Jan feb 2015 podiatry review final version

INSIDE THIS ISSUE: • CHILBLAINS - A PERNICIOUS AFFLICTION • KEY FACTS - EBOLA • 2015 CONFERENCE PROGRAMME

Podiatry Review Supporting the Private Practitioner

A step in the right direction

ISSN 1756-3291 Volume 72 No. 1

January/February 2015

The Institute of Chiropodists and Podiatrists 150 Lord Street, Southport, PR9 0NP 01704 546141 www.iocp.org.uk

Podiatry Review January/February 2015 Volume 72 No. 1 ISSN 1756-3291 Published by The Institute of Chiropodists and Podiatrists 150 Lord Street, Southport, Merseyside, PR9 0NP Tel: 01704 546141 Email: bernie@iocp.org.uk Web: www.iocp.org.uk Editor: Mrs B Hawthorn HMInstChP

National Officers

President Mrs L. Pearson MInstChP BSc Pod Med

Vice-Chairman Executive Committee Mr A. Reid MInstChP Chairman Board of Ethics Mrs J. Dillon MInstChP Acting Chairman Board of Education Miss Joanne Casey MInstChP BSc

Academic Review Team: Mrs J Barbaro-Brown

Honorary Treasurer Mrs J. Drane MInstChP

Ms B Wright

Standing Orders Committee Mr M. Hogarth MInstChP

MSc PGDip PGCE BSc (Hons) BA (Hons) DPodM MChS HonFInstChP MSc BSc (Hons) PGCE PGDip MInstChP

Mr S Miah BSc(PodM) MInstChP Mrs J Casey BSc (Pod) MInstChP

Secretary Miss A. J. Burnett-Hurst Hon FInstChP Area Council Executive Delegates:

Midland Area Council Mr S. Miah BSc (Pod M) MInstChP

© The Institute of Chiropodists and Podiatrists Disclaimer: 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.

Published by Mitchell & Wright Printers Ltd, The Print Works, Banastre Road, Southport, PR8 5AL 01704 535529 Annual Subscription £30 UK/£45 Overseas

North West Area Council Mrs M. Allison MInstChP Republic of Ireland Area Council Mrs C Tindall MInstChP BSc (PodMed) LCh Scottish Area Council Mrs H. Jephcote MInstChP Southern Area Council Mr D. Crew OStJ FInstChP DChM CertEd Yorkshire Area Council Mr N. Hodge MInstChP

CONTENTS Contents 2

Editorial

3

President’s Message

4

Rotary’s Helping Hand to a threatened community in Tanzania Dr John Philip

6

Chilblains - a pernicious affliction Iain B McIntosh MBChB

10 Ebola Virus 13 Arthritis Research 14 Medical Alert Assistance Dogs for Young People Claire Pesterfield, Claire Guest, Simone Brainch, Lydia Swanson 16 CPD - Hyperkeratosis of the foot: Part 1 Ivan Bristow, Lecturer, School of Health Professions & Rehabilitation Sciences, University of Southampton 23 Obituaries 24 Diabetes News 26 Management of Anaphylaxis David Crew OStJ, FInstChP, DChM 28 2015 Conference Programme 29 Conference booking form 30 Branch News 32 Protect your skin Greet Clares BSD MSc and Lindsey Upton, NAQI 33 Cosyfeet

http://twitter.com/iocp_chiropody The Institute of Chiropodists and Podiatrists-Southport

Podiatry Review Vol 72:1

34 The Big Bike Ride Nicole Nanton, Podiatrist 36 Forthcoming events

page 1

EDITORIAL

Dear Readers, A very happy New Year to each and every one of you and we hope you have recovered from the stresses and strains of the Christmas period; no doubt much lighter in the pocket!

January really is the time for new beginnings and our branches around the country will be arranging their annual general meetings and voting for their branch officials. Don’t forget to complete the branch information sheets and get them in to Head Office as soon as possible so that we may amend details where appropriate. If you have chosen dates for your branch calendars throughout the year so much the better; we can include them on the website and in the diary of events in the journal. Please remember to put venue, time, contact details and whether or not you have any CPD planned. Should you wish to advertise a planned event in greater detail, please send it in.

We have some interesting articles and features in this issue starting with part one of a CPD article written by Ivan Bristow – “Hyperkeratosis of the Foot” Ivan has forwarded this to us and part 2 will be in the March-April issue.

Former Chiropody Schools Inspector, Iain McIntosh has supplied another topical article, this time “Chilblains”. Chilblains are often dismissed as a minor disorder by health professionals but anybody who has ever been affected will be aware just how painfully debilitating they are.

Thank you Iain and please do keep the articles coming.

Julie Dillon (Leeds Bradford branch) attended a harrowing but interesting talk held by Dr John Philip, past District Governor of Rotary International explaining the Rotary’s helping hand to a threatened community in Tanzania.

She was so moved and impressed she felt it deserved recognition and would

page 2

be of considerable interest to our readers. (please see the article on pages 4 and 5) John also sent in a letter which stated that a team of 9 people will be going to Tanzania in February to undertake a variety of projects, working alongside local Rotarians.

Once you have read the article, if anybody is interested in joining the teams either on the next trip or subsequent trips, please get in touch with John: johnphilip@btconnect.com (full details are at the end of his article).

John estimates the cost to be in the region of £1,600 and the plan is as follows:1. To assess the impact of previous interventions 2. Within ability, to undertake any repairs and to make good any problems in the installations and renovations previously undertaken 3. To inspect the microcredit projects and the bee keeping programme funded by the Trust and provide a refresher training course 4. To extend the provision of biosand water filters 5. To improve water supply to Murutunguru Teachers’ training college 6. To help improve some aspects of health care 7. To undertake eye checks and distribute spectacles 7. To visit the Albino community and initiate vocational training You may be put off by the constant worry in the news about Ebola? How many people are aware of the etiology, symptoms and treatments? Ebola has

Podiatry Review Vol 72:1

certainly had an affect on the safari industry even though the West African countries are actually closer to London and Europe than they are to popular safari destinations such as Kenya and Tanzania. However, nobody can be complacent wherever they live and an article on the Ebola virus starting on page 10 is certainly worth reading.

The North West Area Council once again held a successful seminar at the University of Central Lancashire. For those of you who have never attended one; you really don’t know what you are missing. The venue is perfect, the lectures outstanding and the food is wonderful too!

Very well done to all who organise this event. Its not an easy job!

David Crew (Surrey and Berkshire branch) felt it was time to brush up on the management of anaphylaxis.

Allergies and allergic reactions to products and treatments should always be uppermost in practitioners minds as you just never know when you will need to use it. Please ensure your clinical emergency training is up to date (please enquire at Head Office if you are looking for a course – Julie@iocp.org.uk or phone her on 01704 546141).

We can’t end without congratulating our friend, Nicole Nanton on organising a 72 mile foot health awareness campaign in Trinidad. She has sent us a write up and some pictures for inclusion. Now that is dedication for you!

Thank you to all who commented on your journal last year. We have altered the look slightly and hope you continue to enjoy it. Please feel free to pass on comments and articles.

All the best for a fantastic 2015.

Bernadette Hawthorn, Editor

PRESIDENT’S MESSAGE

day was had by all.

As you may be aware, Mrs Colette Johnston recently resigned her post as chair of the executive committee. Alisdair Reed (West of Scotland branch and vice chairman) has now taken over the reins. I would Just to assure you the executive committee are focused and following an emergency EC meeting on 30th November, we’re hoping that the IOCP can continue to move forward and progress to progress positively. I appreciate your continued trust and support during this time.

Dear Colleagues,

Since my last letter, long serving member of the IOCP Robert Cleary has passed away.

Robert was an extremely hard working member of the IOCP team and will be sadly missed by all his friends and colleagues The Institute of Chiropodists and Podiatrists would like to extend sincere sympathy and condolence to his wife and family.

On Thursday 24th November a few EC members including myself met with the late John Patterson’s son Noel and daughter Eunice. After a tour of the building and light refreshments, Noel and Eunice presented us with a cheque for just over £500 bequest in John’s memory for the use of educational purposes.

If members in Ireland could submit information for their branch seminars and meetings for 2015, then other members who may like to attend can see the CPD on offer.

Having attended my first Irish seminar at St Mary’s Hospital, Dublin in 1999, which was an amazing time with excellent CPD.

Hoping to see you at the AGM in May. No need to remind you that this is our DIAMOND anniversary and we really hope as many members as possible will come along to make it a weekend to remember!

I recently attended the SOCAP conference in Bournemouth, it was very informative and I have made a lot of new contacts.

Members attending by vehicle and staying overnight at the Ramada Plaza Hotel, please apply now for your Wyndham Rewards Card, which costs nothing but will assist with parking charges.. All is explained on the conference page of our website

I also attended the NWAC seminar in Preston and the Leicester & Northants Seminar in Lutterworth, both were excellent days.

On Sunday 23rd November thirty delegates, myself included, attended the Leicester and Northants Seminar at Lutterworth Golf Club.

There were four excellent presentations two

by Robert Isaacs, Martin Harvey and Dr Vivek Dhukaram. £110.00 was raised on the raffle; the proceeds are being donated to Birmingham Childrens Hospital. The lunch was very nice. On the whole the day was very enlightening, especially regarding the melanomas and the casting was also great fun. (Nice socks David!). There were goodie bags from Des Currie and Canonbury, a great

Noel and Eunice Patterson with EC members.

h tt p : / / w w w. i o c p . o r g . u k / D i a m o n d Anniversary-Conference-2015.php

Or you can apply at www.wyndhamrewards.co.uk

Also don’t forget to support your local branches so that you can put your ideas forward.

Remember this is YOUR organisation, run by YOU for you.

Linda

Renewal 2015 

Insurance for the members of the Institute of Chiropodists & Podiatrists          

As a valued member of the IOCP, we are delighted to offer renewal of your insurances for 2015.

This document briefly explains exactly what is included in your policy, how it differs from other insurance                   available  it is so vital   to  a practicing    or Foot products and why Chiropodist, Podiatrist Health Practitioner to                     right insurance    in place.    ensure you have the As your policy is underwritten by RSA & DAS, you have direct                    to claim  specialists     experienced     in dealing         access with claims.          medical   insurance    Should    there  ever                        you will        be the need to use them be supported throughout, with a dedicated claims handler and expert                  addition,    Arthur   J Gallagher  have a team  dedicated  to IOCP  members.      advice. In                               team  are ready to your    Should you have  any  questions,   the  take  call.         







 







 

 





 



What does my policy include?     Public Liability Insurance: This type of insurance would cover you if a patient or member of the public was to suffer a loss or injury    and they made a claim for compensation against you. This could be a slip or trip in your premises resulting in injury or damage to their  cover is  included as standard                        property. Public Liability with an indemnity limit of £5,000,000.

 Insurance:  type   of insurance   would  cover   you for any legal   costs     during   the  defence   of  a claim. For     Legal Expenses This incurred 







 

 

 





 

 

 









 

 







  

  

example, it would help barristers and expert witnesses.

Also included is access to the DAS legal advice     cover the  appointment of solicitors,                      helpline, which can help you disputes with suppliers, tax enquiries or problems with employees. Legal Expenses is included as  deal with        indemnity  of £100,000.        standard  with an    limit                          







 

 

 





 

 

 









 

 



      Medical  Malpractice of insurance would cover  Insurance:   This type      you in  the  event   of  any potential   negligence   committed    by you  

  malpractice   insurance        such things   as  court   costs, settlements    resulting in harm to a patient.

Medical covers you for and the award of    cover   damages. Medical Malpractice is included with an limit     as standard    indemnity      of £5,000,000.              cover,    personally   for   any of these    Without Malpractice you  Medical   could   be   held     liable  costs.   Alternative     insurance   policies    rarely             Medical  Malpractice    include cover as standard, making the policy available to IOCP members so valuable.



 









 

 









 

   for 2015  kept   in line  year  meaning    premium   increase.  The costs no  of your   policy    have   been  with last 





 





























 







 Podiatry    Review   Vol 72:1  























 

page 3

AWARENESS ARTICLE

page 4

Podiatry Review Vol 72:1

AWARENESS ARTICLE

Podiatry Review Vol 72:1

page 5

TECHNICAL ARTICLE

Chilblains- a pernicious aiction

Iain B. McIntosh MBChB Former Chiropody Schools Inspector

page 6

Podiatry Review Vol 72:1

TECHNICAL ARTICLE

continued overpage

Podiatry Review Vol 72:1

page 7

TECHNICAL ARTICLE

continued from previous page

page 8

Podiatry Review Vol 72:1

FEATURE

Its time to go to Germany again!

Hilary Supplies are once more arranging a limited number of places for a visit to Franz Lutticke – manufacturers of Mykored and the Laufwunder range of creams in Meinerzhagen, Germany.

Final details will be confirmed once we know the number of delegates registering for the trip. It is expected that as it is educational CPD points will be awarded.

THE DETAILS Thursday 5th September 2015 – Saturday 12th September 2015 Flights from Heathrow Airport to Dusseldorf.

Anticipated costs – Practitioners up to £300 each (Partners up to £500 each) Includes flights, transfers and hotel (Dinner bed & breakfast). A visit to the recently extended, state of the art factory and view the filling and packaging process, educational talk on the key products and their uses. Then enjoy some real German hospitality!

What else can you do once there?

Guided tour around Dusseldorf, Visit Cologne – a short journey by train – just a few thoughts. Or perhaps a visit to Ratinger Straße (The longest bar in the world – a whole street of bars!)

So reflect on your experience and add to your CPD balance.

Register your interest by calling Sonia @ Hilary Supplies on 0116 230 1900 or email SoniaK@hilarysupplies.co.uk - this does not commit you but does enable us to clarify final prices.

As places are limited preference will be given to earliest registrants. No commitment until invoices issued and paid.

Jacquie Drane

Podiatry Review Vol 72:1

page 9

EBOLA VIRUS ARTICLE

Ebola Virus

The Ebola Virus disease has spread outside of Central and West Africa. Most people will have heard something of it in the news recently but many people still remain ignorant of the facts.

Ebola virus disease (EVD) or Ebola hemorrhagic fever (EHF) is the human disease caused by the Ebola virus.

Symptoms typically start two days to three weeks after contracting the virus, with a fever, sore throat, muscle pains, and headaches. Typically nausea, vomiting, and diarrhoea follow, along with decreased functioning of the liver and kidneys. At this point, some people begin to have bleeding problems.[1]

Ebola first appeared in 1976 in 2 simultaneous outbreaks, in Nzara, Sudan, and in Yambuku, Democratic Republic of Congo. The latter was in a village situated near the Ebola River, from which the disease takes its name.

Genus Ebolavirus is 1 of 3 members of the Filoviridae family (filovirus), along with Marburgvirus and genus genus Cuevavirus. Genus Ebolavirus comprises 5 distinct species:

• • • • •

Bundibugyo ebolavirus (BDBV) Zaire ebolavirus (EBOV) Reston ebolavirus (RESTV) Sudan ebolavirus (SUDV) Taï Forest ebolavirus (TAFV).

BDBV, EBOV, and SUDV have been associated with large EVD outbreaks in Africa, whereas RESTV and TAFV have not.

The RESTV species, found in Philippines and the People’s Republic of China, can infect humans, but no illness or death in humans from this species has been reported to date.

The virus may be acquired upon contact with blood or bodily fluids of an infected animal (commonly monkeys or fruit bats).[1] Spread through the air has not been documented in the natural environment.[2] Fruit bats are believed to carry and spread the virus without being affected. Once human infection occurs, Ebola then spreads in the community

page 10

through human-to-human transmission, with infection resulting from direct contact (through broken skin or mucous membranes) with the blood, secretions, organs or other bodily fluids of infected people, and indirect contact with environments contaminated with such fluids. Burial ceremonies in which mourners have direct contact with the body of the deceased person can also play a role in the transmission of Ebola. Men who have recovered from the disease can still transmit the virus through their semen for up to 7 weeks after recovery from illness.

Ebola can be difficult to identify as other diseases produce similar symptoms, therefore, before a diagnosis of EVD can be made others are excluded these include: malaria, typhoid fever, shigellosis, cholera, leptospirosis, plague, rickettsiosis, relapsing fever, meningitis, hepatitis and other viral haemorrhagic fevers.

Ebola virus infections can be diagnosed definitively in a laboratory through several types of tests:

• antibody-capture enzyme-linked I immunosorbent assay (ELISA) • antigen detection tests • serum neutralization test • reverse transcriptase polymerase chain reaction (RT-PCR) assay • electron microscopy • virus isolation by cell culture.

Samples from patients are an extreme biohazard risk; testing should be conducted under maximum biological containment conditions.

Vaccine and treatment

No licensed vaccine for EVD is available.

Several vaccines are being tested, but none are available for clinical use.

Severely ill patients require intensive

Podiatry Review Vol 72:1

supportive care. Patients are frequently dehydrated and require oral rehydration with solutions containing electrolytes or intravenous fluids.

No specific treatment is available. New drug therapies are being evaluated.

Prevention and control

Controlling Reston domestic animals

ebolavirus

in

No animal vaccine against RESTV is available.

Routine cleaning and disinfection of pig or monkey farms (with sodium hypochlorite or other detergents) should be effective in inactivating the virus.

If an outbreak is suspected, the premises should be quarantined immediately. Culling of infected animals, with close supervision of burial or incineration of carcasses, may be necessary to reduce the risk of animal-tohuman transmission. Restricting or banning the movement of animals from infected farms to other areas can reduce the spread of the disease.

As RESTV outbreaks in pigs and monkeys have preceded human infections, the establishment of an active animal health surveillance system to detect new cases is essential in providing early warning for veterinary and human public health authorities.

Reducing the risk of Ebola infection in people

In the absence of effective treatment and a human vaccine, raising awareness of the risk factors for Ebola infection and the protective measures individuals can take is the only way to reduce human infection and death.

In Africa, during EVD outbreaks, educational public health messages for risk reduction should focus on several factors:

• Reducing the risk of wildlife-to-human transmission from contact with infected fruit bats or monkeys/apes and the consumption of their raw meat. Animals should be handled with

gloves and other appropriate protective clothing. Animal products (blood and meat) should be thoroughly cooked before consumption.

• Reducing the risk of human-to-human transmission in the community arising from direct or close contact with infected patients, particularly with their bodily fluids. Close physical contact with Ebola patients should be avoided. Gloves and appropriate personal protective equipment should be worn when taking care of ill patients at home. Regular hand washing is required after visiting patients in hospital, as well as after taking care of patients at home.

Communities affected by Ebola should inform the population about the nature of the disease and about outbreak containment measures, including burial of the dead. People who have died from Ebola should be promptly and safely buried.

Pig farms in Africa can play a role in the amplification of infection because of the presence of fruit bats on these farms.

Appropriate biosecurity measures should be in place to limit transmission. For RESTV, educational public health messages should focus on reducing the risk of pig-tohuman transmission as a result of unsafe animal husbandry and slaughtering practices, and unsafe consumption of fresh blood, raw milk or animal tissue.

Gloves and other appropriate protective clothing should be worn when handling sick animals or their tissues and when slaughtering animals. In regions where RESTV has been reported in pigs, all animal products (blood, meat and milk) should be thoroughly cooked before eating.

Controlling infection in health-care settings

Human-to-human transmission of the Ebola virus is primarily associated with direct or indirect contact with blood and body fluids. Transmission to health-care workers has been reported when appropriate infection control measures have not been observed.

Podiatry Review Vol 72:1

EBOLA VIRUS ARTICLE

Key facts • Ebola virus disease (EVD), formerly known as Ebola haemorrhagic fever, is a severe, often fatal illness in humans.

• EVD outbreaks have a case fatality rate of up to 90%.

• EVD outbreaks occur primarily in remote villages in Central and West Africa, near tropical rainforests.

• The virus is transmitted to people from wild animals and spreads in the human population through human-to-human transmission.

• Fruit bats of the Pteropodidae family are considered to be the natural host of the Ebola virus.

• Severely ill patients require intensive supportive care. No licensed specific treatment or vaccine is available for use in people or animals. page 11

EBOLA VIRUS ARTICLE

It is not always possible to identify patients with EBV early because initial symptoms may be non-specific. For this reason, it is important that health-care workers apply standard precautions consistently with all patients – regardless of their diagnosis – in all work practices at all times. These include basic hand hygiene, respiratory hygiene, the use of personal protective equipment (according to the risk of splashes or other contact with infected materials), safe injection practices and safe burial practices.

Health-care workers caring for patients with suspected or confirmed Ebola virus should apply, in addition to standard precautions, other infection control measures to avoid any exposure to the patient’s blood and body fluids and direct unprotected contact with the possibly contaminated environment. When in close contact (within 1 metre) of patients with EBV, health-care workers should wear face protection (a face shield or a medical mask and goggles), a clean, non-sterile longsleeved gown, and gloves (sterile gloves for some procedures).

Laboratory workers are also at risk.

Samples taken from suspected human and animal Ebola cases for diagnosis should be

handled by trained staff and processed in suitably equipped laboratories.

WHO response

WHO provides expertise and documentation to support disease investigation and control.

Recommendations for infection control while providing care to patients with suspected or confirmed Ebola haemorrhagic fever are provided in: Interim infection control recommendations for care of patients with suspected or confirmed Filovirus (Ebola, Marburg) haemorrhagic fever, March 2008. This document is currently being updated.

WHO has created an aide–memoire on standard precautions in health care (currently being updated). Standard precautions are meant to reduce the risk of transmission of bloodborne and other pathogens. If universally applied, the precautions would help prevent most transmission through exposure to blood and body fluids.

Standard precautions are recommended in the care and treatment of all patients regardless of their perceived

or confirmed infectious status. They include the basic level of infection control—hand hygiene, use of personal protective equipment to avoid direct contact with blood and body fluids, prevention of needle stick and injuries from other sharp instruments, and a set of environmental controls.

References

"Ebola virus disease Fact sheet N°103". World Health Organization. March 2014. Retrieved 12 April 2014.

"2014 Ebola Virus Disease (EVD) outbreak in West Africa". WHO. Apr 21 2014. Retrieved 3 August 2014. Check date values in: |date= (help) C.M. Fauquet (2005). Virus taxonomy classification and nomenclature of viruses; 8th report of the International Committee on Taxonomy of Viruses. Oxford: Elsevier/Academic Press. p. 648. ISBN 9780080575483. "Ebola Viral Disease Outbreak — West Africa, 2014". CDC. June 27, 2014. Retrieved 26 June 2014. "CDC urges all US residents to avoid nonessential travel to Liberia, Guinea, and Sierra Leone because of an unprecedented outbreak of Ebola.". CDC. July 31, 2014. Retrieved 2 August 2014. "Outbreak of Ebola in Guinea, Liberia, and Sierra Leone". CDC. August 4, 2014. Retrieved 5 August 2014. "Ebola virus disease update - West Africa". WHO. Aug 4, 2014. Retrieved 6 August 2014.

Wiki http://en.wikipedia.org/wiki/Ebola_virus_disease WHO Media centre Telephone: +41 22 791 2222 E-mail: mediainquiries@who.int

The Cosyfeet Podiatry Award supports one person each year in developing their professional knowledge and skills while benefitting others. The £1000 award is open to any podiatrist or podiatry student who is planning voluntary work, a work placement or research, whether in the UK or abroad. It is designed to contribute to travel and expenses.

Former winners have undertaken a wide range of projects including those relating to wound management, Lymphatic Filariasis and Talipes Equinovarus. Some have travelled to Asia or Africa while others have conducted voluntary work or research here in the UK.

Jay Wasilewski, Cosyfeet’s 2014 winner, has used the award to finance her voluntary initiative: Foot Care United, which provides free training on foot care to friends, family and carers of those who can no longer look after their own feet.

If you would like to apply for the award, visit www.cosyfeet.com/award for further information and to enter online before the closing date of April 24th 2015.

The winner will be requested to submit a report and photographs of their experience, and to be included in Cosyfeet publicity relating to the award.

Cosyfeet is the UK’s leading supplier of footwear, socks and hosiery for extra wide, swollen or problem feet. 11,000 health professionals recommend Cosyfeet products to their patients. For more information email prof@cosyfeet.com or call 01458 449071.

page 12

Podiatry Review Vol 72:1

ARTHRITIS RESEARCH

Lupus 'could be controlled better through management of gut bacteria'

Patients with lupus could potentially benefit from altering their diet to include foods that can influence the make-up of their gut bacteria, according to a new US study.Carried out by Virginia Polytechnic Institute and State University, the animal-based study has revealed that gut bacteria may contribute to lupus, which would suggest that probiotic foods such as live culture yoghurts could have an effect on the disease.

Data published in the journal Applied and Environmental Microbiology has revealed that lactobacillus species - which are commonly seen in yoghurt cultures - generally correlate with the mitigation of lupus symptoms, while high levels of another bacterial species called lachnospiraceae tends to exacerbate the condition.

Lab mice with lupus used in the study had higher levels of lachnospiraceae and lower lactobacillus than control mice, a trend that was only present in females. This aligned with the researchers' expectations, since lupus disproportionately affects women over men.

The research suggests - but does not prove - that altering the gut microbiota could mitigate lupus. As such, the scientists will be continuing to examine the trends, but have in the meantime suggested that people with lupus could consume higher

quantities of food such as probiotic yogurts as a potential means of reducing lupus flares.

Principal investigator Xin Luo of Virginia Tech said: "Our results suggest that the same investigation should be performed in human subjects with lupus. The use of probiotics, prebiotics, and antibiotics has the potential to alter microbiota dysbiosis, which in turn could improve lupus symptoms.

"An Arthritis Research UK spokesperson, commenting on the study, said: "The role played by the bacteria naturally found in our gut, collectively termed our gut microbiome, in the development of autoimmune and inflammatory conditions is currently an emerging area of research. Although a link between the gut microbiome and inflammatory bowel conditions such as Crohn's disease has been established, less is understood about its role in conditions such as lupus and rheumatoid arthritis.

"This interesting work has shown that dietary changes in mice can be successful at improving disease symptoms and further research is now required to investigate whether altering the bacteria in our guts has potential as a new approach to treating disease symptoms in humans.”

See more at: http://www.arthritisresearchuk.org/news/

New extreme grip technology to assist in the icy weather this winter

VIBRAM® MultiControl Tech replacement soles to be exclusively distributed in the UK by Charles Birch Group

New extreme grip sole technology from the world leader of high-tech soles has arrived in the UK, just in time for the seasonal arrival of icy weather.

VIBRAM® MultiControl Technology, distributed in the UK by Charles Birch Group, has been specifically developed to reduce the risk of slipping on wet or icy surfaces and is sure to be a popular addition in the fight to prevent injuries caused by slips and trips this winter.

Whilst this new technology is suitable for a number of applications and will be attractive to a wide range of customers, it is anticipated that senior citizens concerned about walking on icy surfaces will benefit the most.

Each winter the UK is caught off-guard by the arrival of fierce cold weather conditions with many people, including vulnerable pensioners, finding themselves trapped in their own homes, fearful of stepping out just in case they should fall.

Often people are left depending on the support of others during this difficult period.

For those that do brave it outside, many are admitted to hospitals having being caught out by the icy conditions. Figures

show that in 2012/13, hospitals saw 90,060 cases of slips, trips and stumbles and 7,030 admissions for falls on ice and snow*.

VIBRAM® have stepped up the battle against the elements with their MultiControl Technology which can dramatically help reduce the chance of slipping.

Designed to increase grip in wet or icy conditions, VIBRAM® MultiControl Technology features three synergic layers, combining a layer of fabric with rubber into the production of the lugs that make contact with the ground.

The fabric, which has been exclusively designed by VIBRAM®, has distinct properties which provide enhanced grip in wet conditions.

The special rubber manufactured by Vibram is very hard wearing which means performance is maintained over a long period of time Costing from only £44.95, VIBRAM® MultiControl Technology can be fitted to current shoes, replacing their original soles to give enhanced grip. A list of local shoe repairers and VIBRAM® specialists can be found at www.icesteady.co.uk.

*From the Health and Social Care Information Centre Web Site: http://www.hscic.gov.uk/article/3798/Twas-the-nightbefore-Christmas

Podiatry Review Vol 72:1

page 13

AWARENESS ARTICLE

A dog is for life, not just for hypos: Medical alert assistance dogs for young people Claire Pesterfield, Claire Guest, Simone Brainch, Lydia Swanson

Evidence suggests that medical alert assistance dogs can help to reduce hypoglycaemic events by alerting owners when their blood glucose levels drop.

Medical Detection Dogs is a charity that trains dogs to recognise the scent of lowered glucose levels and teaches them how to alert their owners while they are still able to act to prevent a hypo- or hyperglycaemic episode. The charity matches people with a suitable detection dog and 12 of the 26 dogs trained for diabetes have been placed have been with young people with type 1 diabetes. The article includes a case report of a successful placement, which has resulted in a complete elimination of hypoglycaemic events for the dog’s teenage owner. The authors recommend that healthcare professionals keep an open mind about medical detection dogs and remain aware of patients that might benefit from their services.

Service delivery, Type 1 diabetes

Evidence suggests that some domestic dogs are able to detect episodes of hypoglycaemia in their human owners (Lim et al, 1991; Chen et al, 2000). The fear of hypoglycaemia in children and young people with diabetes can be great (Haugstvedt et al, 2010) and a medical alert assistance dog for diabetes can be a useful adjunct to the usual treatment modalities. Animals, particularly dogs, are used frequently in today’s healthcare setting, fulfilling many roles such as guide dogs, hearing dogs, seizure dogs and making therapeutic visits to hospitals, care homes and special schools. Research has shown that dogs may be able to prevent and facilitate recovery from illness and even detect ill health (Wells, 2007), as is the case with hypoglycaemia in people

page 14

with type 1 diabetes.

A national charity set up in 2008, Medical Detection Dogs (www.medicaldetectiondogs.org.uk) is dedicated to the detection of human disease by canine olfaction – a dog’s ability to smell disease.

A human nose has about 5 million olfactory cells, whereas a dog’s has over 200 million; this enhanced ability to detect scent compared with humans can open up a new world to the healthcare professional and people with diabetes. Dogs use smell as their primary sense with over 10% of their brain dedicated to olfaction – 40 times greater than a human – and their sense of smell is about 1000 times better than ours (Correa, 2011). Medical Detection Dogs is able to train dogs to detect an odour change that occurs as someone’s blood glucose level drops or rises and then to make this known to the individual, often before they are aware themselves, allowing them to take the appropriate action to avoid emergency situations such as collapse.

Over the past five years, 26 dogs have qualified as medical alert assistance dogs for diabetes and a further nine are in advanced training. Of this number, 12 have been placed with children and young people with type 1 diabetes.

The evidence base

There is currently little research in this area, but there is plenty of anecdotal evidence and stories of pet dogs reacting to emergency situations and alerting their owners to an impending episode. As early as 1992, Lim et al (1991) indicated that up to one-third of dogs living with people with diabetes had reportedly shown a change in behaviour during their owner’s hypoglycaemic episodes.

Chen et al (2000) describe three cases where pet dogs were able to detect episodes of hypoglycaemia before the owner was aware and, in some cases, they were even able to detect hypoglycaemia overnight and wake their owner so they could take corrective action. This was followed by a larger study (Wells et al, 2008) that also suggested dogs could detect hypoglycaemia often without visual cues, although the actual mechanism of detection needs further investigation.

Only one study (Ward et al, 2013)

Podiatry Review Vol 72:1

showed an inability to detect hypoglycaemia. This was, however, a small study, investigating whether dogs could detect hypoglycaemia scent on the skin from samples obtained from participants who were not known to the dogs. Ward et al (2013) suggested that further research was required, particularly using other scent samples and behavioural cues from the dog’s usual owners before discounting a dog’s ability to reliably detect hypoglycaemia.

Recent research by Rooney et al (2013) has shown that the presence of a trained detection dog improved glycaemic control, client independence and quality of life, confirming many of the findings from the anecdotal reports. Further studies are needed to identify the mechanism of blood glucose level detection and benefits to health, but this can only be done when more medical alert assistance dogs have been placed with people with diabetes.

From application to placement: How Medical Detection Dogs work

Following a successful application process to Medical Detection Dogs, each person with diabetes is partnered with an appropriate dog following an intensive assessment and trial. The dog’s personality and character are matched to the requirements of their new owner so that the dog can adapt easily to their daily routine and needs. The dogs are with their partner at all times, day and night. For young people and adults this may mean the dog has to attend their place of work or study, and for children these dogs may be required during school hours or during the walk to and from school.

All dogs undergo intensive training in obedience and public access by a small group of devoted “socialisers” before undergoing intensive alert training while living with an instructor who trains the dog to detect and act upon the client’s specific hypoglycaemic scent. This process from puppy to placement, can take up to 18 months and at no stage is the dog placed in kennels – it always lives with volunteers or staff at the charity. When ready, the dog is placed full-time with their new owner who is given intensive training in caring for a dog and the dog is trained to develop their hypoglycaemia alert skills for their

AWARENESS ARTICLE

about hypoglycaemia awareness, carbohydrate counting, insulin dose adjustment and self-management skills, and even the use of continuous subcutaneous insulin infusion (insulin pump) therapy with or without continuous glucose sensor technology and psychological interventions.

new owner. For younger children, a “team leader” is nominated (usually a parent or guardian) and they must all attend the training, with the team leader having overall responsibility for the dog.

Each owner is required to maintain accurate records of blood glucose levels, hypoglycaemic episodes and dog behaviour to ensure that the dog is progressing and performing as expected, as well as highlighting any areas that may need further training. Once the dog has been placed, consistent and reliable hypoglycaemia detection can take up to a further 6 months to achieve. Regular visits and training from the charity’s instructors continue for about 6–12 months until the dog is assessed and recognised officially as a fully fledged medical alert assistance dog, accredited in line with Assistance Dogs UK and Assistance Dogs Europe regulations and guidelines.

The dogs are trained to alert the owner when blood glucose levels drop below 4.5 mmol/L (although this level can be adjusted to suit the client’s needs in particular circumstances), allowing time to measure the blood glucose level by the usual method and take the appropriate action to prevent a hypo. In some cases, dogs are now alerting their owners up to 30 minutes before their blood glucose level drops to below the desired range.

Many dogs are now also providing alerts for high blood glucose levels, again allowing the owner to monitor their blood glucose level and take the appropriate action. Follow-up and support from Medical Detection Dogs continues throughout the partnership until the dog is retired, the timing of which varies depending upon the age and ability of the dog.

The charity can currently place only 12– 16 dogs per year, as they are totally reliant on donations to fund the service. The careful selection of owners is, therefore, vital. Medical alert assistance dogs are not for everyone, but they are suitable for people who meet the selection criteria and have tried all conventional methods to reduce the incidence of hypoglycaemic events.

Children and young people over the age of 5 years who have had diabetes for more than 12 months should be considered eligible when diabetes has caused a significant impact upon daily life, such as hypoglycaemia causing frequent collapse requiring hospital admission or significant absence from school. The family must be able to care for the dog, undergo regular and intensive training and commit to undertaking a long-term placement.

Experience with dogs is not essential as training and support are provided by the charity, but of paramount importance is the realisation that the dog is not just for “hypos”, but requires a long-term commitment – a decision that should be discussed in depth by all the family. The waiting list to receive a medical alert assistance dog can be up to 4 years after a successful application. There are about 30 puppies in training, each costing about £12 000 to train and support throughout its working life.

Diabetes healthcare professionals can advocate for a medical alert assistance dog as a useful adjunct to existing therapy when conventional methods have failed to reduce the occurrence of hypoglycaemic episodes. The use of the dogs for the care of children and young people is still in its infancy. It is important to consider possible conventional methods to alleviate hypoglycaemia, such as extra education

The work of Medical Detection Dogs is in its infancy, but it is pioneering for many people with diabetes who have significant problems with hypoglycaemia awareness, which affects quality of life and functioning. The development of social media has exposed many new, novel and unconventional methods of diabetes management that can improve the lives of children with diabetes. It must be remembered that insulin pumps were

The role of the healthcare professional

Suitability

Conclusion

Podiatry Review Vol 72:1

viewed as a novel method of diabetes management 30 years ago. Diabetes healthcare professionals need to keep abreast of these newer and novel methods of diabetes management, to support their research and to signpost appropriate families who may benefit from such interventions.

Visit www.medicaldectiondogs.org.uk for further information about the work of Medical Detection Dogs.

Authors

Claire Pesterfield Lead Paediatric Diabetes Specialist Nurse, Addenbrooke’s Hospital, Cambridge Claire Guest Chief Executive Officer and Director of Operations, Medical Detection Dogs Simone Brainch Client Services Manager, Medical Detection Dogs Lydia Swanson Assistance Dog Instructor, Medical Detection Dogs

References

Chen M, Daly M, Williams G (2000) Non-invasive detection of hypoglycaemia using a novel, fully biocompatible and patient friendly alarm system. BMJ 321: 1565–6 Correa J (2011) The Dog’s Sense of Smell.

Alabama A&M and Auburn Universities, Alabama, USA Haugstvedt A, Wentzel-Larson T, Graue M et al (2010) Fear of hypoglycaemia in mothers and fathers of children with type 1 diabetes is associated with poor glycaemic control and parental emotional distress: a population-based study. Diabet Med 27: 72–8 Lim K, Wilcox A, Fisher M, Burns-Cox CJ (1991) Type 1 diabetics and their pets. Diabet Med 9: S3–S4 Rooney N, Morant S, Guest C (2013) Investigation into the value of trained glycaemia alert dogs to clients with type 1 diabetes. PLoS ONE 8: 1–12 Ward K, Dehlinger K, Tarnowski K et al (2013) Can trained dogs detect a hypoglycemic scent in patients with type 1 diabetes? Diabetes Care 36: e98–9 Wells D (2007) Domestic dogs and human health: an overview. Br J Health Psychol 12: 145– 56 Wells D, Lawson S, Siriwardena A (2008) Canine responses to hypoglycemia in patients with type 1 diabetes. J Altern Complement Med 14: 1235– 41 First published in Diabetes Care for Children and Young People Vol 3 No 2 2014 p 65 – 68 http://www.diabetescareforchildrenandyoungpeople.co.uk/journal-content/view/a-dog-is-forlife-not-just-for-hypos-medical-alert-assistance-d ogs-for-young-people

page 15

Continuing

Professional Development Supported by an educational grant from Galderma UK Limited

Hyperkeratosis H of the foot: part 1 Ivan Bristow, Lecturer, School of Health Professions & Rehabilitation Sciences, I University of Southampton.

I Introduction The plantar surface of the foot is a specialised area of skin.

Despite its relatively small surface area, its integrity is essential for normal locomotion and health. The key to its role, in part, is the thickened, keratinised epidermis. The process of keratinisation is a normal physiological mechanism which maintains viability by the generation of new epidermal cells in the basal layer and differentiation of the cells ascending through the epidermis. By the time they have reached the stratum corneum, cells have matured and finally desquamate from the

“ hyperkeratosis” 1. The most common cause of the condition on the foot is as a response to the intermittent forces of locomotion although many dermatological conditions may demonstrate hyperkeratosis as part of their pathophysiology. This article will review some of the causes of plantar hyperkeratosis and how they may be recognised clinically.

Approach to assessment As with all assessments, when approaching a patient with hyperkeratosis, a standard procedure should be followed: History Examination Further Tests

Table 1. Common causes of Plantar Hyperkeratosis • Mechanically induced • Dermatological disease • Infection • Drugs

page 16

History should encompass the normal details including medical history, family history (with particular attention to skin disorders), and medication. In addition, inspection of the patient’s footwear, an often neglected area, is important. Badly worn or incorrectly fitting shoes can lead to the development or aggravation of hyperkeratosis (see case study 1). Attention should be paid to the insock and lining as well as the sole and heel areas.

Podiatry Review Vol 72:1

Hyperkeratosis of the foot: part 1

result in a mild plantar rubrum Examination should be hyperkeratosis, carried out in particularly a methodicalT fashion. infections. a number of clues should be sought.

Firstly, it isDiagnostically, important to assess the skin of the foot and where Firstly, skin appears dry with a conditions chalky white appearance possiblethe legs, palms and arms.

Many may affect the 14 accentuated in skinand creases . Itching is can often The palms concurrently recognition of this aid absent. diagnosis.

It infection is usually one foot andareas can be is also pertinent toasymmetrical, question the affecting patient about other of confirmed mycology. the useOther of topical skin whichby may not be Management available for requires examination. key antifungal oral agents in more chronic infections. aspects are agents bulletedorbelow.

Attention should also be paid to the hands and groin which may harbour infection. symmetrical, asymmetrical, arch • Patternco-existing of hyperkeratosis: sparing?

Secondary syphilis, although uncommon, produces a psoriasis• Appearance of lesions elsewhere on the skin?

15 like eruption onthis the feel soles ofnormal the feetmechanical . Typicallykeratosis? beginning as • Texture: does like colour papules that develop a •coppery Is the hyperkeratosis easilyand liftedmacules, or well attached? surfaceofand central keratinous plugs.

•hyperkeratotic Visual examination individual lesions - magnifying lamp or dermatoscope. a contagious thescrapings skin by the Sarcoptes •Scabies Fungalis infection ruledinfestation out? Take of skin if suspected. scabei mite. Symptoms of severe itching develop around 4 weeks after exposure, worse when the patient is warm. Typically, it may Table 2. of the patient with occur around theExamination arch of the foot, mimicking eczematous-like hyperkeratosis eruptions in the very young. Debilitated and immunocompromised patients may develop crusted scabies which presents Plantar surface as• hyperkeratotic patches on the feet which are home to millions • Non-weight bearingin orsuch weight bearing of active mites. Treatment cases is oral areas? ivermectin.

• Symmetry • Texture and characteristics Hyperkeratosis due to drugs and other chemical agents Background erythema Any• patient presenting with a recent skin problem should be

questioned about medications and other chemical agents which • Legs and arms may be applied to the skin as a medicine or in the course of their • Examine where possible occupation or recreational pursuits. Particular attention should be• paid to any agents that were first used around the time the Palms eruption began.

Causation canmay onlybebemore confirmed the drug is • Signs of hyperkeratosis subtle ifhere discontinued and the symptoms then subside. Drugs including • Footwear lithium, gold salts, bleomycin, methyldopa and verapamil have • Inspect the shoes most frequently all been implicated as occasional causes.worn Arsenic intoxication • Internal and external assessment of the shoe of small, has also been shown to lead to the development punctuate plantar keratoses identical to seed corns16.

Causes of Hyperkeratosis In routine podiatry practice, mechanically induced skin changes are the most common cause of hyperkeratosis on the foot (as corns and callus). Thickening of the stratum corneum may be regarded as a physiological response to mechanical trauma2.

Burzykowski and colleagues3 in a study of over 70 000 adult feet found that around 10% suffered with the condition with an increased prevalence in women and with ageing. Such lesions can be a source of high pressure and lead to complications such as ulceration in the diabetic foot4. Mechanically induced hyperkeratosis will be discussed further in a future CPD article.

Non-mechanical hyperkeratosis Although no specific data is available, non-mechanically induced hyperkeratosis is probably less common in podiatric practice. From a clinician’s point of view, it is important to establish the differentiation between the mechanically induced and non-mechanically induced lesions as therapeutic success Figure Hyperkeratosis due tothe lymphatic relies3 :on elucidating causefailure and selecting an appropriate (taken from Dawber, Bristow & Turner ) treatment. For example, chronic, hyperkeratotic eczema on the 18

Lymphoedema plantar surface will not benefit from operative reduction and Chronic swelling of the leg (see has case many causes.

Typically may lead to other complications study 2). Table 3 lists lymphatic failure leads a painless swelling of the leg and foot. some of the causes of to non-mechanical hyperkeratosis.

Due to Water logging of a hyperplasia the restrictions onthe thedermis length leads of thistopublication it is of notoverlying possible skincover due to presence of growth factors to allthe these in detail and the readerand is cytokines. encouragedThis to in turn can tofurther hyperplasia skin with velvety or needs. warty research thelead topic if it isof ofthe relevance to their CPD like changes17. A brown coloured hyperkeratosis may occur overlying these plaques. Treatment for the underlying cause and Causesalong of non-mechanical reduction Table of the3.oedema with good skin care can hyperkeratosis frequently reverse these changes (Figure 3).

• Skin Disease • Psoriasis Rarely, hypothyroidism can lead to a diffuse plantar • Eczema / dermatitis hyperkeratosis of the palms and soles. Typically the patients are • Keratoderma blennorrhagica middle aged with a more severe eruption on the palms than on • Keratoderma climactericum the soles. The plantar surfaces may show patchy hyperkeratosis • Lichen planus with fissuring. The condition appears to be unresponsive to • Pityriasis rubra pilaris topical steroids but shows rapid improvement upon thyroxine • Palmo-plantar keratoderma (PPK) 19

Hypothyroidism

replacement therapy .

• Infection • Tinea pedis Keratoderma Palmo-plantar Plantar warts The• term palmo-plantar keratoderma (PPK) is given to a diverse • Scabies group of conditions which describe a hyperkeratosis • Syphilis affecting the palms and the soles of the sufferer. concurrently Traditionally, the term was used to describe those conditions • Drugs suspected to be genetic in origin, although it is generally • Lithium accepted that acquired types of PPK do occur as well.

• Verapamil Conditions causing PPK are distinguished by their genetics, • Bleomycin clinical appearance, symptoms and features additional to the • Systemic Disease palmo-plantar involvement. Stevens et al.20 attempted to classify Hypothyroidism the •disease by its presentation and described it as: • Lymphoedema • Diffuse (widespread plantar involvement, usually arch • Malnutrition sparing) • Zinc deficiency • Focal (discrete foci of thick hyperkeratosis on the plantar • surface) Internal malignancies • Idiopathic • Punctate (multiple corn-like presentation across the soles) • PPK with ectodermal dysplasias (such as altered sweat functioning, deafness, abnormal dentition, nail deformities andDisease neurological deficits) Skin Psoriasis affects around 2-3% of the population and in a subset Over 50 types have beenthe described many either of the inheritable of patients may affect plantarand surfaces as part of types have been well documented and readers directed to ita widespread eruption or as localised disease.areClassically, 21 review

by Itin and scaly Fistarol for further of presentsarticle as erythematous plaques.

Clues information to its presence specific Clinically, when confronted with suspected rely on conditions. its symmetrical presentation with sharply demarcated PPK it iswith important to obtain a fulland family history and examine borders a tendency to relapse remit.

Examination may the hands. of the palms with reveal the Hyperkeratosis disease elsewhere including the these scalp,conditions extensor may not of be the so obviously affected subtle scaling and similar surfaces elbows and knees.and Fingernail involvement may changes should whilst be noted.

Referral dermatologist maysubbe include pitting, toenails tendtotoashow onycholysis, required if a definitive and diagnosis being sought.

Management ungual hyperkeratosis rapid is growth.

Lifting the scale may of PPK be frustrating difficult.

Owingsign” to thewhich thickness lead to can pinpoint bleeding and known as “ Auspitz can of hyperkeratosis, anddebridement other topical aid the diagnosis.

On that emollients basis, scalpel of therapies psoriatic have little effect.

Oral retinoids are occasionally used to manage lesions is not recommended.

Management of the condition on the condition under the direction a consultant foot can be difficult althoughofemollients maydermatologist. be helpful in These drugs turnover and as a result cause thinning softening thereduce lesions.cell Topical steroids may be used to treat the of the epidermis, relieving from symptoms for the patient.

However, condition, but withdrawal them often leads to a worsening

Podiatry Review Vol 72:1

page 17

Malnutrition Zinc deficiency has been iscited as a cause of plantar Keratoderma blennhorragica an uncommon hyperkeratotic hyperkeratosis The condition itself is usually hereditary (as an eruption of the28.soles which is virtually indistinguishable from autosomal recessive or acquired through malnutrition. plantar psoriasis.

Thetrait) condition is a cutaneous manifestation of 28 Weissman has also presented cases of zinc deficiency occurring Reiters disease, a seronegative polyarthritis seen particularly in in patients with alcoholic cirrhosis of the liver who young men with the B 27 haplotype. demonstrated plantar involvement.

Keratoderma climactericum is a hyperkeratosis of the soles Summary which slowly develops in the heel and forefoot area and Hyperkeratosis the most common disorder ofplaques the adultwhich foot. develops into isnon-itchy, hyperkeratotic In most cases the causes mechanical in nature should be subsequently fissure andarebecome painful.

With and time, lesions managed appropriately.

A minority cases are are caused byora may develop on the palms.

Generally,ofthe lesions round rangeinof shape other conditions.

Effective treatment for these oval and are light in texture (See figure 1).requires Fungal a firm diagnosis.

Where is uncertain referral to a infection should be ruled the out aetiology by microscopy and fungal culture. specialist should be sought.

References 1.

MacDonald D. Histopathology of the skin. In: Hall-Smith P, Cairns R, eds. Dermatology:current concepts and practices. London: Butterworth; 1981.

2. Thomas SE, Dykes PJ, Marks R. Plantar hyperkeratosis: a study of callosities and normal plantar skin. J Invest Dermatol. Nov 1985;85: 394-397.

3. Burzykowski G, Molenberghs D, Abeck E, et al. High prevalence of foot diseases in Europe: results of the Achilles project. Mycoses. 2003;46: 496-505.

4. Young MJ, Cavanagh PR, Thomas G, Johnson MM, Murray H, Boulton AJ. The effect of callus removal on dynamic plantar foot pressures in diabetic patients.

Med. Jan-Feb 1992;9: 55-57.

FigureDiabetic 1: Keratoderma climactericum

page 18

5. Spuls Hadi Rivera L, Lebwohl M. Retrospective The diseasePI,was firstS,described in 1934

by Hauxthausen who analysis the treatment of psoriasis of the palms and soles. described theofcondition in menopausal women.

Subsequently J 9Dermatolog 2003;14 Suppl 2: 21-25.

Gram noted that Treat. typically women sufferers were moderately 9 6. Gong JQ, Lin L, and Linhad T, arthritis et al. of Skin colonization overweight, hypertensive the knees . Studies by so Staphylococcus aureus patients with eczema and atopic far have been unable to showina link to fluctuating oestrogen levels dermatitis and structure relevant has combined topical therapy: although collagen been demonstrated to bea double-blind randomized controlled trial. influenced by sex multicentre hormones10 and may explain the disease.

British Journal Dermatology.

Management of theofcondition as a 2006;155: first step 680-687. should include 11 7. Hauseremollient C, Wuethrich B, Matter L, Wilhelm intensive therapy . Fissuring can JA, be Sonnabend managed W, Schopfer Staphylococcus skin colonization in successfully with K. topical steroids as aureus a cream/ointment or as an ® atopic dermatitis Dermatologica.

1985;170: impregnated adhesivepatients. tape (Haelan , Typharm Ltd). 35-39.

Under 8. Onder M,and Atahan AC, Bassoy B. from the current access supply, podiatrists areFoot only dermatitis able to access mildly shoes.

Intcorticosteroids J Dermatol. Aug 565-567. potent topical (1%2004;43: hydrocortisone) and so referral 9. be Gram H. Keratoderma Archives Dermatol will necessary to obtain theClimactericum. more potent steroid preparations.

Syph. 1943;40.

10. Shuster S, Black M, McVitie E. The influence of age and sex on skin thickness, skin collagen and density. Brit J Dermatol. 1975;93: 639-643.

11. Robinson H. Keratoderma climactericum: a case study. J Brit Pod Med. 1997;52: 178-190.

12. Cram DL, Kierland RR, Winkelmann RK. Ulcerative lichen planus of the feet. Bullous variant with hair and nail lesions. Arch Dermatol. Jun 1966;93: 692-701.

13. Iraji F, Kiani A, Shahidi S, Vahabi R. Histopathology of Skin Lesions With Warty Appearance in Renal Allograft Recipients. American Journal of Dermatopathology.

2002;24: 324-325.

14. Bristow I. Tinea Pedis:diagnosis and management. Podiatry Now. 2004;7: S1-S8.

15. So SG, Kovarik CL, Hoang MP. Skin clues to a systemic illness. Secondary syphilis. Arch Pathol Lab Med. May 2006;130: 737-738.

16. Brown KG, Ross GL. Arsenic, Drinking Water, and Health: Figure 2 : Pityriasis rubra pilaris A Position Paper of the American Council on Science and Health.

Regulatory Toxicology Other dermatological conditions whichandmayPharmacology. give rise to 2002;36: 162-174. hyperkeratosis include lichen planus and pityriasis rubra pilaris.

17. Stoberl C, Partsch byH. lymphostatic The former is characterised itchy,[Congestive purple, flat topped papules papillomatosis]. around the ankles Hautarzt. and wristsJulof1988;39: adults. 441-446.

Occasionally, the 18. Dawber R, Bristow Turner W. A text atlas podiatric condition may involve I,the plantar surface and ofpresent as dermatology.

London: Martin Dunitz; 2000. may develop diffuse, yellow hyperkeratosis.

Rarely, ulcerations 19. the Miller Roling rubra D, Spiers A, Rawlings P, on sole12J, . Pityriasis pilarisE,is Davies an uncommon follicular Leyden J. which Palmoplantar keratoderma hyperkeratosis affects adults between theassociated ages of 40with and hypothyroidism.

British Journal appearance. of Dermatology.

60 leading to scaly plaques with yellow-red Palmo1998;139: 741-742. plantar involvement causes a diffuse hyperkeratosis (Figure 2).

20. Stevens Kelsell DP, resolve Bryant SP, et al.years, Linkage an Most cases HP, spontaneously in 2-3 butoforal American palmoplantar keratoderma and retinoids may pedigree hasten itswith remission.

Retinoids are described malignancy ectodermal dysplasia under the Section(palmoplantar ‘Palmo-plantar Keratoderma’ (pagetype 5). III) to 17q24. Literature survey and proposed updated classification of the keratodermas. Arch Dermatol. Jun Infections 1996;132: 640-651.

Warts commonly affect the foot and plantar lesions in particular 21. Itin PH, an Fistarol SK. Palmoplantar Clin may develop overlying hyperkeratosis keratodermas. hampering topical Dermatol.

Jan-Feb the 2005;23: treatment.

Diagnosing lesion 15-22. is straightforward but lesions 22. immuno-suppressed Howel-Evans W, McConnell Carcinoma of the in individualsR.(such as transplant oesphagus keratosis palmaris and plantaris recipients) may with be larger and more hyperkeratotic and(tylosis). require Quart J Med. 1958;27: 413. careful assessment, as malignant transformation is not uncommon in these patients13. Tinea pedis occasionally may

Podiatry Review Vol 72:1

Hyperkeratosis of the foot: part 1

thethe frequent side (a effects of the drug often meanand a proportion of of psoriasis “ rebound” phenomenon) so they are the patients unable to sustain the drugmay regime longtopical term. seldom used.are Dermatological management include 5 Typical side effects include dryness ofciclosporin the mouth, nose bleeds, vitamin D derivatives, oral retinoids, and PUVA . hair thinning, altered liver function and skeletal hyperostosis.

Eczema is another common skin disorder which may affect the Internal Malignancy and Hyperkeratosis foot.

Causes can be internal or external (such as allergens, Hyperkeratosis the palms and soles has been recognised irritants or skinof infections).

Chronic eczema of the footas isa marker of internal malignancy.and A number of rare (exaggeration forms of PPK hallmarked by hyperkeratosis lichenification 6 areskin known to with be associated with an increased risk of of creases a leathery texture) . Anecdotally, it may developing cancers.

For example, present as a internal diffuse plantar hyperkeratosis but Howel-Evans with a brittle syndrome is a familial form of PPK present a small number texture which bleeds when debridement is in undertaken.

Heel of families. those members of the family who develop the fissures are aOf common accompaniment to the disorder (see case palmo-plantar hold 95% chance of study 2). Wherekeratoderma, fissuring and they weeping areapresent, secondary developing an oesophageal carcinomaaureus, in later life22common . Other bacterial infection, with staphylococcus is very 7 similar associations have been reported in patients with in patients with eczema . Management, like psoriasis, requires 23 hereditary and diffuse gastric cancer and antibacterial in a population with emollients topical steroids although measures 24 cancer the oesophagus . co-existing infection if steroids are will be of required to treat any to be applied.

Aside from inheritable forms of PPK, a number of papers have published cases where PPK of the palms andfeet, soles hastypically been a Contact dermatitis can occur anywhere on the most marker forof internal malignancies of the lung,nickel bladder, stomach as a result sensitivity to adhesives, rubber, buckles and 25-27 and colon often preceding any internal symptoms.

Any adult leather dyes.

Most commonly it is seen as symmetrical, patient presenting a recent onset hyperkeratosis wheretoa hyperkeratotic areaswith on the dorsum of the feet, corresponding discernable is not apparent shouldAbethorough referred history for medical the points ofcause contact with the allergen. and assessment. patch testing can help rule out other causes such as mechanical irritant dermatitis, eczema and psoriasis8.

Hyperkeratosis of the foot: part 1

result in a mild plantar hyperkeratosis, particularly T rubrum infections. Diagnostically, a number of clues should be sought.

Firstly, the skin appears dry with a chalky white appearance accentuated in skin creases14. Itching is often absent. The infection is usually asymmetrical, affecting one foot and can be confirmed by mycology. Management requires the use of topical antifungal agents or oral agents in more chronic infections.

Attention should also be paid to the hands and groin which may harbour co-existing infection.

Secondary syphilis, although uncommon, produces a psoriasislike eruption on the soles of the feet15. Typically beginning as coppery colour papules and macules, that develop a hyperkeratotic surface and central keratinous plugs.

Scabies is a contagious infestation of the skin by the Sarcoptes scabei mite. Symptoms of severe itching develop around 4 weeks after exposure, worse when the patient is warm. Typically, it may occur around the arch of the foot, mimicking eczematous-like eruptions in the very young. Debilitated and immunocompromised patients may develop crusted scabies which presents as hyperkeratotic patches on the feet which are home to millions of active mites. Treatment in such cases is oral ivermectin.

Hyperkeratosis due to drugs and other chemical agents Any patient presenting with a recent skin problem should be questioned about medications and other chemical agents which may be applied to the skin as a medicine or in the course of their occupation or recreational pursuits. Particular attention should be paid to any agents that were first used around the time the eruption began. Causation can only be confirmed if the drug is discontinued and the symptoms then subside. Drugs including lithium, gold salts, bleomycin, methyldopa and verapamil have all been implicated as occasional causes. Arsenic intoxication has also been shown to lead to the development of small, punctuate plantar keratoses identical to seed corns16.

Figure 3 : Hyperkeratosis due to lymphatic failure (taken from Dawber, Bristow & Turner18)

Lymphoedema Chronic swelling of the leg has many causes. Typically lymphatic failure leads to a painless swelling of the leg and foot.

Water logging of the dermis leads to a hyperplasia of overlying skin due to the presence of growth factors and cytokines. This in turn can lead to hyperplasia of the skin with velvety or warty like changes17. A brown coloured hyperkeratosis may occur overlying these plaques. Treatment for the underlying cause and reduction of the oedema along with good skin care can frequently reverse these changes (Figure 3).

Hypothyroidism Rarely, hypothyroidism can lead to a diffuse plantar hyperkeratosis of the palms and soles. Typically the patients are middle aged with a more severe eruption on the palms than on the soles. The plantar surfaces may show patchy hyperkeratosis with fissuring. The condition appears to be unresponsive to topical steroids but shows rapid improvement upon thyroxine replacement therapy19.

Palmo-plantar Keratoderma The term palmo-plantar keratoderma (PPK) is given to a diverse group of conditions which describe a hyperkeratosis concurrently affecting the palms and the soles of the sufferer.

Traditionally, the term was used to describe those conditions suspected to be genetic in origin, although it is generally accepted that acquired types of PPK do occur as well.

Conditions causing PPK are distinguished by their genetics, clinical appearance, symptoms and features additional to the palmo-plantar involvement. Stevens et al.20 attempted to classify the disease by its presentation and described it as: • Diffuse (widespread plantar involvement, usually arch sparing) • Focal (discrete foci of thick hyperkeratosis on the plantar surface) • Punctate (multiple corn-like presentation across the soles) • PPK with ectodermal dysplasias (such as altered sweat functioning, deafness, abnormal dentition, nail deformities and neurological deficits) Over 50 types have been described and many of the inheritable types have been well documented and readers are directed to a review article by Itin and Fistarol21 for further information of specific conditions. Clinically, when confronted with suspected PPK it is important to obtain a full family history and examine the hands. Hyperkeratosis of the palms with these conditions may not be so obviously affected and subtle scaling and similar changes should be noted. Referral to a dermatologist may be required if a definitive diagnosis is being sought. Management of PPK can be frustrating and difficult. Owing to the thickness of the hyperkeratosis, emollients and other topical therapies have little effect. Oral retinoids are occasionally used to manage the condition under the direction of a consultant dermatologist.

These drugs reduce cell turnover and as a result cause thinning of the epidermis, relieving symptoms for the patient. However,

Podiatry Review Vol 72:1

page 19

5.

6.

Internal Malignancy and Hyperkeratosis Hyperkeratosis of the palms and soles has been recognised as a marker of internal malignancy. A number of rare forms of PPK are known to be associated with an increased risk of developing internal cancers. For example, Howel-Evans syndrome is a familial form of PPK present in a small number of families. Of those members of the family who develop the palmo-plantar keratoderma, they hold a 95% chance of developing an oesophageal carcinoma in later life22. Other similar associations have been reported in patients with hereditary diffuse gastric cancer23 and in a population with cancer of the oesophagus24.

Aside from inheritable forms of PPK, a number of papers have published cases where PPK of the palms and soles has been a marker for internal malignancies of the lung, bladder, stomach and colon25-27 often preceding any internal symptoms. Any adult patient presenting with a recent onset hyperkeratosis where a discernable cause is not apparent should be referred for medical assessment.

7.

8.

9.

10.

11.

12.

13.

Malnutrition Zinc deficiency has been cited as a cause of plantar hyperkeratosis28. The condition itself is usually hereditary (as an autosomal recessive trait) or acquired through malnutrition.

Weissman28 has also presented cases of zinc deficiency occurring in patients with alcoholic cirrhosis of the liver who demonstrated plantar involvement.

14.

15.

16.

Summary Hyperkeratosis is the most common disorder of the adult foot.

In most cases the causes are mechanical in nature and should be managed appropriately. A minority of cases are caused by a range of other conditions. Effective treatment for these requires a firm diagnosis. Where the aetiology is uncertain referral to a specialist should be sought.

17.

18.

19.

References 1.

2.

3.

4.

MacDonald D. Histopathology of the skin. In: Hall-Smith P, Cairns R, eds. Dermatology:current concepts and practices. London: Butterworth; 1981.

Thomas SE, Dykes PJ, Marks R. Plantar hyperkeratosis: a study of callosities and normal plantar skin. J Invest Dermatol. Nov 1985;85: 394-397.

Burzykowski G, Molenberghs D, Abeck E, et al. High prevalence of foot diseases in Europe: results of the Achilles project. Mycoses. 2003;46: 496-505.

Young MJ, Cavanagh PR, Thomas G, Johnson MM, Murray H, Boulton AJ. The effect of callus removal on dynamic plantar foot pressures in diabetic patients.

Diabetic Med. Jan-Feb 1992;9: 55-57.

page 20

20.

21.

22.

Spuls PI, Hadi S, Rivera L, Lebwohl M. Retrospective analysis of the treatment of psoriasis of the palms and soles.

J Dermatolog Treat. 2003;14 Suppl 2: 21-25.

Gong JQ, Lin L, Lin T, et al. Skin colonization by Staphylococcus aureus in patients with eczema and atopic dermatitis and relevant combined topical therapy: a double-blind multicentre randomized controlled trial.

British Journal of Dermatology. 2006;155: 680-687.

Hauser C, Wuethrich B, Matter L, Wilhelm JA, Sonnabend W, Schopfer K. Staphylococcus aureus skin colonization in atopic dermatitis patients. Dermatologica. 1985;170: 35-39.

Onder M, Atahan AC, Bassoy B. Foot dermatitis from the shoes. Int J Dermatol. Aug 2004;43: 565-567.

Gram H. Keratoderma Climactericum. Archives Dermatol Syph. 1943;40.

Shuster S, Black M, McVitie E. The influence of age and sex on skin thickness, skin collagen and density. Brit J Dermatol. 1975;93: 639-643.

Robinson H. Keratoderma climactericum: a case study. J Brit Pod Med. 1997;52: 178-190.

Cram DL, Kierland RR, Winkelmann RK. Ulcerative lichen planus of the feet. Bullous variant with hair and nail lesions. Arch Dermatol. Jun 1966;93: 692-701.

Iraji F, Kiani A, Shahidi S, Vahabi R. Histopathology of Skin Lesions With Warty Appearance in Renal Allograft Recipients. American Journal of Dermatopathology.

2002;24: 324-325.

Bristow I. Tinea Pedis:diagnosis and management. Podiatry Now. 2004;7: S1-S8.

So SG, Kovarik CL, Hoang MP. Skin clues to a systemic illness. Secondary syphilis. Arch Pathol Lab Med. May 2006;130: 737-738.

Brown KG, Ross GL. Arsenic, Drinking Water, and Health: A Position Paper of the American Council on Science and Health. Regulatory Toxicology and Pharmacology.

2002;36: 162-174.

Stoberl C, Partsch H. [Congestive lymphostatic papillomatosis]. Hautarzt. Jul 1988;39: 441-446.

Dawber R, Bristow I, Turner W. A text atlas of podiatric dermatology. London: Martin Dunitz; 2000.

Miller J, Roling D, Spiers E, Davies A, Rawlings P, Leyden J. Palmoplantar keratoderma associated with hypothyroidism. British Journal of Dermatology.

1998;139: 741-742.

Stevens HP, Kelsell DP, Bryant SP, et al. Linkage of an American pedigree with palmoplantar keratoderma and malignancy (palmoplantar ectodermal dysplasia type III) to 17q24. Literature survey and proposed updated classification of the keratodermas. Arch Dermatol. Jun 1996;132: 640-651.

Itin PH, Fistarol SK. Palmoplantar keratodermas. Clin Dermatol. Jan-Feb 2005;23: 15-22.

Howel-Evans W, McConnell R. Carcinoma of the oesphagus with keratosis palmaris and plantaris (tylosis).

Quart J Med. 1958;27: 413.

Podiatry Review Vol 72:1

Hyperkeratosis of the foot: part 1

the frequent side effects of the drug often mean a proportion of the patients are unable to sustain the drug regime long term.

Typical side effects include dryness of the mouth, nose bleeds, hair thinning, altered liver function and skeletal hyperostosis.

Hyperkeratosis of the foot: part 1

23. Robertson EV, Jankowski JA. Genetics of Gastroesophageal Cancer: Paradigms, Paradoxes, and Prognostic Utility. The American Journal of Gastroenterology. 2007;102: 1-7.

24. Ilhan M, Erbaydar T, Akdeniz N, Arslan S. Palmoplantar keratoderma is associated with esophagus squamous cell cancer in Van region of Turkey: a case control study. BMC Cancer. 2005;5: 90.

25. Murata I, Ogami Y, Nagai Y, Furumi K, Yoshikawa I, Otsuki M. Carcinoma of the stomach with hyperkeratosis palmaris et plantaris and acanthosis of the esophagus. Am J Gastroenterol. Mar 1998;93: 449-451.

26. Cuzick J, Harris R, Mortimer PS. Palmar keratoses and cancers of the bladder and lung. Lancet. Mar 10 1984;1: 530-533.

27. Powell F, Mackey JP. Bronchial carcinoma and hyperkeratosis palmaris et plantaris. Postgrad Med J. Jan 1981;57: 57-59.

28. Turgut S, Ergin S, Turgut G, Erdogan BS, Aktan S. The role of essential and non-essential elements in Mal de Meleda. J Basic Clin Physiol Pharmacol. 2007;18: 11-19.

29. Weismann K, Hoyer H, Christensen E. Acquired zinc deficiency in alcoholic liver cirrhosis: report of two cases.

Acta Derm Venereol. 1980;60: 447-449.

Acknowledgements Original article published in Podiatry Now June 2008 Thanks go to Ivan Bristow and the Society of Chiropodists and Podiatrists for permission to reproduce the article in its entirety.

Case Study 1

Case Study 2

A 70 year old woman presented to the clinic with a scaly, symmetrical hyperkeratosis affecting both heels. The condition had been gradually worsening, but now was becoming uncomfortable for the patient who enjoyed walking (Figure 4). Her medical history revealed nothing of note.

Examination of the hyperkeratosis showed a close relationship to the heel area of the insock of Figure 4 her favourite shoes, which showed a high sheen (Figure 5).

It was suspected that the motion of the sole over the insock was leading to inflammation of the skin and the development of the hyperkeratosis. The insole was removed and replaced with a simple cushioning insole. The hyperkeratosis subsided within a few weeks.

A 45 year old man presented with hyperkeratosis and fissuring to the plantar surface of the feet. Prior to this, he had had regular debridement and reduction with a Moores disc but this had proven unsatisfactory as the callus would frequently bleed (Figure 6). The patient’s history revealed that he had suffered intermittently with eczema elsewhere on the body. Moreover, the hyperkeratosis on the foot was variable and not related to activity levels. On examination, the soles of the feet were hyperkeratotic with a vague erythema and fissuring around the heels. The texture of the hyperkeratosis was light and brittle. A diagnosis of chronic plantar eczema was made and he was treated for 10 days using a potent topical steroid and emollients*.

Figure 6

Figure 5

* For guidance on the use of emollients, please refer to the earlier CPD article on “ Emollients: selection and application” in the September 2005 edition of Podiatry Now.

Podiatry Review Vol 72:1

page 21

Reflection After reading this CPD article spend some time reflecting on its content, using the sub-headings as prompts. Keep the reflections, notes and key points in your CPD portfolio 1. How would you define hyperkeratosis?

2. What are the main causes of hyperkeratosis on the feet?

3. What percentage of my own caseload may have hyperkeratosis attributable to causes other than mechanical?

4. Will this article change my practice at all? If so how?

5. How will this impact on the care of my patients / service users?

6. After reading this, have I identified any new CPD needs (for example revision of specific topics, acquisition of new skills etc).

page 22

Podiatry Review Vol 72:1

Hyperkeratosis of the foot: part 1

Post-reading activity

OBITUARY

Eileen Jeffery

Memories of Buckingham Palace Garden Party

I was sorry to learn of the death of Eileen Jeffery, whom I knew from way back when her husband George, was the Honorary Treasurer of the Institute.

Eileen and George ran the Conferences in Solihull for about ten years and were always cheerful and welcoming.

In the late 1980’s, the Institute was awarded places at one of the Buckingham Palace Garden Parties and Eileen was one of those picked to attend along with the President at the time, Stanley Harrison.

Others included Margaret Harper, Jean and Philip Basham, Stewart Cole, David Crew, my late husband Jim and myself.

(Apologies to anyone I have forgotten to include).

We met just before 2pm at the Palace gates and joined one of the queues. All of us dressed in our best, including hats for the ladies. The queue meandered round the railings and in through a side gate, across to the arched walkways in the middle and into the inner quadrangle where we entered the Palace through the grand entrance, up lots of stairs. The splendour of the entrance hall was breathtaking. We then moved slowly through various rooms, all somewhat awe struck at the sumptuous furnishings,

paintings and chandeliers, until we reached the terrace which overlooks the back garden. There you had a vista of tents, seats, bands and lots of people, some had formed lines already for the Royal party.

We took Margaret Harper’s advice, gained from one of her patients who had been before, and got a table and chairs beside the tea tent. We queued for our cups of tea, served from one of the enormous silver samovars and small armed with a plate of goodies, enjoyed these whilst people watching.

Finishing our tea, we moved over to one of the lines to await the arrival of HM The Queen and The Duke of Edinburgh. At the appointed time, I think 4 o’clock, the military band struck up the National Anthem and there was the Queen and the Duke standing on the terrace. They each then went down separate lines and were introduced to various extra special guests, who had been lined up in small groups in the middle of the lines. Various other members of the Royal Family were traversing down similar lines all leading to the royal tea tent. It took the Queen about an hour to reach the Royal tent where Diplomats and Ambassadors were waiting.

I was very saddened to learn of Robert’s recent death. He was a true ‘gentle’ man in every sense of the word.

I remember Robert from my early days with the Institute. He was always very kind to me and it was a real pleasure working with him whilst he served as a Director of the Institute. Robert was such a lovely person, who was always quick to help whenever he could. Even though he had retired from the Executive Committee, Robert always kept in touch with the girls and I at Head Office, and I am sure that I, along with all who knew him, will miss him dearly.

Good night and God bless Robert, Jill Burnett-Hurst, Company Secretary

He and his wife Agnes, became dear friends of my late husband Jim and myself and he sent me a lovely letter when Jim died.

My sincere thoughts and prayers go to Agnes and family.

Susan Kirkham, Former Secretary

Robert Cleary

I was so sorry to hear of the passing of Robert Cleary. For many years he held the position of Scottish Area Delegate to the Executive Committee and served the members in that area very well.

He was a great support to the National Officers and especially to us all in Head Office at the time.

I first met Robert at an Open Study Group week-end in 1986. The group had come to Dundee to visit the factory of Ross Fraser. I travelled back on the coach to Edinburgh next to Robert. He told me he was a member of the Institute of Chiropodists (as it was at that time.)

He encouraged me to join the Institute and the rest is history……. Robert was a tremendous help and encouragement to me in the early days of my career.

We regularly travelled to the AGM’s held at that time in various parts of the country.

Robert was a delegate to the Scottish Area Council and then moved on to the Executive as the Scottish area delegate.

He was totally committed to the

Podiatry Review Vol 72:1

Among several well known faces that were in attendance, I remember seeing the late Earl Spencer and his wife striding across the grass together with a few other recognisable “celebs”.

We then walked round the gardens, which are lovely and found ourselves looking through the windows of the large summerhouse. Chairs were formed in a semi-circle, looking outwards, with a large chair in the middle.

After wandering to the lake and admiring more flower beds, we were allowed to walk out through the Palace the way we had come and to gaze again at the paintings and chandeliers.

It was a lovely day and one which I am sure we all remember. Outside official photographers were taking your photograph. No photographs allowed in the Palace. I still have the one of Jim and I to this day. Hopefully Eileen’s family will still have hers too.

Susan Kirkham, Former Secretary

Institute and served on that committee for a number of years. He was also a man who committed his life to God at an early age and served on the Executive of a number of churches in the Glasgow area, devoting much of his spare time to church work. He played a key role in establishing a number of new churches over a period of time.

He was also a great family man, and loved to spend time with his family including the grandchildren.

During the last few years, Robert’s health deteriorated, but he never complained at any time, always thinking of his wife, Agnes, who also suffered poor health.

Our thoughts and prayers are with Agnes and the family at this sad time.

I have absolutely no doubt whatsoever that, as he went to meet his Maker, Robert would be greeted with these words, ‘Well done, good and faithful servant’ He is now absent from the body, present with the Lord.

Robert Beattie, Former Chairman

page 23

DIABETES NEWS

Prediabetes: what’s it all about?

During the last few weeks, prediabetes has been talked about a lot in the media. But there is still some uncertainty around what it Simon O'Neill actually means.

Here Simon O’Neill, Director of Healthcare and Professional Liaison, explains just why it’s important that we identify people who have a high chance of getting Type 2 diabetes and do all we can to help them avoid it if they can.

“We know that doctors use a range of terms such as prediabetes, borderline diabetes, Impaired Fasting Glucose (IFG), Impaired Glucose Tolerance (IGT) and Impaired Glucose Regulation (IGR). And these might sometimes sound confusing.

Your first question might be ‘does this mean I have Type 2 diabetes?’, ‘does this mean I’ll definitely get Type 2 diabetes?’ or even ‘does this mean I’m in the clear?’

“The answer to all of these is no. You don’t have Type 2 diabetes at the moment, but you do need to act now if you want to try and avoid it.

“Simply put, these terms can all be used to explain that your blood glucose levels are higher than normal, but not high enough for you to be diagnosed with Type 2 diabetes.

They are largely based on an individual

measurement of your blood glucose levels, regardless of any other factors. Having high blood glucose levels can increase your risk of developing Type 2 diabetes and other health complications, although this is not inevitable.

“Prediabetes isn’t actually a clinical term which is recognised by the World Health Organization. In fact, the American Diabetes Association has set the level for prediabetes at a blood glucose measurement of HbA1C 5.7% (39mmol/mol) but it is the only organisation which uses this criteria. In the UK there is no defined criteria for prediabetes or borderline diabetes.

“So why do some clinicians still use it?

Well we know that sometimes it can be useful when explaining your individual risk of developing Type 2 diabetes. It emphasises how serious it is to have high blood glucose levels. Between 5% and 10% of people with prediabetes go on to develop Type 2 diabetes each year.

“It can also be helpful when looking into the risk of Type 2 diabetes within a population. So, knowing that up to 18 million people in the UK potentially fall into this category highlights the need for public health interventions in order to avoid a dramatic increase in Type 2 diabetes.

“At Diabetes UK, we use another way of measuring someone’s risk of going on to develop Type 2 diabetes. Our risk score was developed in partnership with the University of Leicester and it determines the

likelihood of getting Type 2 diabetes based on seven different risk factors, including family history, age and BMI. It doesn't look at blood glucose levels.

"If you haven’t already found out your risk, why don’t you head over to our online risk score which only takes a few minutes to complete, or see whether we have a Healthy Lifestyle Roadshow coming to your area where you can be risk assessed.

Riskscor.diabetes.org.uk/start “Whether you’re found to be at risk using our online tool, or whether your doctor has told you that you have prediabetes or any of the other similar terms I’ve mentioned, this means you have a higher chance of developing Type 2 diabetes, which is a lifelong condition. Knowing this is the first step to being able to do something about it.

“Around 80% of cases of Type 2 diabetes could be delayed or prevented through making lifestyle changes. Eating a healthy balanced diet, low in salt, sugar and fat and rich in fruit and vegetables, as well as being physically active is the best way of reducing your risk. Even if you’re not overweight, maintaining a healthy weight through eating well and being active is an important part of managing blood glucose levels and avoiding other health complications.

“Of course, it’s not just down to you.

Healthcare professionals should support all people who have a higher risk of Type 2 diabetes, whichever way this has been identified.”

Journeys made by foot fall by a third in less than 20 years

The number of journeys made on foot has fallen by a third (30 per cent) in less than 20 years, according to a new analysis

by Diabetes UK. The analysis, based on the National Travel Survey, suggests that people made an average of 203 journeys by foot in 2013, which is significantly down on the average of 293 journeys in 1995.

The number of journeys made on foot now accounts for just a fifth (22 per cent) of journeys, while over two thirds (64 per cent) are made by car or van.

Diabetes UK says that this should act as a wake-up call for people to walk more, as walking is a good way to incorporate physical activity into your daily routine.

Walking, along with other physical activity, can play an important role in maintaining a healthy weight, which in turn reduces risk of developing Type 2 diabetes. For the 3.8 million people in the UK who have

page 24

diabetes, regular physical activity is also important for managing their condition.

To help encourage physical activity, as well as raise money to help it continue with its work, Diabetes UK has partnered with Truvia, no-calorie sugar alternative’, to organise the Walk for Diabetes series.

They are encouraging people to sign up to the final walk of 2014, the London Bridges Challenge on Sunday, 2 November.

Simon O’Neill, Diabetes UK Director of Health Intelligence and Professional Liaison, said: “Leading an active lifestyle and eating a healthy balanced diet are important steps to take to reduce your risk of Type 2 diabetes – or to help manage diabetes if you already have it. There is now strong evidence that you are much more likely to stick to a type of physical activity if you can incorporate it into your daily routine. This is why things like regular walking, or cycling to work rather than

Podiatry Review Vol 72:1

taking the bus, are great ways to get more physically active and this is why it is a real cause for concern if all of us are now walking less.

“We hope that as well as helping raise vital funds for us to help people with diabetes or those at high risk of the condition, our London Bridges Challenge can play a part in getting into the habit of walking.”

Tony Lucas, from Truvia, said: “We are delighted to be supporting Diabetes UK London Bridges Challenge. Being active and eating a balanced diet is vital to leading a healthy lifestyle and this event really embraces that ethos. We look forward to getting the message out there about how important it is to get physically active and healthy to help reduce your risk of Type 2 diabetes.”

Diabetes-related kidney failure predicted to almost double over next 10 years The number of people with diabetes in England and Wales who have kidney failure is set to almost double in the next 10 years, according to a new analysis by Diabetes UK. If the rate of diabetes-related kidney failure stays the same, then the projected increase in diabetes prevalence would mean the number of people with diabetes-related kidney failure would rise from about 18,800 this year to 35,000 by 2025.

Kidney failure is one of the most severe and life-threatening complications of diabetes and the most expensive to treat, with costs of diabetes-related kidney failure currently running at £940 million each year. So the projected increase in diabetes-related kidney failure would cost the NHS hundreds of millions of pounds.

Diabetes is the most common cause of end-stage kidney failure which generally requires dialysis or a kidney transplant. But the risk of kidney disease can be cut by half by keeping control of blood glucose and blood pressure and crucially, if recognised early, its progress can be stopped or significantly slowed.

A series of annual checks should be part and parcel of the healthcare received by people with diabetes, as directed by NICE. Two of these are around blood glucose and blood pressure; as well as helping prevent kidney failure, these are also important

for preventing other diabetes-related complications such as heart disease and stroke.

But one of the checks for kidney function, which involves testing the urine for the presence of a protein called microalbumin, is the least carried out care process and figures from the latest National Diabetes Audit show that about a quarter of people do not get this check.

This is a concern because if people have microalbumin in their urine that is an early warning sign that there is something wrong with the kidneys. If kidney failure is identified at this stage, it can often be treated successfully. So the fact that one in four people is missing out on this check means they are putting the health of their kidneys at risk.

Barbara Young, Chief Executive of Diabetes UK, said: “It is a real cause for concern that, if we were to continue along the same path, our ageing population and the growing numbers of people with diabetes mean we would be faced with a huge rise in diabetes-related kidney failure. This would have awful consequences, as kidney failure has a devastating impact on people’s lives and is one of the reasons that so many people with diabetes die prematurely.

“A big part of addressing this is making sure that people get the education and ongoing support they need to keep their blood glucose and blood pressure at a healthy level. But at the moment, too

Postcode Lottery

Barbara Young, Chief Executive of Diabetes UK, said: “It is deeply worrying that there is a postcode lottery in diabetes healthcare and also huge variation in the proportion of people who have their diabetes under control. This has serious implications because unless someone has their condition under control they are at higher risk of health complications such as amputation, blindness, kidney failure and, ultimately, early death.

“We would like to think these new figures would act as a spur for the NHS and the Government to set out urgently how they intend to improve diabetes healthcare. But this is just the latest in a long line of statistics that show that diabetes healthcare is hugely geographically variable and

DIABETES NEWS

many people have levels that are running dangerously high and this is putting their future health at risk.

“We also want to see a much higher proportion of people with diabetes getting their kidney checks, as if they do develop kidney problems then it is vital they are identified as early as possible.

The consequences of missing the early signs can be devastating. People with diabetes need to remember to take their urine sample as instructed and not put it off or think it does not matter because they have remembered to have their blood test.

“Everyone with diabetes should be getting this annual check, which is one of our 15 Healthcare Essentials. These are the checks and services that everybody with diabetes should have access to in order to be able to manage their condition properly. It is important that people with diabetes and the healthcare professionals that treat them understand that every precaution needs to be taken to avoid chronic kidney disease.”

To reduce the risk of developing kidney disease if you have diabetes it is important to keep your blood glucose and blood pressure within target range, aim for a healthy weight and, if you smoke, to seek help to quit.

For more information about the 15 Healthcare Essentials and to fill in our survey about the care you are getting go to www.diabetes.org.uk/15-essentials

in many places is not good enough. The public deserve more than politicians and NHS leaders wringing their hands about it but then failing to do anything meaningful to try to fix it.

“It is not even clear in the reformed NHS whose job it is to hold poorly performing areas to account. The end result is that while some areas provide good quality care, too many people have substandard care that is putting their future health at risk. We are supposed to have a national health service and it’s time the Government put the ‘N’ back in ‘NHS’ by insisting that everyone with diabetes gets the care they need, wherever they happen to live.”

Podiatry Review Vol 72:1

page 25

FIRST AID ARTICLE

Management of Anaphylaxis First Aid

A

David Crew OStJ, FInstChP, DChM

naphylaxis is the clinical syndrome that represents the most severe allergic reaction. It is a medical emergency that requires immediate medical attention.

If such medical attention is delayed, death may occur most commonly from cardiovascular collapse or airway obstruction.

Although any substance has the potential to cause anaphylaxis, the most common causes are Bee and insect bites, pollens medications, latex, foodstuff especially peanuts and any other nut compound.

Signs, Symptoms and First Aid Treatment of Anaphylaxis In an anaphylactic reaction, chemicals are released into the blood that dilate the blood vessels and constrict the air passages. The blood pressure falls and breathing is impaired.

The tongue and throat can swell, increasing the risk of hypoxia.

General recognition: ● Anxiety ● Widespread red, blotch skin blotchy skin eruption. (see Urticaria below) Swelling of the tongue and throat. ● Puffiness around the eyes. ● Impaired breathing & Wheezing.

Urticaria

Urticaria

Anaphylaxis is a medical emergency that requires immediate treatment with an injection of epinephrine in dosages of 0.30.5 mL of a 1:1000 dilution, the intramuscular route is the area of choice with the thigh being the largest area of muscle with a good blood supply.

The dosage for children is 0.01 mL/kg, up to a maximum of 0.3mL of a 1:1000 dilution. Epinephrine can be re-injected every 5-15 minutes until there is resolution of the anaphylaxis.

The use of an Auto- injector pre- sprung EpiPen once only syringe is the most common item in the self treatment of anaphylaxis, with the patient being issued with their own EpiPen, which is a prescriptive item.

Packaging varies from a distinctive self injection into thigh muscle Triangular box, to the new type above.

Patients should be encouraged to carry a card or be advised to obtain a Medic Alert or SOS Talisman bracelet or necklace.

page 26

Packaging varies from a distinctive Triangular box to the new type above

Self injection into thigh muscle

First Aid Action: 1. Call for an ambulance immediately 2. Check if patient is carrying epi-pen for self administration; help to use it, if so required.

3. If the patient is conscious help to sit up in a position that relieves any breathing difficulty.

4. If the patient becomes unconscious, open the airway, check breathing and be prepared to give rescue breaths and chest compressions. (New procedure August 2005) 30 chest compressions to 2 rescue breaths).

History of Epinephrine (Chemical Formula: - C9H13NO3)

The American William Bates reported the discovery of a substance produced by the suprarenal gland during May of 1886. Epinephrine was isolated and identified in 1895 by Napoleon Cybulski a Polish physiologist. The discovery was repeated in 1897 by John Jacob Abel. Jokichi Takamine discovered the same hormone in 1900, without knowing about the previous discovery: but in later years, counter evidence is shown from an experiment note that the Takamine team is the discoverer of the first adrenaline which was artificially synthesized in 1904 by Friedrick Stolz.

Although widely referred to as “adrenaline” worldwide the general term is “epinephrine” because “adrenaline” bore too much similarity to the Parke, Davis & Co trademark “adrenalin” (without the “e”) this being a registered trade mark.

Health professionals usually refer to epinephrine when treating anaphylaxis rather than adrenaline, we should however note that when referring to pharmaceuticals that mimic the actions of epinephrine/adrenaline we refer to these as “adrenergics” References:

The author has cited items from the following: 8th Edition First Aid Manual.

Simons FER. Anaphylaxis of Infants, Children & Adolescents 2002 Ellis AK & Day JH. Allergy to Insect bites and stings 1996 Ellis AK & Day JH Diagnosis and Treatment of Anaphylaxis 2004 Resuscitation Council (UK)

Podiatry Review Vol 72:1

OFFERS

Southport is looking

forward to welcoming delegates to the 2015 IOCP Conference

and has put together a super ‘Partner Perks Programme’ especially for members. The aim is to encourage delegates to bring their partners along for the weekend in order to enjoy the fabulous facilities the resort has to offer

keep looking at our website www.iocp.org.uk for more offers

available

Ramada Plaza Hotel, Promenade www.RamadaPlazaSouthport.co.uk

FREE Accommodation

for partners sharing with a delegate. Breakfast £10 if taken. Please quote ‘IOCP Conference’

Trattoria 51, Promenade www.trattoria51.com

FREE Dessert

with every main course (lunch or dinner). Please quote ‘IOCP Conference’

El Rincon Bodega, Lord Street Buy one cocktail get 2nd HALF PRICE. Please quote ‘tourism’

Lavender House Spa, Manchester Road (just off Lord Street) www.lavender.house

Cupcakes & Bubbles Spa Package

* Full Body Massage or Rasul Mud Temple Experience & Pore Refining Express Facial * Thermal Suite (Aromatherapy Steam Room with Salt Inhalation & Herbal Sauna) * A selection of Freshly Baked Cakes & Glass of Bubbles Normally £69 per person 10% OFF. Please quote 'tourism'

Podiatry Review Vol 72:1

page 27

CONFERENCE PROGRAMME

page 28

Podiatry Review Vol 72:1

AGM BOOKING FORM

Podiatry Review Vol 72:1

page 29

BRANCH NEWS

page 30

Podiatry Review Vol 72:1

BRANCH NEWS

Cheshire and North Wales Branch Meeting 19th October 2014 The Dene Hotel - Chester was again our chosen venue to spend our Sunday morning enjoying fellow branch members’ company and gaining some useful CPD content.

Our guest speaker this time was Barbara Coppack from the Macular Degeneration Group.

Barbara gave a very interesting and informative talk on the various types of this all too common condition, its treatments and its’ effect on the sufferer. A common point which was raised repeatedly which was useful to learn was to use strong and contrasting colours in their daily lives enabling them to distinguish between objects more easily. Sadly though some forms can be treated it cannot be cured. Q & A's were many as most members had patients who suffer from some degree of this condition and were interested to learn more.

During the coffee break we had opportunity to visit and buy items from the C & P Medical team who were good enough to set up a trade stand for us to buy goodies from. The remainder of our meeting discussed the forthcoming events such as the branch First Aid Course 16th November and next year’s 60th AGM in Southport. All members were in agreement that it will be a special occasion and that the branch will give as much support as possible. A few female members who attended this year’s AGM also commented that they hoped the Body Builders Competition would be on at the same time again too for entertainment!

Special mention and self congratulations were given for our award of the ‘Best Branch’ and opportunity given to view the shield.

Wound up meeting relatively promptly as Liverpool FC were kicking off at 1.30pm and certain members were keen to be home for the start…

Phil Yeomans

West Middlesex Branch The West Middlesex Branch meets on Mondays, bimonthly, at 8pm. The members travel from Buckinghamshire, Hertfordshire and Middlesex. We usually have a meal then we ‘catch-up’ with each other’s news before the meeting begins .

The members are informed about various matters and correspondence from the IOCP. Clinical and Podiatry issues are then discussed and we share useful podiatry information.

A few West Middlesex Branch Committee members

We are a friendly and supportive group and although numbers have dropped in recent years due to retirement, members moving away and sadly members passing away.

We have had talks from various health professionals which have been well attended. To date, not all the members have met each other, however, I'm sure it will be worth the wait.

Hyacinth Tyrrell, Branch Secretary

Podiatry Review Vol 72:1

page 31

INFORMATION ARTICLE

Protect your skin - How specialist skin care can turn from a luxury to a necessity for diabetes patients Greet Claes, BSD, MSc (science biomedical, orientation cosmetology) Head R&D NAQI® Lindsey Upton, NAQI® Product Consultant The skin and its function Our skin is a living organism and forms an excellent barrier. This barrier reduces water loss through the skin. It also stops anything getting in from outside.

The skin is a complex structure with 3 layers; the epidermis, the dermis and the hypodermis.

The lowest or basal layer of the epidermis is the active, dividing layer. These cells are continually dividing and multiplying and then rise gradually to the surface. Here they undergo changes from living cells (keratinocytes) to dead cells (corneocytes) which are ultimately lost either naturally or by aggression such as detergents or exfoliation.

This continuous process of division and shedding takes about 28 days, but slows with ageing. The dead cells are surrounded by a lamellar lipid structure which is made up of layers of water and lipids. This structure forms the outer layer of the skin and is called the stratum corneum. The outer layer can be compared to a wall and is often referred to as having a bricks and mortar structure. It consists of corneocytes (bricks) which are bound to the lamellar lipid structure (mortar). This structure is essential for an effective barrier and will prevent excessive water loss (trans-epidermal water loss), as well as the penetration of irritating substances. To prevent a drop in water level and skin dehydration, water is constantly sourced from the deeper layers.

Diabetic patients lose more water through urination and usually do not drink enough which causes a lack of water which means that the skin dehydrates quickly. Dry skin is common all over the body but, in most cases it is worse on the extremities: legs, feet, knees, elbows and hands which results in a less supple and cracked skin.

Dry skin In case of dry skin, the unique lamellar lipid structure is damaged and the function of enzymes is slowed. Therefore the stratum corneum is less structured and this weakens the barrier function of the skin. More water evaporates and irritating substances and micro-organisms can penetrate more easily.

This can become a vicious circle; once the barrier is damaged, the protection lessens

page 32

and irritations, allergies and infections are more common. These will weaken the barrier even more. The prevention of dry skin in diabetes patients is therefore necessary as dry cracked skin easily leads to infections which can cause serious complications.

Skin ageing The dermis consists of proteins, collagen and elastin which form a matrix and retains moisture. The dermis gives the skin its suppleness and elasticity. Damage to dermal proteins causes the skin to age.

Collagen and elastin react with sugars to form AGEs (advanced glycation end products) which cause the loss of elasticity and a dull wrinkled skin. Because of a higher blood sugar level and a higher level of AGEs, diabetes patients often have premature skin ageing.

A specialised skincare routine with specific diabetes products can slow down this process.

Daily skincare A healthy life style and control of blood sugar levels are the fundamental basis of diabetic care. Skin cleansing is necessary to maintain healthy skin. The goal is to remove impurities and micro-organisms without disrupting the skin’s natural balance and removing the skin lipids.

Water alone is not sufficient to cleanse.

Soaps can thoroughly cleanse, but have a high pH level. A change in the skin’s pH level combined with cleansing can harm the skin’s barrier.

skin is well hydrated and the barrier is working well.

A body lotion with a natural base with ingredients such as glycerine and panthenol, is recommended.

Do not apply any moisturising products between the toes as micro-organisms easily multiply in warm and moist environments; To intensively hydrate the skin and to slow down premature skin ageing, a product with carnosine and antioxidants such as Naqi Body Care and Naqi Foot Cream are recommended to prevent the formation of AGEs. How healthy is your skin?

The key factor to prevent diabetes-related skin problems is to keep diabetes under control: There are 6 warning signs of a diminished resistance to infections 1. Has your skin become visibly thicker?

2. Has your skin become visibly drier?

3. Is your skin shedding?

4. Is your skin showing cracks?

5. Has your skin become yellower?

6. Do small wounds heal slower?

If the reply to any of these 6 questions is yes, then using specialised diabetes skin care Cleansing with a gentle soap-less cleanser products such as Naqi’s Diabetes range and (pH neutral), such as Naqi’s Body Soap, is following a better skin care routine need to recommended for daily use. Gentle cleansing be your first priority to avoid further is necessary to prevent the dissolving of lipids problems and complications. and damage to the skin’s barrier. The amount of foam is not a sign of intensive cleansing. In fact, the more foam, the higher the risk of For further information please contact: irritation. After cleansing the skin must Lindsey Upton at uptonlindsey21@gmail.com always be carefully rinsed with lukewarm or 07860 805015. water – never hot. The skin must always be carefully dried especially between the toes.

Top diagram courtesy Afterwards the skin must be moisturised with a body lotion such as Naqi’s Body Lotion, to keep a soft and firm which is a sign than the

Podiatry Review Vol 72:1

"Blausen 0810 SkinAnatomy 01" by BruceBlaus - Own work. Licensed under Creative Commons Attribution 3.0 via Wikimedia Commons http://commons.wikimedia.org/wiki/File:Blausen_0810_ SkinAnatomy_01.png#mediaviewer/File:Blausen_0810_ SkinAnatomy_01.png

COSYFEET PRESS RELEASE

Men Love Shoes Too!

While it’s traditionally women who are regarded as fashion-conscious footwear shoppers, men are fast catching up: reports leading extra-wide shoe brand, Cosyfeet.

During most of its three-decade trading history, sales of Cosyfeet footwear have consisted principally of women’s styles, with sales of men’s footwear falling far behind. Sales figures for recent years, however, indicate that men are fast catching up in the shoe shopping stakes. Between 2009 and 2013, sales of men’s shoes and sandals grew by 22% in comparison to a more modest increase in sales of 15% for women’s styles over the same period.

According to the College of Podiatry, the average man now owns nine pairs of shoes, and due to the increase in the nation’s height and weight, feet size and width are increasing too. Companies like Cosyfeet, which specialize in the extra wide footwear market, are reaping the benefits.

Cosyfeet reports that sales of men’s shoes have responded to a 25% range expansion in recent years, with customers now more frequently selecting different colours such as Tan shades, Gaberdine and Oxblood over traditional black and brown, as well as having an eye for more characterful leather finishes such as nubuck.

“Years ago we sold mainly extra-wide slippers for people who led a largely sedentary lifestyle,” says Managing Director, Andrew Peirce.

“But the growth we’re seeing now is in shoes and sandals; today’s Cosyfeet customer is leading a far more active lifestyle and is markedly more fashion conscious.”

In response to the demands of its expanding male customer base, Cosyfeet are now designing fine leather styles that would not look out of place on the shelves of well known high street footwear retailers. The company has also made improvements to maximize comfort and durability, for instance moving from EVA soles to an equally light compound of PU to deliver longevity in wear with greater shock-absorption.

Cosyfeet’s most popular men’s style, the Mason, has a touch fastening strap and a bellows tongue, making for a very adjustable style with a flattering appearance. Styles currently in planning include a top quality deck shoe and a new fabric shoe development, for introduction to the men’s footwear range in 2015. More sporty styles are also on the ’drawing board’.

“As a company we’re very excited about the way the men’s footwear market is moving,” says Peirce. “The male consumer for extra wide footwear is definitely more demanding, and we intend to provide what ‘He’s looking for.”

Added Warmth Without Compromising Extra Width

This faux sheepskin bootee slipper from Cosyfeet comes in a EEEEE+ fitting for extra wide or swollen feet. Called the Dreamy, it’s made from soft, breathable microfibre with a luxurious, fleecy lining for comfort and warmth.

The Dreamy has a cleverly designed ‘collar’ which can be turned up to keep ankles cosy. It also has an adjustable strap to ensure a perfect fit.

This ultra-soft, cosy slipper has support built into the heel area for extra stability, and a flexible, cushioning rubber sole for indoor or outdoor wear.

The Dreamy comes in a choice of Camel or Loganberry, and is available in sizes 3 to 9, priced £35.00 (or £29.17 if patients qualify for VAT relief due to a chronic medical condition). Strap extensions can also be purchased for especially swollen feet.

For more information see www.cosyfeet.com/dreamy or call 01458 447275.

For editorial queries call Marianne Wilson on 07796 690326.

Cosyfeet was the first British company to make shoes for people with swollen feet. More than 30 years on, they still offer the biggest range of extra roomy footwear on the market.

Podiatry Review Vol 72:1

page 33

ARTICLE

Raising Awareness

the public about general Foot Care.

On the 21st September I held a 72mile Foot Health Care Awareness ride from Port of Spain to the rural village of Grande Rivere. The aim of the ride was to spark the interest of

The general public’s approach toward caring for their feet is simple..….you, the public wait for a problem before you start to give your feet regular attention, not knowing that your feet have so much control over the health of your circulatory system, muscles, tendons and ligaments in your lower limbs which also affects your entire skeleton.

continues to find a location that is suitable and sustainable.

I know that with continued support and the increasing support for this much needed type of care, the Foot Care Unit WILL become a reality in the not too distant future.

Nicole Rose Nanton

The publicity before the ride, such as the radio shows that

interviewed me, made the phone at the clinic ring non-stop, which tells me, there are more people with “foot problems” than we think. This created a small but vital influx of new patients.

As word-of mouth is still powerful, especially in this part of the world, the interest continues to grow giving more attention and support to the project that I have taken on—which is; to open a Free Foot Health Care Unit here in Trinidad. Since my last article I have had several new cases of foot ulcers. So.….the challenge

Classified

Chiromart UK “WHY PAY MORE?”

Suppliers of Autoclaves and Chiropody Surgery Equipment.

Single Items to full surgery set-ups. Quality used and new.

Also your equipment wanted. Surgery clearances, trade-ins and part exchange CASH WAITING… www.chiromart.co.uk

Tel: 01424 731432 (please quote ref: iocp)

For Sale – Offers (Photos on request)

• Multi Couch - model M7185/6 with electronic hand switch controls.

• Prestige Medical - Autoclave - Podia Clave + (including printer).

• Orthofit Orthotic Oven • Medi-Link Laser - Electric Medical supplies model 87 • Omron M1 Huntleigh Diagnostics Blood Pressure / Pulse Monitor • Ultrawave Water Bath • Hadewe SB Dust Extraction Drill • Dentron Biogun • Huntleigh Diagnostics Multi Dopplex 11 & DPU414 Thermal Duplex Printer • MJS Healthcare Pulse Press 3 • Various sets of instruments • Various medical text books and publications Tel No: 01823 490541 Email: stuart.w.mark@btinternet.com

page 34

Nicole Nanton (Front Centre) and her team of cyclists.

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

Podiatry Review Vol 72:1

Bookings Now Being Taken

Podiatry Review Vol 72:1

page 35

DIARY OF EVENTS

Forthcoming Events Date 11

Devon & Cornwall

11

Leeds/Bradford

11

Teeside

11

Western

11

Wolverhampton

12

Surrey and Berkshire

13

North West

14

London

14

Hants and Dorset

15

Birmingham

18

Essex

18

Cheshire North Wales, Staffs and Shropshire

18

Nottingham

18

Sussex

18

West of Scotland

page 36

January 2015

Branch AGM and meeting - 11am The Exeter Court Hotel, Kennford EX6 7UX Lecturer to be confirmed Tel Mark Smith 01803 520788 or email mrkjoanne@aol.com for further details Branch AGM - 10am The Oakwell Motel, Birstall, Leeds, WF17 9HD Tel: 01423 819547 Branch AGM - 11 a.m.

Tel: 01287 639042 fur further details Branch AGM & Meeting - 12.00 noon Blair Bell Education Centre, Room 1, Liverpool Women’s Hospital, Crown Street, L8 1SS Business meeting followed by presentation - TBA. Also John Rose will be calibrating autoclaves and traders will be invited.

Tel: 01745 331827 Branch AGM - 9.30am 4 Selmans Parade, Selmans Hill, Bloxwich W53 3RN Tel: 0121 378 2888

Branch AGM Pirbright Village Hall, GU24 0JE Tel: 01252 514273

Branch AGM St Joseph’s Parish Centre, Harpers Lane, Chorley PR6 0HR Tel: 01257 411272 Branch AGM Ozzie Rizo, 14 Hay Hill, Mayfair W1J 8NR Tel 07790 717833 Branch AGM Romsey Tel: 01202425568 Branch AGM - 7.30pm Red Cross Centre, Vine Street, Evesham, Worcs Tel: 01905 454116 Branch AGM - 2pm Southend University Hospital Education Centre, Carlingford Drive, Southend on Sea SS0 0RY Tel: 01702 460890 AGM - 10am The Dene Hotel, Hoole Road, Chester, CH2 3ND Tel: 0151 327 6113 Branch AGM - 10.00am Feet and Co, 85 Melton Road, West Bridgford, NG1 6EN Tel: 0115 931 3492

Branch AGM - 9.30am at the Bent Arms, Lindfield High Street, Lindfield, West Sussex, RH16 2HP. This will be followed by a CPD lecture on dealing with patients having Multiple Sclerosis . The cost of the day will be £40 to include coffee and biscuits on arrival, during a mid-morning break and a delicious lunch.

Any further enquiries please contact Mrs Valerie Probert-Broster on 01273 890570

Branch AGM - 11.00am – 1.30pm Holiday Inn Express, Springkerse Business Park, Stirling FK7 7XH Tel: 0141 632 3283

Podiatry Review Vol 72:1

DIARY OF EVENTS

Forthcoming Events 24

Southern Area

25

Leicester and Northants

25

South Wales

Date 8

Leeds/Bradford

8

Midland Area

Date 8

Leeds/Bradford

Council AGM Victory Services Club

Branch AGM - Lutterworth Cricket Club Starts 10am with refreshments at 9.45am Contact Sue 01530 469816 Branch AGM - 2 – 4pm Venue to be confirmed Tel: 01656 740772

February 2015

Branch Meeting at 10am The Oakwell Motel, Birstall, Leeds, WF17 9HD Tel: 01423 819547

Council Meeting Kilsby Village Hall, Kilsby CV23 8XX Tel: 01536 269513

March 2015

Branch Meeting - 10am The Oakwell Motel, Birstall, Leeds, WF17 9HD Tel: 01423 819547

15

Therapeutic Ultrasound for Lower Limb, Southport Head Office 01704 546141

25

Branch Meeting - 7.30pm Ozzie Rizzo, 14 Hay Hill, Mayfair, W1J 8NR Tel: 07790 717833 for further details

Southport London

Date 12

Leeds/Bradford

Date 28

Southport

Date 2

London

Date 25

London

April 2015

Branch Meeting - 10am The Oakwell Motel, Birstall, Leeds, WF17 9HD Tel: 01423 819547

June 2015

Musculoskeletal Examination, Southport Head Office 01704 546141

September 2015

Branch Meeting - 7.30pm Ozzie Rizzo, 14 Hay Hill, Mayfair, W1J 8NR Tel: 07790 717833 for further details

November 2015

Branch Meeting - 7.30pm Ozzie Rizzo, 14 Hay Hill, Mayfair, W1J 8NR Tel: 07790 717833 for further details

Podiatry Review Vol 72:1

page 37