2yrs post grad with experience of private practice.

Successful candidate to be employed as part of a professional and friendly forward thinking team.

Applications and CV's to : sandra@feetandcohealth.co.uk 0115 9820100

EqUIPMENT/SUPPLIES FOR SALE HEMEL HEMPSTEAD, HERTS

Professional, retiring Christmas. For Sale: Drills; autoclave; couch; cabinets; instruments Phone 01442 268458

RHYL, NORTH WALES

MDS 12L Autoclave and Water Distiller £950 ONO Buyer Collects Linda: Mobile 07851 500 9917 Home 01745 331827

“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)

Chiromart UK

DES CURRIE INTERNATIONAL (+44) (0) 1207 505191

Business Cards 1 sided; 1,000 - £40 /10,000 - £99 Record Cards/Continuations/Sleeves (8” x 5”) 1,000 - £68 Appointment Cards 2 sided; 10,000 - £99 Small Receipts 2,000 - £49; 4,000 - £71 Flyers 10,000 - £82 + type setting + carriage FOR ALL YOUR STATIONERY NEEDS

To advertise in this section and on our website Call 01704 546141 or email bernie@iocp.org.uk page | 35

DIARY

What’s on in your area?

November 2013 3 3

3

3

Leeds Bradford Branch Meeting 10 a.m.

Oakwell Motel, Leeds WF17 9HD Scottish Area Council Meeting

Tel: 01924 475338

South Wales and Monmouth Branch Meeting 2 - 4p.m.

The Village Hotel, Coryton, Cardiff CF1 7EF Tel: Esther 01656 740772

West of Scotland Branch Meeting 11 a.m.

Express by Holiday Inn, Springkerse Business Park, Stirling, FK7 7XE Tel: 0141 632 3283

11 West Middlesex Branch Meeting 8 p.m.

The Harvester, Watford Road, Croxley Green, Rickmansworth WD3 3RX Tel: 0208 903 6544

13 London Branch Meeting 7. 30 p.m.

Ozzie Rizzo, 14 Hay Hill, Mayfair, London W1J 8NR Tel: 0208 586 9542

24 Essex Branch Meeting 2 p.m.

Southend University Hospital Education Centre Carlingford Drive, Southend on Sea SS0 0RY Tel: 01702 460890 24 Leicester and Northants Branch Seminar Lutterworth Golf Club

December 2013 1 6

Leeds Bradford Branch Meeting 10 a.m.

Oakwell Motel, Leeds WF17 9HD

Tel: 01234 851182

Tel: 01924 475338

Hants and Dorset Branch Christmas Social Meeting 7.45 p.m.

Crosfield Hall, Broadwater Road, Romsey SO51 8GL Tel: 01202 425568

Leeds Bradford Branch AGM 10 a.m.

Oakwell Motel, Leeds WF17 9HD

36 | page

12 Cheshire North Wales, Staffs and Shropshire Branch AGM 10 a.m. The Dene Hotel, Hoole Road, Chester, CH2 3ND

12 Western Branch AGM 12.15 p.m.

Blair Bell Education Centre, Liverpool Women’s Hospital, Crown Street, Liverpool.

Trade, Raffle and Presentation (to be confirmed) Tel: 01745 331827

14 North West Branch AGM 7.00 p.m.

St Joseph’s Parish Centre, Harpers Lane, Chorley, Lancs

Tel: 0161 486 9234

15 Hants and Dorset Branch AGM 7.45 p.m.

Crosfield Hall, Broadwater Road, Romsey SO51 8GL Tel: 01202 425568

16 Birmingham Branch AGM 8 p.m.

British Red Cross Centre Evesham, Worcs.

Tel: 01905 454116

17 Sheffield Branch AGM 7.30 p.m.

SWD Sports Club, Heeley Bank Road, Sheffield S2 3GL Tel: 01623 452711

January 2014 5

11 Surrey and Berkshire Branch AGM 1.30 p.m.

Greyfriars Centre, Reading Berkshire Tel: 0208 660 2822

Tel: 01924 475338

17 East Anglia Branch AGM 10.30 a.m.

Barrow Village Hall, Bury St Edmunds IP29 5DX Tel: 01992 589063

19 Devon and Cornwall Branch AGM and Meeting 11 a.m.

Exeter Court Hotel, Kennford, Exeter EX6 7UX Includes CPD Lecture – to be confirmed Email mrkjoanne@aol.com Tel: 01803 520788

19 Essex Branch AGM 2 p.m.

Southend University Hospital Education Centre Carlingford Drive, Southend on Sea SS0 0RY Tel: 01702 460890

DIARY 19 Teeside Branch AGM 2.p.m.

The Dolphin Centre, Darlington

Tel: 01287 639042

19 West of Scotland Branch AGM 11 a.m.

Express by Holiday Inn, Springkerse Business Park, Stirling, FK7 7XE Tel: 0141 632 3283 25 Southern Area Council AGM 1 p.m.

Victory Services Club 63-79 Seymour Street, London W2 2HF

26 Leicester and Northants Branch AGM

Tel: 01992 589063 Tel: 01234 851182

28 London Branch AGM 7. 30 p.m.

Ozzie Rizzo, 14 Hay Hill, Mayfair, London W1J 8NR Tel: 0208 586 9542

Febuary 2014

March 2014 2

21 Sheffield Branch Meeting 7.30 p.m.

SWD Sports Club, Heeley Bank Road, Sheffield S2 3GL Tel: 01623 452711

April 2014 6

Northern Ireland Branch AGM Lagan Valley Hospital

2

Midland Area Council Meeting and AGM Kilsby Hall, Hall Lane, Kilsby CV23 8XX Tel: 01536 269513

Tel: 028 9446 2423

Cheshire North Wales, Staffs and Shropshire Branch Meeting 10 a.m.

The Dene Hotel, Hoole Road, Chester, CH2 3ND Presentation to be confirmed

October 2014 2

2

Cheshire North Wales, Staffs and Shropshire Branch Meeting 10 a.m.

The Dene Hotel, Hoole Road, Chester, CH2 3ND Presentation to be confirmed

North West Area Council Seminar â&#x20AC;&#x201C; Details to follow

19 Cheshire North Wales, Staffs and Shropshire Branch Meeting 10 a.m.

The Dene Hotel, Hoole Road, Chester, CH2 3ND Presentation to be confirmed

page | 37

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