Podiatry Review March/April 2014

43498 Podiatry Rev Mar 20/02/2014 15:43 Page A

ISSN 1756-3291

Volume 71 No. 2 March/April 2014

Podiatry Review A step in the right direction

Inside: u Erchonia laser therapy study u Evaluation of dermatophytes microorganisms u 2014 AGM Booking Form

The Institute of Chiropodists and Podiatrists “Supporting the Private Practitioner�

43498 Podiatry Rev Mar 20/02/2014 15:43 Page B

National Officers President Mr R. Henry FInstChP DChM

Vice-Chairman Board of Education Miss Joanne Casey MInstChP BSc

Chairman Executive Committee Mrs C. Johnston MInstChP BSc (Hons)

Honorary Treasurer Mrs J. Drane MInstChP

Vice-Chairman Executive Committee Mr A. Reid MInstChP

Standing Orders Committee Mr M. Hogarth MInstChP

Chairman Board of Ethics Mrs J. Dillon MInstChP

Mrs L. Pearson MInstChP BSc Pod Med

Chairman Board of Education Mr R. Sullivan BSc (Hons) Podiatry MSc Pod,

Secretary Miss A. J. Burnett-Hurst

Surg PgDip Mio Acu FIChPA MInst ChP

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

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43498 Podiatry Rev Mar 20/02/2014 15:43 Page 1

March/April 2014 | Volume 71 No. 2 ISSN 1756-3291

Podiatry Review

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Contents

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

Editorial ..................................................................2 Evaluation of Dermatophyte Microorganisms ..........4 Malcolm Holmes MInstChP BSc (Pod Med), DCHM LCh

Erchonia Laser Therapy in the Treatment of Onychomycosis .................................6 Robert Sullivan MInstChP BSc (Hons) MSc Pod S and Deirdre O’Flynn MInstChP BSc

Editor Mrs B Hawthorn HMInstChP

Compliance ..........................................................10 Denise Willis MInstChP BSc Volunteering in Columbia ......................................12

Academic Review Team

Sarah Laferty

Mrs J Barbaro-Brown MSc PGDip PGCE BSc (Hons) BA (Hons) DPodM MChS

Ms B Wright MSc BSc (Hons) PGCE PGDip MInstChP

Mr R Sullivan BSc (Hons) Pod MSc Pod Surg PgDip MioAcu FIChPA MInstChP

NHS Choices........................................................15 Behind the Headlines CPD – Anatomy and Physiology for Practice Part 2 ...........................................17-20 Beverley Wright MSc BSc(Hons) PGCE PGDip, MInstChP

Mr S Miah

Management of dry skin in the elderly...................22 Michelle Taylor MInstChP BSc

BSc(PodM) MInstChP

Mrs J Casey BSc (Pod) MInstChP

Branch News........................................................24 Cheshire North Wales Member’s News ...................................................25 Helen Lloyd MInstChP Diabetes UK .........................................................26 Health Awareness Information ..............................30 Acupuncture and Downs Syndrome

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Forthcoming Events ........................................32-33 Classified adverts .................................................34

The Institute of Chiropodists and Podiatrists

Booking form ..................................................35-36 Press Release - Doctors without borders..............37

© 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.

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Annual Subscription £30 UK/£45 Overseas

Podiatry Review Vol 71:2

EDITORIAL

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Editorial Dear Members

Hopefully by the time this goes to print, the atrocious and unpredictable weather that has battered Britain since the start of the New Year will be on the wane and you will have survived without too much disruption or damage. We, in Southport, have been very lucky in that respect and it has possibly been one of our mildest winters for years!

Our technical articles this issue include an evaluation of microorganisms dermatophytes which have particular relevance in podiatry by Malcolm Holmes (pages 4 & 5). Malcolm describes the basic cell structure of fungi and how infection spreads concluding with the treatments available. Following on from this theme Robert Sullivan and Deidre O’Flynn have produced a preliminary report on an ongoing clinical trial in laser therapy using the Erchonia Laser for the treatment of

onychomycosis. (starting from page 6) This product is being trialled over an eighteen month period and we thank them for providing the findings so far. In addition, we have another excellent article from Michelle Taylor on the management of dry skin in the elderly (pages 22 & 23) and an interesting and informative article on patient compliance by Denise Willis (pages 10 and 11).

Part two of anatomy and physiology for practice by Beverly Wright, can be found in the centre pages.

Helen Lloyd of Western branch has sent in an amusing anecdotal account of her debut as a chiropodist.

1964 - the year that epitomized the swinging sixties! How many of you will remember the photographs?

We would love to hear more accounts like this from members.

Have you thought of entering the Cosyfeet Podiatry Award competition? This is open to any podiatrist or podiatry student who wishes to develop their skills whilst benefitting others. In this issue we report on the 2013 winner, Sarah Laverty, who travelled to Colombia.

Preparations are well under way for our annual conference in May. A slightly updated booking form appears on pages 35 and 36 following confirmation of certain workshops and lectures. Please either complete the forms and send to this office with a cheque or telephone Julie on 01704 546141 and she will book you in and take payment via the phone. Please be aware that some of the workshops may be full so provide alternative choices wherever possible.

Bernadette Hawthorn, Editor

Have you had a look at the website lately?

Have you logged onto the members’ only area?

If not…...why not? This is YOUR website. Log onto www.iocp.org.uk which will take you to the homepage.

At the top right hand corner is the members’ sign-in area which will bring up the access box (as illustrated).

address and a password will be generated for you. This can be changed later to one of your choice. Alternatively give the girls at Head Office a call and they will sort it all out for you.

Your username is generally your membership number and the password should have already been supplied to you. If you require a password you can request one yourself by going to the very bottom of the home page. On the right hand side you will see a line: Contact/Legal & Disclaimer/Members.

Click on ‘Members’ and it will bring up the login to the

‘members only area’ page which invites you to request a new password. All you need to do is type in your own email

EDITORIAL

Podiatry Review Vol 71:2

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This is an evaluation of dermatophyte microorganisms, which have particular relevance in podiatry Malcolm Holmes MInstChP BSc (Pod Med) DCHM LCh

The majority of fungi are benign, but those of concern to the podiatrist are invasive parasites causing pathology to the host. The general term for these organisms is dermatophytes, those causing the Tinia Pedis and Onychomycosis infections are trichophytons, epidermophytons and microsporums.

The basic cell structure of fungi is common to all types. They consist of the nucleus and chromosomes contained in the nuclear membrane, ribosomes and mitochondria, the whole surrounded by the cell membrane and wall. The cells have no flagella and are thus non motile. Unlike bacteria and protozoa, fungi are plant cells, however they do not photosynthesise.

Fungal cells have the ability to produce extra cellular enzymes, these break down lipids, proteins and polysaccharides causing skin damage. Dermatophytes generally are able to produce keratinase to metabolise keratin as a food source, as in onychomycosis. The cell wall does not contain peptidoglycan, so although it will react to Gram stain this will give no information about the structure. The structure of the cell membrane is basically the same as a bacterium or a human cell, so causing difficulties in the development of treatments. However the sterol lipids in fungal cells and human cells differ and it is this difference that is used in many anti fungal treatments. Another possible target is the cell wall, as human cells do not have one.

Reproduction is of two main types; yeasts reproduce by budding a new cell from an existing cell. Moulds produce hairlike chains of cells called hyphae, these

Fungal hyphae

TECHNICAL ARTICLE

mat together to form the mycelium. They have the ability to form a new mycelium from a single piece of hyphae, so fragments shed with skin easily cause new infections.

Additionally, moulds and some yeasts can produce fungal spores. These are more resistant than hyphae, especially to dry conditions. Asexual spores produced from one parent are present in larger numbers in the atmosphere, more so than sexual spores which require genetic input from two parents.

Tinia Pedis

underneath, white marks may also appear indicating fissuring of the nail. Treatment with systemic antifungals should continue until the new nail plate has formed which may take many months.

Fungal spores

Infection spreads horizontally, where one person infects many contemporaries in the same population. Fit, healthy skin with normal levels of natural flora and normal ph is much more resistant to infection, and will require a much higher level of exposure to the infecting organism.

Human skin is normally too dry for fungi to flourish, so it is important to prevent excess sweating. It should be noted that antibiotics can affect levels of skin flora causing an increased susceptibility.

Symptoms of fungal infections of the skin include intense itching of the infected area, maceration of skin tissue and cracking of the epidermis with associated pain. In later stages there may be vesiculation and desquamation of the epidermal cells leaving the area very sore and tender.

Fungal nail infections (onychomycosis) are able to proliferate in the nail bed and nail plate. An infected nail plate becomes thickened and brittle, it has a yellowish brown appearance and a distinctive odour.

As the infection progresses the nail becomes onycholytic as debris builds up

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A suspected fungal infection can be confirmed by microscopy, when spores or hyphae can be identified in skin or nail samples. It is important that no fibres are introduced whilst collecting the sample

Onychomyciosis (cotton wool strands duplicate fungal hyphae under microscopic examination), as this will make the hyphae more difficult to determine. There are also commercially available culture trays, which will give results in 24 hours, for yeasts and 2 to 5 days for dermatophytes.

Treatment is usually by topical anti fungal creams like Clotrimazole (Canesten) or Terbinafine (Lamasil), which work well on skin, many of these can be bought over the counter. These preparations belong to the Imidazole group and are fungicidal, rupturing the cell membrane and killing the

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cell; they are not generally well absorbed as a systemic treatment. The choice of product is not by anti fungal activity but, rather infection site, solubility, toxicology etc., so it is important to know the medication properties before use. Anti fungal dusting powders are of limited use in treatment, but may be useful in helping to prevent re-infection. Deep infections especially nail infections will require systemic treatments such as Grisovin (Griseofluvin) or Nizoral (Ketoconazole), which target the nail bed and act on the membranes of fungal cells to prevent active growth. The active ingredient of Nizoral is Ketoconazole which is an imidazole that is better absorbed than others, however it has been associated with liver damage. Griseofulvin, the active ingredient if Grisovin is generally well tolerated and can be used for children.

These are prescription only medicines and cannot be supplied by the podiatrist, so the patient should be referred to their GP. Each case should be judged individually and treated accordingly, a good treatment

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plan should effect a fairly rapid recovery.

Patient compliance is important as the treatment needs to be consistent, so the podiatrist must be sure the patient (or carer) fully understands the regime. In addition to the medicaments already mentioned, there are other steps which will expedite recovery and, or prevent reinfection and cross-infection. A good standard of hygiene, regular washing of the feet and hosiery is essential. Good skin quality is of importance, the skin needs to be kept dry and wearing sandals without socks where possible is beneficial. Shoe sprays should be used to kill the infection in footwear, and suitable footwear such as Flip Flops should be worn in public areas to prevent cross-infection. It should also be stressed that the patient should never wear another person’s shoes and vice versa.

It is important to continue with the treatment even after the symptoms have disappeared, as re-infection is likely. Fungal organisms are destroyed at relatively low temperatures, typically 60 degrees

Podiatry Review Vol 71:2

centigrade. A normal wash cycle would therefore eliminate these in hosiery, however fungal spores may survive several washes before being completely eliminated.

The podiatrist should always be aware of the possible presence of fungal infections and employ aseptic techniques at all times. Although fungi are classified as non motile their construction gives them the ability to travel on air currents and thus land anywhere. This should be considered when such infections are being treated, especially with regard to the post treatment cleaning process.

With this information on fungi, the diagnosis and treatment of fungal infections, and prevention of re-infection, and cross infection, the podiatrist should be more aware of the organisms involved and be able to develop a good standard operating procedure as well as effective treatments.

TECHNICAL ARTICLE

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Erchonia Laser Therapy in the Treatment of Onychomycosis Robert Sullivan1 and Deirdre O’Flynn2

Clinical Director of Midleton Foot Clinic, Midleton, Ireland Deirdre O’Flynn Senior Associate, Midleton Foot Clinic

1 2

A preliminary report on an ongoing clinical trial Abstract

This is the preliminary report of an ongoing clinical trial in laser therapy using the Erchonia Laser for the treatment of onychomycosis. The study has to date been carried out on 320 patients both male and female with an average age of 40. There is a further 400 patients awaiting treatment to conclude this study. The laser treatment consists of 4 treatments at weekly interval using the Lunula Laser manufactured by Erchonia. This is a laser that combines two different wavelengths of laser light - one at 405 nm for direct fungicidal activity and one at 635 nm to stimulate a natural immune response - to provide effective clearing of the nail bed; it is claimed, within three months. Unlike other lasers used for the treatment of this condition, the Lunula laser is reported to cause no pain to the patient treated and no temperature change to the area exposed to the lights.

This is an eighteen month study and is ongoing at this time. The treatment target is eight hundred patients. The follow up intervals are twelve weeks post final laser, twenty four week post final laser, fifty two weeks post final laser and finally at seventy six weeks post laser. Usual studies of this type normally conclude in fifty two weeks or less, however, it is the aim of the researchers to observe the nail up to seventy six weeks to ascertain the efficacy of the treatment. In the treatment to date there has been 36 reports of side effects and the majority 93% of patients are happy with the treatment. It is the primary aim of this study to present laser as an effective treatment for onychomycosis with a good evidence base.

Key words: onychomycosis, fungal nail infection, Lunula Laser,

Introduction

Onychomycosis is a persistent nail infection of the nail bed, the nail matrix and or the nail plate, statistically it is the most common nail disorder in adults affecting up to 50% of patients presenting with nail disorders (Zaias et al 1996, Schlefman 1999, Ghannoum et al 2000).

Fungal skin infections account for 33% of all skin infections (Zaias et al 1996,

TECHNICAL ARTICLE

Schlefman 1999). Onychomycosis is caused by dermatophytes that colanise dead skin, nail and hair tissue and nondermatophyte moulds, Candida species rarely form part of this condition (Evans 1998). The most common dermatophytes seen in the mycology of onychomycosis are Trichophyton rubrum and Trichophyton mentagrophytes, Trichophyton rubrum is responsible for approximately 90% of all presentations (Zaias et al 1996, Schlefman 1999). The over all prevalence of onychomycosis in the general population ranges from 2 to 14%. The risk of infection increases with age and 15 to 20% of the population aged between 40 and 70, 32% of those between 60 and 70 and 48% of those over 70 (Schlefman 1999). Evidence suggests that the instance of onychomycosis in the population is on the rise (Schlefman 1999, Ghannoum et al 2000). There are several conditions that present visually in the same way as onychomycosis including lichen planus, nail trauma, atopic dermatitis and psoriasis.

There are many treatment options for onychomycosis; these include systemic antifungal agents, topical antifungal agents, mechanical debridement, chemical debridement, combinations of these treatments and palliative approaches. The treatment choice is dependent on the practitioners training, experience and other available modalities and interventions as well as cost (Gupta et al 2003) The treatment of advanced onychomycosis is expensive due to the input needed from the clinician and is subject to high failure rates. Antimycotics prescribed for the treatment of onychomycosis are usually delivered over several months and have cure rates of 40 80%, Terbinafine, Fluconoazole and Intraconazole are among the more frequently used drugs (Gupta et al 1998, De Doncker et al 1996). These drugs however are associated with a number of common side effects such as headache, rash, gastrointestinal and endocrine disturbances (liver) (Gupta et al 1998, Scher 1999). The usual course of drug therapy is for three months unless a pulse

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dose is used. Patients have the inconvenience of frequent blood tests during drug therapy. Topical antifungal products are widely promoted on the television and other media, these products are available direct to the public without a prescription, they are safe to use and relatively cheap, these topical products are seldom effective (Ciclopirox 2000).

Lasers have been used in medical settings for a considerable time. Lasers used however in the treatment of onychomycosis have not, nor have they undergone any rigorous examination.

There has to date been no significant clinical trial carried out on a large demographic to support the claims made by manufacturers of laser devices claiming market advantage with their products. It is the intention of this study to produce good quality information from research that will support or deny the use of laser in the treatment of onychomycosis to inform best practice.

This study is presented using simple statistics expressed as a percentage, the figures shown are as the authors and other clinicians understand. P values etc will be calculated and extensive statistical analysis made at the end of this study. But in this the primary report the authors have kept it simple and basted their finding in clinical evidence based practice.

Methods

This clinical study relies on all subjects having a positive mycology, therefore there is no need for a control group as all patients received active laser. 320 patients or 2320 toes were subject to laser irradiation at 405nm and 635nm for twelve minutes at weekly intervals for four weeks.

Inclusion criteria

Participation in this study is reliant on the following:• onychomycosis present in at least one great toenail.

• Disease involvement in the great toenail(s) with onychomycosis of at least 10%.

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• Spikes of disease extending to the nail matrix in the affected great toenail(s).

• Proximal subungual onychomycosis.

• Distal subungual onychomycosis.

• White superficial onychomycosis.

• Patient is willing and able to refrain from using other (non-study) treatments (traditional or alternative) for his or her toenail onychomycosis throughout study participation.

the time of treatment in the 320 patients.

All patients were given a diary to fill in ever week noting any adverse response to treatment along with and any visual changes to the nail. No support products were given and all subjects had to refrain from using any nail cosmetics for the duration of the laser active stage in the study.

ultraviolet and infrared light spectrums.

The device is mains powered and stands on the floor. The treatment area of the unit is aseptically cleaned after each patient is treated. The diagram show the, 1.) laser diodes, 2.) the magnetic catch for closing the unit, 3.) the heel plate which is also the door to the unit and 4.) the aperture into which the forefoot sits for the 12 minute treatment.

Graph showing % nail inclusion

Diagram showing the laser unit used

All patients were treated as outlined below at each of their four visits.

• Patient has not used other treatments for at least 6 months prior to participation in the study.

• Patient is willing and able to refrain from the nail cosmetics such as clear and/or colour nail lacquers throughout study.

• Male or female. 18 years of age or older.

A copy of the study protocols is available on request.

Exclusion criteria

Patients who have used oral antifungal medicines within 3 months prior to the administration of the first laser treatment are excluded from this study as are patients who are unable to abstain from the use of nail cosmetics. Other exclusions are nevoid subungual formation, psoriasis of the nail plate, atopic dermatitis and lichen planus.

Treatment procedure

This treatment has two principle aims, 1.) to restore the affected nails to health within the 18 month course of this study, and 2.), to eradicate the fungus from the nail and related area within the four week treatment protocol.

As this is a positive mycology study only patients who test positive for onychomycosis and meet the inclusion criteria are offered treatment. Samples were collected and cultured in the normal way. Patients were treated in groups dependent on the percentage nail inclusion. The graph shows the average percentage amount of total nail infected at

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1. The foot to be treated was cleansed using a clinell wipe.

2. Nails were clipped and reduced using a bur where necessary.

3. The foot was cleansed to remove any debris and dust.

4. The forefoot was photographed using a high resolution digital camera. These photos were taken from a fixed position that was repeatable throughout the study.

Measurements were taken from the pictures by an independent lab using digital measures.

It is important to note that no chemicals were used to pre soften thickened nails as the researchers wanted to remove any possibility of interference from outside sources.

This is a four week protocol where the laser is administered on the same day each week for 12 minutes. All laser units are programmed to deliver constant therapy for this time and then turn off.

After the pre-treatment was complete the laser therapy was administered using the LanulaLaserTM (Erchonia FX-405™).

This is a double-headed laser with a dualdiode omitting a light wavelength of 635 nm and 405 nm covering both the

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Unlike other lasers applications used for the treatment of onychomycosis no reports of any pain were made by any of the 320 patients (2320 toes) which have currently been treated.

Treatment reviews points

It is important to remember that this is an 18 month study. 18 months was chosen in order to evaluate the long term effects of the treatments and to chart any recurrence rate. It should be further noted that a recurrence after a clear nail is presented is not evidence of treatment failure as environmental factors must be taken into account. All patients on this study are issued with a “Maintaining Your Foot Health” leaflet.

Follow up measurements were taken at 12 week post final (forth) laser as well as at 24, 36 (samples taken for mycology), 48, 52, 64 and 76 weeks. A patient is discharged from the study once a clear nail is presented and maintained for 12 weeks.

Interim results

The following graphs represent the finding to date and show the amount of remaining infected nail at the time of publication:-

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• 4 patients felt numbness to the forefoot

• 2 patients related that they had diarrhoea that they felt was a direct result of the treatment.

Graph 1

Of the 80 patients shown in this graph 72 or 90% were discharged by week 48 as they presented with clear nails which remained clear for 12 weeks. None of these patients required additional treatments at this time and it is expected that by week 52 all will have been discharged.

Graph 4

from the study by week 48 as they presented with clear nails, this represents a 45% success rate with 80% nail inclusion

Graph 5

Graph 2 The above graph shows the average remaining infected nail at 48 week. 61 or just over 87% of patients were discharged from the study due to clear presentaton at 48 weeks and 2 were recommended to have further treatments.

1 was recommended further treatment.

No patients were discharged from this group and all patients have been recommended further treatments as they have all seemed to reach a plateaux where the nail has no significant growth from week 36 to week 48. The average growth rate in this cohort is 51% over 36 weeks.

Blood and tissue analysis was carried out on samples taken from the nail matrix and it was noted that there was a lack of fat cells at the matrix. Further investigation is ongoing.

Findings from patient’s diary’s

Graph 3

At week 48, 88 patients, or just over 80% were discharged from the study as they presented with clear nails. 5 patients were recommended to have further treatments.

Of the 40 patients 18 were discharged

TECHNICAL ARTICLE

Adverse reactions from the notes of the 320 participants involved to date

The total of adverse events was 36 of the patients involved in this study 201 were women and 119 were men. 72 patients reported using nail cosmetics during the treatment stage of the study.

Types of Onychomycosis

Onychomycosis may be classified into several types: distal subungual, white superficial, proximal subungual, endonyx, and total dystrophic.

Distal subungual onychomycosis, was the most common type seen in this study today, this involves the nail bed and subsequently the nail plate. White superficial onychomycosis was seen as superficial white patches with distinct edges on the surface of the nail plate.

Proximal subungual onychomycosis is a result of the fungal organism entering via the cuticle and the ventral aspect of the proximal nail fold. In endonyx onychomycosis, fungal organisms invade the nail plate without resulting nail bed hyperkeratosis, onycholysis, or nail bed inflammatory changes. In total dystrophic onychomycosis, complete dystrophy of the nail plate occurs; these changes may be primary or secondary.

Data to date in plain English

All of the above graphs and results are predicated on four laser treatments over 4 weeks with these results processed as per the finding up to and including week 48.

Further results will be published at the end of the study for all timelines as per the protocol.

• Tingling sensation during treatment was reported by 29 patients, all however said that this was slight and the common consent was that it felt like a vibration in the forefoot.

• 1 patient reported headache every time the laser was activated. Glasses were given for the frequencies used but the pain still persisted.

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Graph 1 shows the progression of the 20% infected nail cohort. There were 80 patients in this group, by week 48, 72 of these patients had been discharged and therefore one can conclude that over 48 weeks with four laser applications a success rate of 90% was achieved.

Graph 2 is the results of the second treatment cohort with 40% nail inclusion.

These patients had at least 21% inclusion and show a success rate of 87% with a four week treatment protocol.

Graph 3 is the result drawn from the third cohort with 60% nail inclusion. All of these patients had at least 41% inclusion and show a success rate of 80%, again with a four laser application.

Graph 4 shows the results of the fourth cohort with 80% nail inclusion. All of these patients had at least 61% inclusion and show a success rate of 45%, with the standard delivery protocol applied.

Graph 5 is the result of the fifth cohort with 100% nail inclusion. No patient has been discharged form this cohort at this time but all show good growth, the average being 51%

From the above interim results from this study it is possible to say that this type of cold laser (Lunula Laser manufactured by Erchonia) with a duel light frequency is 84.25% effective over 48 week on onychomycosis for nails up to 80% effected with the condition, and 51% affective on nails that are totally included and or endonyx or dystrophic.

Discussion

Dermatophytes cause infections of the skin, hair and nails due to their ability to obtain nutrients from keratinised material.

The organisms colonize the keratin tissues and inflammation is caused by host response to metabolic by-products. They are usually restricted to the nonliving cornified layer of the epidermis because of their inability to penetrate viable tissue of an immunocompetent host. Invasion does elicit a host response ranging from mild to severe. Acid protenases, elastase, keratinase and other proteinases reportedly act as virulence factors (Rosenberg and Gallin 1999).

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Dermatophytes are transmitted by direct contact with infected host (human or animal) or by direct or indirect contact with infected exfoliated skin or hair in clothing, combs, hair brushes, theatre seats, caps, furniture, bed linens, shoes, socks, towels, hotel rugs, sauna, bathhouse, and locker room floors (Ajello and Getz 1954).

Depending on the species the organism may be viable in the environment for up to 15 months. There is an increased susceptibility to infection when there is a pre-existing injury to the skin such as scars, burns, excessive temperature and humidity.

Increasingly Onychomycosis is being viewed as a more cosmetic problem as people become ever more conscious of their appearance. Fungi from the nails may happen before secondary bacterial infections such as cellulitis, idiopathic reactions and chronic urticarial. Infected toenails may act as a reservoir for fungi, facilitations their transmission to other parts of the body and potentially to other people.

Clinical diagnosis of Onychomycosis is based on physical examination, microscopy and culture of nail specimens. Factors such as diabetes, hyperhidrosis, nail trauma, poor peripheral circulation; can contribute to the condition. Differential diagnosis for onychomycosis, as mentioned earlier, should be considered so as to allow the clinician to choose the most appropriate treatment.

It has been found to date, in this study, that 4 treatments for nails up to 60% inclusion has a satisfactory outcome and that nails with over 60% benefit from further pain free treatments. The authors

of this study would agree with a recent comment made by Kerry Zang, one of the lead developers of this laser system, Unlike other treatment modalities, such as systemic anti-fungal agents or repeated Class IV lasers, the Lunula cold laser system can be utilized as many times as necessary to resolve the problem and can be utilized without fear of any side effects or adverse reactions (Zang 2013).

Conclusion

Lunula laser has performed consistently throughout this study. This study is now approximately half way through and some end point data (18 months post last laser) is now being generated and this is looking very promising. The authors of this study report agree with Kerry Zany when he says, I believe that the Lunula laser system stimulates the production of peroxyntrite which interacts with the lipid portions of the cell membrane as well as DNA and other protein components of the invading micro-organisms which is cytotoxic to and inactivates the mycosis. The patients general medical condition influences the rate of nail growth and the effects the risks for re-infection. Depending on the patients general condition will determine the number of treatments necessary to cytotoxic to the mycosis present.

References and full study protocols are available on request from the principal author robertsullivan01@gmail.com

The above plates show the before treatment (top) and the below plates show 48 post treatments

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TECHNICAL ARTICLE

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Compliance

Denise Willis BSc MInstChP Why do patients agree to a treatment programme only to return later without following any instructions?

When medicines are administered in hospital there is a high degree of certainty that medicines are given to or taken by the patient for whom they are intended. In the community, however, such certainties do not exist, and one of the major drawbacks in our reliance of pharmacotherapy in treating ill health is that, either intentionally or unintentionally, a high proportion of patients do not take their medicines in the way that is intended.

Obviously when we make suggestion to a patient to use an orthotic prescribed, or a medicament such a emollient, how do we as health professionals ensure that patients will comply ?

The concept of compliance is notoriously difficult to measure.

Compliance can be described as unintentional (where the patients simply forgot ) or intentional (where the patients consciously decides not to). In the latter case in particular, causes of noncompliance are complex.

Understanding non-compliance to improve patient behaviours

There are many myths about compliance in patient behaviour (Shirley,2012). It is important to dispel the myths that surround the subject if the rates of non-compliance and their costly consequences are to be reduced. Millions of pounds per year are wasted on unused prescription drugs, finding out the motivations behind why patients do or don’t take their medications as prescribed is vitally important for health professionals.

According to the Medicines Partnership the proportion of patients classified as noncompliant at six and twelve months was 61% and 68% respectively which is undoubtedly a huge concern.

As we will have experienced, compliance is a lot easier when it is once daily rather than three times a day. Often a daily preparation can be simpler to remember than twice weekly. It can fit more naturally into a patient’s routine.

When taking medicines fears starts to increase about having a ‘foreign chemical’

INFORMATION ARTICLE

in your body for a long duration, leads to non-compliance.

Non compliance can be improved by simply reminding patients to take their medications

There have been numerous compliance programmes adopted over the years that have provided a simple reminder service to patients to take their medication. These are popular for chronic preventative conditions where often there was little obvious reward for taking the medication.

While some of these services did show at least some short terms gain, many were destined for failure.

It is difficult for health professional to design a programme that will work for everyone. An elderly patient may forget or simply cannot reach their feet to use an orthotic, or use emollients effectively.

These restrictions could be caused by arthritic conditions that would make the process painful. The chiropodist will make orthotics for patients to use when they leave the clinic but will never admit that they cannot reach or have enough strength in the arms or fingers to use them. When using creams the patient will find it difficult to rub them in.

Some patients are fine to do these, but just can’t be bothered, only to return to the clinic with the same problem time and time again.

Haynes et al (1979) defined compliance as: the extent to which the patient’s behaviour (in terms of taking medications, following diets or other lifestyle changes) coincides with medical or health advice.

Damrosch (1995) prefers the term adherence, since this implies a more mutual relationship between the patient and the practitioner. ‘Compliance’ implies that the practitioner is an authority figure, while the patient is a fairly passive recipient.

It’s an important area of research primarily because following health professionals’ recommendations is considered essential to patient recovery.

According to Damrosch (1995), poor adherence is almost epidemic. Reviews of adherence research have shown 20-80 per

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cent non-adherence, depending on the patient population and definitions used.

Patients with chronic conditions (such as hypertension and diabetes) are less adherent than those with short-term problems. According to Ogden (2000), about half of these patients are noncompliant.

Practitioner Variables

Doctors’ sensitivity to patients’ nonverbal expression of feelings (such as tone of voice) is a good predictor of adherence.

For example, Dimatteo et al (1993) conducted a two-year longitudinal study of over 1800 patients with diabetes, heart disease or hypertension and 186 doctors.

The doctors’ job satisfaction, willingness to answer questions and practice of scheduling follow-up appointments, were all powerful predictors of adherence. The way practitioners communicate their beliefs to patients also influences compliance.

Misselbrook & Armstrong (2000) asked patients whether they would accept treatment to prevent a stroke and presented the effectiveness of this treatment is four different ways. Although the actual risk was the same in all four cases: • 92% said they would accept the treatment if it reduced their chances of a stroke by 45% (relative risk)

• 75% if it reduced the risk from 1/400 to 1/700 (absolute risk) • 71% if a doctor had to treat 35 patients for 25 years to prevent one stroke (number needed to treat)

• 44% if treatment had a 3% chance of doing them good and a 97% chance of doing no good/not being needed (personal probability of benefit)

According to Ogden (2000), these results indicate that:

...Not only do health professionals hold their own subjective view but... these views may be communicated to the patient in a way that may then influence the patient’s choice of treatment.

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In conclusion what can we do as podiatrists to ensure patients comply with treatment regimes?

Forshaw (2002) recommended that ...Careful education of patients as to exactly what to expect from a treatment can improve adherence, especially in cases where non-adherence stems from lack of knowledge rather than rebelliousness...

So maybe the next time we discuss treatment with a patient whether it be applying a verucca treatment, using emollients to ease skin conditions, or simply popping an orthotic in shoes - make it easy to understand why they need to do this.

Does the patient have difficulty remembering? – Try making a suggestion of a programme that they enjoy on T.V ( Eastenders, Coronation Street). By suggesting a ‘prompt’ the patient will associate this with using the medicament.

Change the time of day. Most working people are busy getting children off to

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school, or getting ready for work in the morning. By changing the morning to the evening it will make timing easier and patients will remember.

Make the task easier. Question an elderly patient or a patient with disabilities whether they can do the task required.

They may live on their own so asking them to do a certain task may be problematic.

Show the patient you have a certain empathy with them and show a caring nature that will encourage the patient to do the task required.

References

Understanding non-compliance to improve patient behaviours.Shirley 2012) HSJ Resource Centre/Best Practice/Patient-involvement. Internet Accessed Nov 2013 Compliance and Concordance.

Nursingtimes.net/compliance-andconcordance/288619.article accessed Nov 2013

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Haynes,et al (1979) Compliance in Health Care, BaltimoreJohn Hopkins University Press Damrosch, S (1995). Facilitating Adherence to Preventive and Treatment Regimes. In D.Wedding (ed).

Behaviour and medicine (2nd edition).

St. Louis, MO: Mosby Year Books Ogden, J. (2000) Health Psychology: A Textbook, (2nd Edition) Buckingham Open University Press Forshaw (2002). Essential Health Psychology. London. Arnold Gross (2005) Psychology The Science of Mind and Behaviour (5th Edition) Hodder Education Misselbrook, D & Armstrong, D (2000) How do patients respond to presentation of risk information? A survey in General Practice of willingness to accept treatment for hypertention (cited in Ogden 2000)

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Volunteering in Colombia Glasgow Caledonian student, Sarah Laverty, won the Cosyfeet Podiatry Award 2013. She spent a month volunteering in Colombia. Here she reports on her experiences.

In June 2013, having completed my third year of a BSc (Hons) Podiatry degree at Glasgow Caledonian University, I travelled with recent graduate Podiatrist, Sian Steele to Colombia to spend a month as a volunteer at Children’s Vision International (CVII) based in Bogota.

CVII is a donation-dependent charity, which provides a safe and

The wound care team including our translators

loving environment for vulnerable children from the streets and surrounding hills of Bogota. Having begun with just a handful of children, they have built three houses in the city, together with a school and health clinic, catering for 185 children.

Their work is not limited to Bogota, in that they provide humanitarian aid through annual medical missions to some of the most destitute communities in the nation.

I have been inspired by the work that CVII do, as the director has been a family friend for years. Since I started my studies in podiatry, he encouraged me to come out to Colombia to see the work first-hand and be a part of what they do for local communities, using my skill set in the annual medical mission.

This amazing experience enabled me to observe and administer treatment of a variety of medical conditions concerning the lower limb. I acquired many new skills and gained confidence in my clinical

COSYFEET ARTICLE

practice, learning to be innovative and make maximum use of the limited resources that were available. Having reflected on this experience in the field hospitals I am incredibly grateful for the vast array of resources available to podiatric practitioners in the UK.

When we first arrived in Bogota we were met at the airport and transferred to our accommodation, which became our home for the duration of our stay. This took the form of a typically tall, narrow three storey Colombian building. Our bedroom happened to be located on the top floor.

This wouldn’t have presented with any difficulties at home in the UK, but we were now 2800 metres above sea level and the stairs were enough to leave fit young women like ourselves very short of breath, and so began our daily battle with the altitude.

After taking a few days to adjust to the altitude and time difference we got caught up in last minute preparation for the medical mission. This included sorting out medical supplies and paperwork as well as helping with the finishing touches of the new medical centre, which CVII hope will provide an environment for the provision of free medical care to the local community all year round.

Once the entire medical team had arrived from the United States, Canada, England and Northern Ireland, everyone assisted in packing a few lorries with the medical supplies required for the mission and made plans for our first destination outside the city.

We took a five hour drive to Barbosa, where we were to set up our first field hospital in a school. When we arrived at the school we were welcomed by a large crowd of local people requiring medical attention. This was a very overwhelming sight, as I had never experienced anything remotely like this before. We worked as a team to unload the lorries and set up the field hospital. Most of my time was spent in wound care, assisting an experienced wound care specialist.

I found the first day very stressful. It was hard to adjust to my new surroundings, suddenly having to improvise to provide

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care for these needy people due to lack of equipment that we would regularly use at home. Many people came to the field hospital with advanced venous and arterial disease and we found ourselves emotionally and physically drained by the end of each day as we reflected on the enormity of the physical problems that some of these people had to contend with.

In one particularly memorable case a woman aged sixty-four had an ulcer located proximal to the anterior of the ankle joint. This ulcer was a result of an accident in a river where she bathed at the age of fourteen; it has slowly deteriorated since then. Having received no medical treatment she persisted in using her own remedies and masking tape to keep it clean. On presentation the wound was moist with granulating and sloughy tissue surrounding the edges. It looked fairly clean and the woman reported that she hadn’t been feeling unwell but the healing process was complicated because she had venous insufficiency. We were able to cleanse the wound with saline, debride it as far as possible and then dress it with flaminal and gauze. We also issued appropriate advice regarding how to clean and dress the wound with the dressings we provided. We supplied a shaped tubigrip to give graduated compression to the leg to encourage improvement of the venous supply after checking suitability for extra compression. This was done by checking arterial supply at the dorsalis pedis pulse and the posterior tibial pulse with a hand held Doppler.

Another experience from Barbosa was being able to undertake my first total nail avulsion with phenol under the supervision of Dr Haughey, a podiatric Surgeon from the United States. I was apprehensive as I was learning new skills and had only ever observed this procedure before, however Dr Haughey walked me through the process step by step offering reassurance.

The second town we travelled to, Patio Bonito, was a homeless village based in a rubbish dump. This was the most eye opening and harrowing place I have ever been to. The people here made their living from recycling rubbish and I even witnessed kids washing in the sewers that

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ran alongside the village. A lot of the wounds we treated here were the result of gunshots, as gang warfare is rife here. One of the most distressing cases was an eightyear-old girl with a gunshot wound to her arm. These people were so grateful for the medical attention as they are used to being outcast in society.

the need for anaesthetic as he was neuropathic, and I was able to assist.

Neither of us had ever witnessed anything like this before and were concerned for the gentleman’s health, but we were glad that we were able to provide the medicine he needed and the treatment he required to help.

As you can imagine there are people who need support in their medial arch in many of these places from wearing inappropriate footwear through no fault of their own. For patients with plantar fasciitis and medial longitudinal arch pain I made some devices with the equipment we had.

These consisted of an absorbent dressing stuck together and then folded in two and

The homeless village

Venous ulceration on anterior aspect of the ankle

The third field hospital we set up was in a sports arena in Usme. On this occasion I worked alongside Dr Guinn, an orthopaedic surgeon from the United States. Dr Guinn guided me through giving corticosteroid injections for plantar fasciitis and heel pain.

At Usme one of my colleague’s patients presented with a neuropathic ulcer on the plantar aspect of the right foot at the 4th5th metatarsal head, which the patient was completely unaware of, and with onychogryphotic 1st and 2nd nails on both feet. The patient was unable to manage the nails which had been causing discomfort and wouldn’t fit into his footwear. My colleague was able to remove both the 1st and 2nd nails without

Improvising with supplies cut into a shape that would provide slight support. It was attached to the foot with tape, and made so that the patient could take it on and off.

Successful nail surgery

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Sian with a removed fungal nail

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In between setting up all the field hospitals I had the opportunity to observe pre-operative appointments for surgeries such as talipes equino varus repair, tophus gout removal and hallux abducto valgus osteotomy. The most severe case was that

COSYFEET ARTICLE

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of a 15 year old boy who had no or malformed bones in his feet and legs.

Medical care isn’t advanced enough in Bogota, therefore CVII planned to fly him to America for 6 months for an above knee amputation and extensive rehabilitation

I hope to return to Colombia again in the near future and utilize my skills, as there is still such great need out there. To be immersed in the culture there was amazing, as was the experience of working as part of such an incredible international multi-disciplinary team. It was not only the local communities that benefitted. I did too!

Hallux Valgus Deformity

programme with prosthetics. This was a very difficult case to observe as this was the first time the possibility of an amputation had been discussed and as some of the family were present the situation became very emotional.

Tophus Gout

COSYFEET ARTICLE

Colombia was everything I expected it to be and more. I couldn’t believe how much CVII had set in place to help people in and around the area of Bogota. I experienced so many new procedures and learnt how to work on my own initiative with a lack of resources. As well as dealing with podiatric cases we assisted a lot in orthopaedic practice, which has broadened my horizons in medicine and has encouraged me to consider further study of surgery in the future.

The Directors of the medical mission

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None of this would have been possible if it wasn’t for the hard work and great effort the kids in the organisation and the directors of the medical mission put in before we all got there.

Sarah Laverty

Having read this if anyone would like any further information about the work CVII do in Bogota, or if you would like to offer help through the donation of supplies for future medical care that will be done out there, please do not hesitate to contact me at colombiasupport@outlook.com

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Behind the Headlines Coffee may aid aspects of memory With exams on the horizon for many students, the somewhat dubious claim made by The Independent is that the "Secret to passing exams is [a] large espresso after revision".

But while the study it reports on did find an association between caffeine intake and enhanced memory, the effect was inconsistent.

The study, which involved 160 people between the ages of 18 and 30, showed that giving a dose of 200mg caffeine pills (roughly equivalent to two mugs of instant coffee) enhanced their ability to distinguish between subtly different objects one day after studying them.

However, no enhancing effects were found when recalling which objects were identical to the day before and which were new, so the memory enhancement effect was not consistent across the elements tested.

This may be a sign that caffeine enhances memory in a very specific way.

Alternatively, the one significant result may be a chance finding and there really is no effect.

The study did not address whether caffeine has any effect upon children's learning or retention at school, or whether caffeine could have any effect upon older adults with diseases affecting their memory, such as Alzheimer's disease.

These results need to be replicated in further research, as the effect observed may be a chance finding.

If you do have a big exam coming up, we would recommend that you stick to plain old tap water instead. As the lead author of the study warns, "Caffeine can have side effects like jitteriness and anxiety in some people. The benefits have to be weighed against the risks".

The study was carried out by researchers from Johns Hopkins University and the University of California. The researchers were funded by the US National Institute on Aging, the US National Science Foundation, and Johns Hopkins University.

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It was published in the peer-reviewed journal Nature Neuroscience.

The media generally reported the story accurately, although many of the headlines hyped the strength of the evidence provided in the study. For example, the Sunday Mirror's claim that "Scientists reveal caffeine provides huge boost to your short-term memory" is groundless.

However, BBC News did include a particularly useful quote from the main study author, Professor Michael Yassa, who cautioned that the findings "do not mean people should rush out and drink lots of coffee, eat lots of chocolate, or take lots of caffeine pills".

The negative effects associated with caffeine, such as irritability and insomnia, also need to be considered in weighing up the potential benefits and harm. The amount and quality of sleep we get can also influence learning and memory, so there may be some trade-offs in terms of the potential benefits of caffeine.

This was a double-blind randomised controlled trial looking at the effect of caffeine on memory.

The researchers say that some studies have shown caffeine enhances short-term cognitive (brain) performance, but most long-term studies found little or no effect.

However, these studies gave people caffeine before they tried to learn or memorise objects or tasks. This means the other effects of caffeine, such as increased wakefulness or arousal, may impact learning in ways other than enhancing memory, and could cloud the findings specifically on memory.

The difference with the new research was that it gave people caffeine after the learning phase in an effort to investigate any potential effects it had on memory in isolation. That is, whether caffeine intake after a specific cognitive task helps "fix" the resulting piece of information in the memory.

The researchers showed 160 healthy participants individual pictures of objects to study. Half the group was randomly

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selected to receive 200mg of caffeine and the other half was given a placebo pill.

The participants were tested on their recollection of the objects 24 hours later.

This test included objects they had seen the previous day (targets), some new objects (foils), and some objects that were visually similar but subtly different to the original objects (lures).

Examples given of "targets" and the corresponding "lures" included images of saxophones and seahorses. For each image, the participants were instructed to decide whether the image was "old", "new" or "similar".

Saliva samples were taken immediately after the participants studied the objects, and again one, two, three and 24 hours after they received the caffeine or placebo so that the researchers could study how the caffeine was broken down in the body.

Participants were described as "caffeine-naïve", suggesting they didn't usually have a caffeine intake in their diets, but this was not described explicitly. Those who consumed more than 500mg caffeine a week were excluded from the study.

The study was described as doubleblind, meaning neither the participants nor the people assessing their memory knew which group (caffeine or placebo) they had been randomly assigned to.

The main analysis compared how well the two groups identified:

• targets – identical objects they had seen the previous day • foils – new objects they had not seen the previous day

• lures – similar, but not identical, objects to the previous day

Participants who received caffeine were more likely to correctly identify the lure objects compared with participants who received the placebo.

There were no differences between those who received caffeine and those who received placebo in the recognition of target or foil objects.

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To rule out any effects of caffeine on memory retrieval, the authors conducted a second delayed caffeine experiment.

They gave participants caffeine one hour before the memory test (still 24 hours after the initial study session).

The authors observed no significant memory enhancement in those given caffeine compared with placebo. They interpreted this as suggesting that caffeine does not affect any other aspect of memory retention performance.

They also studied different doses of caffeine to see what was best for memory and if there was a dose-response relationship. They found: • the dose-response relationship did not appear to be linear – that is, higher caffeine doses did not improve memory in a simple relationship

• 200mg was better than placebo and 100mg, but it was no different to 300mg

• the dose-response curve was described as an "inverted U", meaning the optimum dose was in the middle of the 100, 200 and 300mg range tested, with a diminishing effect at the higher and lower doses

The slightly better performance in the caffeine group when identifying lures was interpreted as meaning that, "Caffeine enhanced consolidation of the initial study session such that discrimination during retrieval was improved".

This study showed that giving a 200mg dose of caffeine to people who don't usually consume it enhanced their ability to distinguish between subtly different objects one day after studying them.

However, no effects were found when identifying identical or new objects, so the memory enhancement effect was not consistent.

It is unclear what benefit this very specific effect would lead to in a real-life situation, such as an exam, if replicated in a wider population.

The result may also be a chance error and caffeine actually has no effect on memory. We will only be able to know if the effects are real if the study is repeated more times in different and larger populations.

This study also has a number of other limitations to consider when interpreting its findings:

The researchers concluded that at least 200mg was required to observe the enhancing effect of caffeine on memory.

The authors concluded that the lack of difference in identifying identical objects (hits) and recognising when the objects were new (foils) meant that basic recognition memory was unaltered by caffeine.

• The study sample was relatively small, with 160 participants.

• The study sample was relatively young (mean age 20 years) and excluded those aged under 18 or over 30. It therefore does not address whether caffeine has any effect on a child's ability to learn or remember, or whether caffeine may have any effect on older adults with diseases affecting memory, such as Alzheimer's.

• The study subjects were aware they were participating in a study of caffeine. However, a survey of the participants suggested they didn't know which group they had been assigned to (caffeine or placebo), indicating the blinding element of the trial was effective and unlikely to bias the results.

• The sample sizes were small in the experiments comparing different caffeine doses (sometimes just 10 people), increasing the chance that no differences would be found between groups, even if real differences existed. These findings should therefore be treated with a pinch of salt.

• Participants with high caffeine consumption of more than 500mg per week were excluded from the study. The potential additional memory enhancing effects may be different or absent in people already consuming high levels of caffeine.

The bottom line is that the study results need to be replicated, as the effect observed may be a chance finding.

Readers should not rush out and consume large amounts of caffeine in the hope it will boost their memory based on the results of this study. Until further studies prove these findings, there is currently no sure-fire short-cut to revision other than hitting the books on a regular basis.

Analysis by Bazian. Edited by NHS Choices. www.nhs.uk/news

Is your First Aid Certificate up to date?

The Institute of Chiropodists and Podiatrists will be holding a HSE/QCF accredited Emergency First Aid Course in Southport, Merseyside on

Friday 14th March 2014

ST Cost £50 per person; includes certificate, manual and resuscitation key ring.

U P FA G N I L To book or for further information S FIL P L AC E Phone: 01704 546141 or visit our website: www.iocp.org.uk

NHS CHOICES

Podiatry Review Vol 71:2

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CONTINUING PROFESSIONAL DEVELOPMENT

THIS ARTICLE IS ONE OF A SERIES OF PULL-OUT EDUCATIONAL SECTIONS THAT CAN BE INSERTED INTO YOUR PORTFOLIO AND BE A CONTRIBUTION TOWARDS YOUR PERSONAL CPD LEARNING.

Anatomy and Physiology for Practice Part 2 Beverley Wright MSc BSc(Hons) PGCE PGDip MInstChP

It is important to understand and remember the position, because when describing relative locations, the body is always assumed to be in anatomical position.

Planes of the body

An Introduction to the Organisation of the Human Body - Part 2 Language of Anatomy

Anatomical terminology has been developed in order to accurately describe body parts and positions. An understanding of these terms is essential to be able to communicate effectively with your colleagues and patients. There were probably many terms that you found overwhelming when you first studied them, which through regular use have now become familiar. The terminology introduced in this section is a reminder of terminology you may or may not currently use during your professional career.

Figure one shows the anatomical position. The body is erect with feet parallel and arms hanging at the sides with the palms facing forward.

Anatomical planes are depicted in anatomical terminology and some of these may be familiar to you. Identify the planes that you are unfamiliar with and become more confident with them.

Insert the other names for the above anatomical planes:

For example: c. The Median plane is also known as the midsagittal plane a. Frontal or ...................................... plane b. Transverse or ................................ plane

Can you guess the name of the plane that cuts through the shoulder, and runs midway down between the leg and foot?

Answer ................... or ...................... plane

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CONTINUING PROFESSIONAL DEVELOPMENT

Directional Terms

Anatomical directions help health professionals to understand the location of the parts of the body, so as we have discovered these have been sectioned into planes to help us understand the relationship among the three-dimensional object of the human body. These therefore, are terms used to explain exactly where one body structure is in relation to another. For example if you were asked to describe the location of your ears in relation to your nose, you may say that your "ears are located on either side of your head to the right and left of your nose." Using anatomical directional terms this can be simplified to the "ears are lateral to the nose." There is often confusion when interpreting or reading about anatomical descriptions in the case of the terms left and right, which always refer to the left and right sides of the subject and not of what is being observed. If you look down at your own body and you know that your right arm is on the right side, but when observing a patient their right arm will be seen to be on the left as you look at them or a diagram in the book. Directional terms are often used to describe the location i.e. wounds or verrucae in order to accurately pinpoint their location. This is particularly important for patients that may have multiple and/or similar verrucae in one area that require treatment. A list of commonly used directional terms is given below.

SUPERIOR

= above

INFERIOR

= below

POSTERIOR

= behind

ANTERIOR MEDIAL

= in front of

Self-Assessment - Part 5

Insert the appropriate directional term in the following statements: a. The forehead is ..................................................to the nose

b. The naval is ............................................to the breast bone. c. The breastbone is ............................................to the spine.

d. The heart is ............................................to the breastbone.

e. The elbow is ......................................................to the wrist. f. The heart is ........................................................to the arm. g. The arms are ....................................................to the chest.

h. The knee is ........................................................to the thigh.

i. The skin is ....................................................to the skeleton.

j. The lungs are ................................................to the rib cage.

k. The armpit is ....................................................between the breastbone and shoulder.

Body Cavities and Organs

Body cavities are spaces within the body that help protect, separate, and support the internal organs. They are divided by Self-Assessment - Part 6

= on the inner side of

LATERAL

= on the outer side

PROXIMAL

= Close to the body origin of the body part or the point of attachment of a limb to the body trunk.

INTERMEDIATE = between a more medial and a more lateral structure.

DISTAL SUPERFICIAL DEEP

= Further from the origin of the body part or the point of attachment of a limb to the body trunk. = at the body surface.

= Away from the body surface, more internal.

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

43498 Podiatry Rev Mar 20/02/2014 15:43 Page 19

CONTINUING PROFESSIONAL DEVELOPMENT

Organs:

Place the listed organs into the correct body cavity.

Stomach; Spleen; Heart; Brain; Urinary bladder; Diaphragm; Gallbladder; Pancreas; Large intestine; Lungs; Thymus; Rectum; Spinal cord; Kidneys; Reproductive organs; bones; muscles; and ligaments. The diagram below shows the major body cavities:

Cavity

Body Organ

Cranial cavity Vertebral cavity

The Body Quadrants and Regions

Most of the body cavities are protected by the skeletal framework that helps to protect the major organs that are housed inside each of them. The abdominal cavity however, is a very large area that is only protected by the formation of trunk muscles surrounding it with no bone protection from the skeletal framework. The abdominal organs contained in this area are vulnerable to any major trauma experienced from an accident.

So this area has been subdivided into four (4) smaller areas in order for medical professionals to study the organs contained within this cavity. For example paramedics and doctors can locate a damaged organ, which is assessed by considering a mechanism of injury (blunt/ penetrating trauma) by palpation to the area of the abdomen in one of the four quadrants as seen in the diagram below: right upper quadrant (RUQ), right lower quadrant (RLQ), left upper quadrant (LUQ) and left lower quadrant (RLQ).

Thoracic cavity Abdominal cavity Pelvic cavity There are several other body cavities:

The Oral and Digestive cavity - contains the teeth and tongue, which are part of the digestive process.

The Nasal cavity is posterior to the nose and associated with the respiratory system.

The Orbital cavity - the eyes are placed in these anterior cavities within the skull.

The Middle Ear cavities contain the tiny bones to enable hearing. These cavities have a medial position to the eardrum within the skull.

The body is further divided by nine (9) regions on the torso represented in the diagrams on the next page.

These nine regions are commonly used by anatomists and are separated by four planes to subdivide the abdominal and pelvic areas. The right and left hypochondriac (hypo= low and chondro =cartilage) flanks (laterally) the epigastric, which is the stomach area (epi =upon and gastric= stomach). This is superior to the right and left lumbar regions (lumbus =loins), which is lateral to the umbilical or naval region (belly button) that is at the centre of the

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CONTINUING PROFESSIONAL DEVELOPMENT

divided regions. The right and left Iliac (Iliac= superior part of hip bone) or inguinal regions are lateral to the hypogastric (hypo= below) or pubic region, which is inferior to the umbilical area.

To support your active learning and CPD the self-assessment answers can be found in any of the text books from the reference list.

Reference List

Brewer, S. 2011. The Human Body A Visual Guide to Human Anatomy. 2nd Ed. London.

Quercus Publishing Pic.

Clancy, J. and McVicar, A. 2009. Physiology & Anatomy for Nurses and Healthcare Practitioners: A Homeostatic Approach. 3rd ed. London: Arnold

Coyle, F., Davis, J., Geddes, L., Meredith, G., Parker, 5., Price, D., Walker, R. & Roberts, A (ed). 2010. The Complete Human Body The Definitive Visual Guide. London. Darling Kindersley Limited.

Davidson, S., Preston, P., Williams, F & Peters M (ed). 2008. The British Medical Association Illustrated Medical Dictionary. 2nd Ed. London. Darling Kindersley Limited.

Foss,M. & Farrine,T. 2000. Science in Nursing and Health Care. Prentice Hall.

Kapit, W., Elson, ML, 2001. The Anatomy Coloring Book. 3'' Ed. San Francisco. Benjamin Cummings.

Marieb, E. N. 2012. Essentials of Human Anatomy and Physiology International Edition.

10'" ed. London: Pearson Education

A

Marieb, E. N. and Hoehn, K. 2010. Human Anatomy and Physiology International Edition.

8'" ed. London: Pearson Education Martini F. H., Nath, J. L. and Bartholomew, E.F. 2012. Fundamentals of Anatomy and Physiology 9th ed. London: Pearson Education.

Rampton, S. 2007. Applied Biological Sciences workbook, APU: Chelmsford.

Tortora, G. J. 2005. Principles of Human Anatomy. 10"' ed. John Wiley and Sons Inc.: New Jersey

Tortora, G. J. and Derrickson, B. 2006.

Principles of Anatomy and Physiology 11 '" ed.

New Jersey: Wiley and Sons Inc. Watson, R. 2011. Anatomy and Physiology for Nurses. 13'" edition. London, Elsevier.

Waugh, A. and Grant, A. 2010. Ross and Wilson Anatomy and Physiology in Health and Illness 11th ed. London: Churchill Livingstone Elsevier

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

43498 Podiatry Rev Mar 20/02/2014 15:43 Page 21

The management of dry skin in the elderly Michelle Taylor MInstChP BSc

The skin of the patient can provide a diagnostic indicator for various systematic disorders and provide an insight into their health and wellbeing. The quality of both deep and superficial peripheral tissues, along with any physical changes can also be noted (Lorimer, D. et al 2006). The skin is the largest organ of the body and makes up roughly 15% of the person’s body weight. As a person’s ages, changes within the skin occur making it vulnerable to damage from mild mechanical injury forces, moisture, friction and trauma (International review 2010).

The skin is known as the Integumentary System [Science Links]. The skin is the outer covering of the body and is made up of 2 main layers. The epidermis is the outer layer of skin, while the dermis is the inner layer which lies on a layer of fatty tissue. The epidermis protects the body from injury and parasites, as well as preventing the body from becoming dehydrated. A combination of erectile hairs, sweat glands and capillaries within the skin forms part of the temperature control mechanisms of the body. The skin also acts as both an excretion organ - via secretion of sweat - and a sense organ, as it contains receptors that are sensitive to heat, cold, touch and pain. The layer of fat underneath the dermis acts as a reservoir of food and water for the skin (Concise Medical Dictionary 2002).

The epidermis is made up of layers or zones, • The top or outer layer being known as the horny layer – stratum corneum.

• Granular (stratum granulosum) layer.

• Germative layer.

• Pickle cell (stratum spinosum).

• Basal layer (stratum basale).

These 5 layers make up the epidermis and cover the dermis and underlying subcutaneous tissue (Watson, R 2005).

The germative layer produces the main cells (keratinocyte) of the epidermis. These cells raise from the basal cell layer through each of the layers of the epidermis – stratum spinosum, gradulosum and lastly the stratum corneum the outer most layers. Once the cells have reached this outer most layer they have gone through a process of differentiation, which has transformed them into dead, flattened, anucleated cells called “coenocytes”, which can take between 28 – 46 days to complete. This outer layer

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Between the epidermis and dermis a dermoepidermal junction forms to help anchor the epidermis and dermis together.

The dermis makes finger like folds into the epidermis which are known as dermal papillae.

These dermal papillae are complement by protrusions from the epidermis known as rete or epidermal ridges or pegs. Where there is an increase in mechanical stress a stronger attachment is formed between the dermal papillae and rete pegs (Gawkrodger, D.J. et al 2012) (Dawber, R et al 2001).

Collagen fibres account for up to 70% of the dermis giving both strength and toughness to the structure. Elastin fibres provide elasticity to the skin; these fibres are loosely arranged in all directions within the dermis (Gawkrodger, D.J. et al 2012).

(Gawkrodger, D.J. et al 2012)

(stratum corneum) is where the barrier function of the skin occurs. Due to the high water content within these cells, it allows the cells to not only keep close to each other but also to form a tight but flexible seal (Bristow, I. 2013)

Cell turgidity is maintained through a natural moisturising process (NMF) – an intercellular humectant – which attracts water to itself. NMF is obtained from a substance called filaggrin, which breaks down into a range of NMF`s – urea, amino acids, pyrolidoncaboxylic acid and latic acid. This process maintains the skins natural acidic PH (around 5.5). Lipids originating from the lamellar bodies in the stratum gradulosum, secrete into the epidermis, acting in a similar way to waterproof mortar between the coenocytes (flattered cells) of the horny layer This chemical and PH balance maintains the thickness of the epidermis (Cork, M.J et al 2009).

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The dermis is made of 2 layers, the papillary and reticular layer. The thin upper papillary layer contains most of the blood and lymphatic vessels, while the reticular layer is not as vascular, it does contain denser collagen and elastic fibres. T – Lymphocytes and mast cells of the immune system are present within the dermis (Dawber, R. et al 2001). Also present within the dermis there are numerous hair follicles and sweat glands (Gawkrodger, D.J. et al 2012).

The paper thin appearance of the skin associated with the elderly is due to an estimated 20% reduction in the thickness of the skin (Haroun, M.T. 2003). Thinning of the dermis sees a reduction in blood vessels, nerve endings and collagen. This causes a decrease in sensation, temperature control, rigidity and moisture retention (Barsnoski, S. et al 2004). A combination of reduced sweat glands and a lack of production of sebum make the skin difficult to keep hydrated leading to dryness and itching (Watkins, J. 2011). The ability to detect temperature changes via the skin makes the elderly prone to the cold and hypothermia. A reduced ability to regenerate, with a less efficient immune system, increases the risk of skin breakdown from even the slightest injury (Voegel, D. 2012). As the skin barrier fails it becomes dry (xerotic), scaly and loses

TECHNICAL ARTICLE

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elasticity, patients may complain of itching and stinging within the skin. Dry skin is often associated with ageing but is usually due to a combination of factors

Physiological

Signs of potential failure of the skin barrier include: • Scaling.

• Red sore skin – due to incontinence, obesity or reduced mobility.

• Young or elderly.

• Dryness.

• Soaps, bubble baths and shower gels.

• Itching, scratch marks (excoriation).

• Menopause.

• Soaking the skin.

• Insufficient rinsing of the skin cleaning products.

• Vigorous drying with a towel.

• Temperature and humidity – air conditioning and central heating.

• Sun exposure

Pathological

• Many skin conditions – eczema, psoriasis, and ecchymosis.

• Skin infection.

• Peripheral vascular Disease.

• Iron deficiency anaemia.

• Hypovitiamins (A, B, C, E).

• Renal failure.

• Diabetes.

• Thyroid Disease.

• Anorexia nervosa.

• Lymphoma and other internal malignancies.

• Drugs – statins, cimetidine, retinoid.

(Bristow, I. 2013).

The major function of health skin is to act as a buffer between the body and the environment. As the skin ages the turnover of the skin slows down along with the production of NMF`s. It results in various levels of dryness, along with the inability to retain water (Tangam, H. 2008). Other changes noted with age are fine to coarse wrinkling of the skin, mottled hyperpigmentation, yellowing and actinosis (skin plaques) (Lorimer, D. et al 2006).

Lifestyle and family history play a large role in how the skin behaves in the older person: • Incontinence.

• Decreased mobility.

• Changes in mental health.

• Poor dietary intake/ poor hygiene due to a consequence of other impairments.

TECHNICAL ARTICLE

• Maceration.

• Infection.

• Pressure areas, skin breaks, ulceration.

(Wingfield, C. 2012).

Dry skin - xerosis – conditions reflect the distruption of the normal function of the skin. As the skin becomes dry it is more vulnerable to splitting/ cracking, causing an increase in water loss, tissue breakdown and infection (All Wales Tissue Viability Nurses Forum 2011). Dry skin is often associated with the aging process, environmental factors and systematic diseases.

A common dermatological problem associated with dry skin is an “itch” – pruritus. The incidences of pruritus increases with age, with those over 60 having chronic pruritus (classified as longer than 6 weeks duration) accounting for roughly 20% of the population. Damage to the skin caused by the patient scratching reduces the effectiveness of the skins natural protective barrier. Discomfort caused by the itch can lead to disturbed sleep, anxiety and depression (Best Practice Statement 2012).

There are numerous reasons for pruritus ranging from: • Allergic contact dermatitis.

• Medication – both topical and systematic (i.e. opioids, aspirin).

• Exogenous – scabies.

• Environmental agents – irritants i.e. soaps.

• Systematic disease – diabetes, CKD (Chronic kidney disease), cholestasis, thyroid dysfunction, anaemia.

Investigations are required to establish the cause of the pruritus, if no cause is found the patient often responses well to treatment for dry skin (Cowdell, F. 2009).

The use of emollients is important in promoting the health of the skin in the elderly. They are seen as the first line treatment for all dry scaling disorders, regardless of age group (NICE 2004).

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Moisturisers or emollients work in 2 different ways, by either blocking the escape of water from the skin (occlusion) or by drawing water to the epidermis from the dermis (humectants). These products are the main element of treatment; they can either be used alone or with other topical treatments such as steroids (Best Practice Statement 2012.).

Moisturisers available include creams, ointments, lotions, bath oils and soap substitutes. Therapeutic preparations differ from cosmetics as the latter contain fragrances and colours which have no therapeutic value (Best Practice Statement 2012). Emollients are effective in the management of dry skin as part of routine foot care (Bristow, I. 2013).

Emollients, often called moisturisers have a number of functions; they soften and raise the moisture content within the epidermis, increase the skins resistance to irritation from outside irritants and improve pliability (Lorden, M. 2005). Emollients contain a lipid base of fat, wax or oil with varying degrees of water content. Ointments tend to have the lowest water content, while creams and gels have increased water content. Lotions feel lighter and are less occlusive due to their low lipid content which can cause increased dryness (Hon, K.A. et al 2013).

Urea is a naturally occurring substance within the skin, and when added to an emollient has demonstrated an effectiveness to hold water within the epidermis and contains antimicrobial properties (Bristow, I. 2013). Loden et al (2013), in recent work have noted that a 15% urea based formulation quickly improves dryness, thinning of hyperkeratosis on the foot without detriment to the water retaining capability of the epidermis.

Latic acid within an emollient has been noted to improve barrier function and reduced susceptibility to both infection and irrigation of the skin (Rawlings, A.V. et al 1996). Petroleum based products act as a barrier when applied to the skin, reducing the amount of evaporation of water from the skin, but do not rehydrate the skin (Rawlings, A.V. et al 2004).

Aqueous cream is best used for its intended purpose as a soap substitute due to the sodium lauryl sulphate content (detergent agent) which has been noted to cause skin thinning and irritation. The

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43498 Podiatry Rev Mar 20/02/2014 15:43 Page 23

number of preservatives in aqueous cream has led to skin sensitivity and stinging in some patients (Wingfield, C. 2012).

Patients with dry skin are advised to apply a moisturiser regularly to the skin, at least References

twice a day. With very dry skin especially on the feet, once the emollient has been applied it is advised to cover the feet with a damp sock, followed with a dry sock over this, to help improve the effectiveness of the emollient (Bristow, I. 2013).

All Wales Tissue Viability Forum (2011). Guidelines for the assessment and management of skin tears. http://welshwoundnetwork.org/dmdocuments/all_wales_skin_tear_brouchure.pd f Baranoski, S. Ayello, E.A. (2004). Wound care Essentials. Practice Principles.

Lippincott, Williams and Wilkins. Springhouse PA.

Best Practice Statement (2012) Care of the Older Person`s Skin Wounds U.K

Bristow, I. (2013). Emollients in the care of the diabetic foot. The Diabetic Foot Journal 16 (2).

Concise Medical Dictionary (2002). Oxford University Press

Cork, M.J. Danny, S. (2009). Skin barrier breakdown: a renaissance in emollient therapy. British Journal of Nursing. 18: 872- 878.

Cowdell, F (2009). Care and management of patients with pruritus

Dawber, R. Bristow, I. Turner, W. (2001). Text Atlas of Podiatric Dermatology.

Martin Dunitz Ltd.

Gawkrodger, D.J. Arden – Jones, M.R (2012). Dermatology. An Illustrated colour text. 5th ed. Churchill Livingston. Elsevier

Haroun, M.T. (2003). Dry skin in the elderly. Geriatrics and Ageing. 16 (2): 40 – 48.

Hon, K.A. Wang, S.S. Pong, N.H. Leung, T.F. (2013). The ideal moisturiser a survey of parental expectations in childhood onset eczema. J. Dermatolog. Treat. 24: 7 – 17.

International Review (2010). Pressure ulcer prevention: pressure, shear, friction, and microclimate in context. Wounds International. www.wounds.international.com/pdf/contect_8925.pdf

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Patient compliance and emollient preference is required in order to improve and maintain skin integrity. Once dry skin has improved it is important that regular emollient use is maintained.

Loden, M. (2005). The clinical benefits of moisturizers. Journal of Euracad.

Dermatol. Venereol. 19:672 – 881.

Lorimer, D. French, G. O’Donnell, M. Burrow, J. G. Wall, B. (2006). Neal’s Disorders of the Foot. 7th ed. Churchill Livingstone Elsevier.

NICE guidelines (2004) Atopic dermatitis (eczema) – pimecrolimus and tacrolimus (TN82) Quick reference guide. NICE London http.//guidance.nice.org.uk/TA82/quickrefguide/pdf/english Rawlings, A.V. Davis, A. Carlomusto, M. (1996). Effects of lactic acid isomers on keratinocyte ceramide synthesis, stratum corneum lipid levels and stratum corneum barrier function. Arch. Dermalolol. Res. 288: 383 – 901.

Rawlings, A.V. Canestrari, D.A. Dobkowski, I. (2004). Moisturiser technology versus clinical performance. Journal Dermalolol. Therapy 17 (suppl): 49 – 56.

Science Links

http://sciencenetlinks.com/student-teacher-sheets/integumentary-system/

Tangam, H. (2008). Functional characteristics of the stratum corneum in photo aged skin in comparison with those found in intrinsic aging. Archives of Dermatology Res. 300 (Supplement) s1 – 6.

Voegel, D. (2012). Moisture associated skin damage: aetiology, prevention and treatment. British Journal of Nursing. 21 (9): 517 – 521.

Watkins, J. (2011). Early identification of skin problems in older patients. British Journal Health care assistants. 5 (9): 424 – 428.

Watson, R. (2005). Anatomy and Physiology for Nurses. 12th. ed. Elsevier.

Wingfield, C. (2012) Changes that occur in older people’s skin. Wound essentials vol. 2 (7) 52 -59.

Podiatry Review Vol 71:2

TECHNICAL ARTICLE

43498 Podiatry Rev Mar 20/02/2014 15:43 Page 24

Cheshire and North Wales Branch Meeting A frosty car scraping morning greeted 24 branch members who arose early to attend their branch meeting on a Sunday morning. Testimony to this enthusiasm is how far and wide members are prepared to travel to attend to meet colleagues and gain valuable quality CPD. However the January meeting is always a busy one with our autoclaves to be serviced, AGM to discuss, future CPD activities, new committee to be voted in, trade stand to attend and an excellent CPD lecture to learn from. Deep breath..

The Dene Court Hotel is our venue just on the outskirts of beautiful historic Chester. The meetings are always well attended so early arrival for a car park space is vital! We went headlong into the Branch AGM where a lively discussion

BRANCH NEWS

took place then followed by the equally engaging Branch Meeting.

Steve Sheldon from Canonbury, a welcome regular visitor to the branch meetings provided some excellent special offers to members during coffee break while sampling some superb homemade cake baked by Christine.

Tummies full we took our seats to draw the raffle, loads of donated goodies to be won. Following Christmas, chocolates were very much in evidence.

Malcolm Holmes, branch member, then presented an excellent practical demonstration of how to use a Doppler and understand the readings generated.

Included was how to take a blood

Podiatry Review Vol 71:2

pressure reading using traditional methods and equipment. Particular attention was given to locating all pulses present in the foot and also compiling the Brachial Index. All members were encouraged to take part and body parts were displayed and examined.

All members enjoyed this presentation immensely and felt that we all learnt much about lower limb peripheral vascular disease.

Understanding the information indicated using this equipment may just help save a patient from suffering complications because of PVD so is a vital part of the practitioner’s diagnostic armory.

Denise Willis Cheshire North Wales

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43498 Podiatry Rev Mar 20/02/2014 15:43 Page 25

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Podiatryâ&#x20AC;&#x2C6;Review Vol 71:2

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43498 Podiatry Rev Mar 20/02/2014 15:43 Page 26

Diabetes UK is 80! we have yet to go. For all the progress made, people with diabetes struggle to get access to quality healthcare, still face discrimination, and ultimately still have a lower life expectancy than the rest of the population.

It is 80 years since the writer H.G. Wells and the doctor R.D. Lawrence, who both had diabetes, founded the charity to provide support for people with the condition.

One of our main aims in our early days was to ensure everyone with diabetes who needed insulin was able to access it for free, and today we continue to campaign for better healthcare for people with diabetes and to fund more research to better understand the condition.

Barbara Young, Chief Executive of Diabetes UK, said, "During our 80th year, we will be celebrating the amazing things that have been achieved since H.G. Wells and R.D. Lawrence decided that people with diabetes needed a charity to represent them.

"Since then, Diabetes UK's research has made a real difference to people's lives in a whole host of ways. In 1964, research funded by us formed the basis of a test that is still used today to identify kidney failure earlier than was previously possible. The first ever insulin pen in 1983, which many people who need insulin prefer using, was launched after a trial that we funded. Equally, we have consistently campaigned for access to the kind of quality healthcare that can give people with diabetes the best possible chance of a long and healthy life.

Reflecting on how far we have yet to go

"But as well as looking back at how far we have come over the last 80 years, this milestone is a chance to reflect on how far

DIABETES UK

"This is why those of us who now hold the baton handed down by H.G. Wells and R.D. Lawrence all those years ago will be redoubling our efforts to ensure that the work we do helps to bring this situation to an end. This is because, while the outlook for an individual person with diabetes is hugely better than it was back in 1934, the huge rise in the number of people with the condition means diabetes is now a bigger issue – and a bigger threat to the nation's health – than ever before."

Leading medical research charities launch 'Sharing data save lives' campaign

Our medical records hold valuable information that could help save and improve lives, say leading medical research organisations today. By allowing researchers access to the information contained within our records, we can contribute towards understanding the causes of diseases and conditions such as diabetes, developing new and better medicines and identifying new outbreaks of infection.

Sharing data with researchers

Leading medical research organisations including Diabetes UK, Arthritis Research UK, Cancer Research UK, the British Heart Foundation and the Wellcome Trust, have today launched an advertising campaign to raise awareness of the importance of sharing data from patient records with researchers. Their campaign coincides with a leaflet drop by NHS England to all 22 million households in England to explain changes in how data from our health records is collected from GP surgeries.

Podiatry Review Vol 71:2

Non-identifiable data

Under the changes, researchers in academia and the pharmaceutical industry will be able to access nonidentifiable data collected from health records. Patients will be given the right to object to their data being stored within a central repository and accessed by researchers.

Extremely valuable resource

Patient records are an extremely valuable resource for research. The information contained within them can be used to understand the causes of disease or to detect outbreaks of infectious diseases. It can help monitoring the safety and efficacy of drugs and identify potential participants to take part in a clinical trial.

The information can also be used to study the effectiveness of treatments and interventions in situations where it is not possible to conduct a clinical trial, for example monitoring the safety of taking prescription medication during pregnancy.

The increasing use of electronic records opens up possibilities to ask new research questions by combining data from very large numbers of patients, and by linking different datasets.

In the 1950s, health data played a major part in uncovering the link between smoking and lung cancer. More recently, the health data of children with autism born since 1979 in eight UK health districts helped scientists establish that there is no link between the Measles, Mumps, Rubella (MMR) vaccination and autism.

"Much to be gained"

Bridget Turner, Director for Policy and Care Improvement for Diabetes UK, said, "We hope that this campaign serves to make the case for the huge benefit this change could bring, which will include improving the lives of people with diabetes and at risk of developing it.

Clearly, there is much to be gained from this and we are pleased that the rules do allow researchers in academia and the pharmaceutical industry to access nonidentifiable data collected from health records. We also want to make sure that people understand what these changes

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43498 Podiatry Rev Mar 20/02/2014 15:43 Page 27

mean so they are in a position to make an informed choice about whether they wish to opt out."

"Rich source of data"

Dr Jeremy Farrar, Director of the Wellcome Trust, said, "The NHS is a unique and incredibly valuable resource for research, providing insights that just would not be possible without such large and comprehensive sets of data. With the correct and necessary safeguards in place to assure public confidence, our patient records will provide a rich source of important data that can help researchers develop much needed treatments and interventions that can improve and even save people's lives."

"New knowledge, insights and treatments"

Sharmila Nebhrajani, Chief Executive of the Association of Medical Research Charities, said, "Under the new system introduced through the NHS, people can choose whether to allow the use of their health data in research. I believe people will be willing to make the public-spirited act of sharing their medical records with researchers as long as they are confident that their data will be treated with care to protect their identity, competence so that leaks and mistakes will not occur, and used only with their consent, allowing those who do not wish to take part to opt out.

And from this sharing, researchers can find new knowledge, insights and treatments that will benefit us all."

"I might not be alive today"

Richard Stephens, who has survived both Hodgkins Lymphoma and basal cell carcinoma, said, "As someone who has survived two cancers, I have seen firsthand how our health records can help improve people's lives. I might not be alive today if researchers had not been able to access the data in the health records of other cancer patients to produce the most effective treatments and the best care for me, and by making my own records available to researchers I know I am helping other patients in the future."

Further information about how sharing data save lives can be found at www.patientrecords.org.uk.

page 27

Action on sugar formed to tackle obesity and diabetes

In response to news that a group has been formed to campaign on the reduction of sugar consumption, Barbara Young, Chief Executive of Diabetes UK, said:

“We fully support any efforts to raise awareness that many foods contain more sugar than people might realise and to call on the food industry to reduce added sugar in our food and drink; this could make a real difference in helping tackle the

obesity epidemic that is fuelling rates of Type 2 diabetes and other chronic conditions.

“But it is important to be clear that we want to reduce sugar consumption because having too much can easily lead to weight gain, as is true with foods high in fat. So reducing the amount of sugar in our diets is not all that we need to do to reduce our risk of Type 2 diabetes.

The evidence that sugar has a specific further role in causing Type 2 diabetes, other than by increasing our weight, is not clear. We look forward to the conclusions of the Scientific Advisory Committee on Nutrition, which is due to report this year.”

THE GIFT

From the makers of the acclaimed genealogy series Who Do You Think You Are?, and the hit family reunion series Long Lost Family, The Gift (working title) is an inspirational new programme for BBC One that helps people express their gratitude or make amends.

Is there someone who has changed the course of your life forever? Someone you never got the chance to thank properly? Or someone you’ve wronged in the past who you feel a burning need to apologise to? Do you long to talk to them but can’t find the courage to do it alone? What if you’ve lost touch with them altogether?

Living with an unpaid debt of gratitude or a long overdue apology can be an enormous burden. For many thousands of people across Britain, it’s often impossible to move on until you’ve had the chance to express your feelings in person. The Gift is the programme that can help. From tracking down the stranger who saved your life to helping you build bridges with people who you’ve seriously wronged in past, The Gift can end the years of guilt, worry or longing and finally let you begin to find closure.

With a team of professional mediators, psychologists and experts in tracing people, The Gift will document the stories of people who want to seek forgiveness or express their gratitude and need our help to do so. We’ll track down the people they want to find, support them as they prepare for a face to face meeting, and film them selecting a gift, which might be a token of thanks or to make amends.

The Gift is planned for broadcast by BBC One in a primetime mid-week slot and will be presented by a well known TV personality.

Wall to Wall Television is one of the UK’s leading production companies, with a reputation for producing ground-breaking, intelligent and sensitively made television content. Programmes include the internationally acclaimed genealogy series Who Do You Think You Are?, and the hit family reunion series Long Lost Family, as well as award-winning TV drama The Girl, and entertainment phenomenon The Voice UK. www.walltowall.co.uk/thegift.aspx

Podiatry Review Vol 71:2

DIABETES UK

43498 Podiatry Rev Mar 20/02/2014 15:43 Page 28

Do you suffer from health anxiety?

Most of us worry about our health from time to time. But for some people, this worry never goes away and becomes a problem in itself.

Health anxiety (hypochondria) is obsessive worrying about your health, usually to the point where it causes great distress and affects your ability to function properly.

Some people with health anxiety have unexplained physical symptoms, such as chest pain or headaches, which they assume are a sign of serious disease despite the doctor's reassurance.

Others may just be permanently anxious about their future health, worrying about things like 'What if I get cancer or heart disease?'

There are many reasons why someone worries too much about their health.

You may be going through a particularly stressful period of your life. There may have been illness or death in your family, or another family member may have worried a lot about your health when you were young.

Personality can play a role; you may be vulnerable to health anxiety because you are a worrier generally. You may find it difficult to handle emotions and conflict, and tend to 'catastrophise' when faced with problems in your life.

Sometimes, health anxiety can be a symptom of a mental illness, such as depression or anxiety disorder, which needs recognising and treating in its own right.

Conditions such as low back pain, irritable bowel syndrome and eczema are known to be triggered or made worse by psychological problems such as stress or anxiety.

When physical symptoms are triggered or made worse by worrying, it causes even more anxiety, which just worsens the symptoms. Excessive worrying can also

HEALTH ARTICLE

lead to panic attacks or even depression.

Health anxiety is a vicious circle in other ways, too.

If you constantly check your body for signs of illness, such as a rash or bump, you will eventually find something. It often won't be anything serious – it could be a natural body change, or you could be misinterpreting signs of anxiety (such as increased heart rate and sweating) as signs of serious disease. However, the discovery tends to cause great anxiety and make you self-check even more.

You may find yourself needing more and more reassurance from doctors, friends and family. The comfort you get from this reassurance may be short-lived, or you may stop believing it, which only means you need more and more of it to feel better. Seeking reassurance just keeps the symptoms in your head, and usually makes you feel worse.

People with health anxiety can fall into one of two extremes:

• constantly seeking information and reassurance – for example, obsessively researching illnesses from the internet and booking frequent GP appointments, or

• avoidant behaviour – avoiding medical TV programmes, GP appointments and anything else that might trigger the anxiety, and avoiding activities such as exercise that are perceived to make the condition worse (when it fact many people find that exercise helps – for example, read about exercise for depression)

Neither of these behaviours are healthy, and need addressing if you are to break the cycle of health anxiety.

If you think you suffer from health anxiety, there is much to be gained from a good consultation with your GP. Once your GP has established that you

Podiatry Review Vol 71:2

do suffer from health anxiety, and there is no underlying physical cause for any symptoms you might have, they should investigate whether you might have a problem such as depression or anxiety disorder that may be causing or worsening your symptoms.

If this is the case, you may be referred for psychological therapy and you may benefit from antidepressants.

If this is not the case, the aim should still be to help you become less worried about your health. You may find that your GP's advice and self-help resources are all you need to start feeling better, or you may still benefit from a referral for psychological therapy.

Cognitive behavioural therapy (CBT) is an effective treatment for many people with health anxiety. It involves working with a trained CBT therapist to identify the thoughts and emotions you experience and the things you do to cope.

On example of an unhealthy thought is jumping to conclusions like "If the doctor sent me for tests, she must be really worried".

The aim is to change unhealthy thoughts and behaviours that maintain health anxiety to those that break this cycle.

CBT looks at ways to challenge the way you interpret symptoms, to encourage a more balanced and realistic view. It should help you to: • learn what seems to make the symptoms worse

• develop methods of coping with the symptoms

• keep yourself more active, even if you still have symptoms.

However, CBT is not the best treatment to try for everyone with health anxiety.

Some people may benefit more from a different psychological therapy, such as trauma-focused therapy or a

page 28

43498 Podiatry Rev Mar 20/02/2014 15:43 Page 29

psychotherapy that will help a particular psychological condition.

Accurate assessment is needed to select the right treatment for you and for your problem, so, if necessary, you may be referred to a mental health specialist for this next step.

Medication

Antidepressant medication may be helpful if you have a psychological problem such as depression. For some people, these may work better than CBT. Your GP can directly prescribe antidepressants or refer you to a mental health specialist for treatment.

However, treating symptoms with drugs is not always the answer. Long-term use of painkillers or sedatives, for example, may lead to dependence. The possible benefits of medication always need to be weighed against the potential side effects.

More Information www.nhs.uk

NHS

Choices

Have I got health anxiety?

If you can answer YES to most of these questions, it's likely you are affected by health anxiety.

During the past six months:

• Have you been preoccupied with having a serious illness because of body symptoms, which has lasted at least six months?

• Have you felt distressed because of this preoccupation?

• Have you found this preoccupation impacts negatively on all areas of life including family life, social life and work?

• Have you felt you have needed to carry out constant self-examination and self-diagnosis?

• Have you experienced disbelief over a diagnosis from a doctor, or felt you are unconvinced by your doctor's reassurances that you are fine?

• Do you constantly need reassurance from doctors, family and friends that you are fine, even if you don't really believe what you are being told?

Source: Anxiety UK

New Study reconfirms peoples’ inability to switch off from technology

A recent study which found that high achievers are at risk of conditions like anxiety and depression due to their inability to switch off the internet and stop working outside of office hours, highlights the fine line between healthy and unhealthy use of modern technology, say Anxiety UK. The study, reported in The Telegraph this week, echoes findings from an Anxiety UK study in 2012 into the mental health consequences of too much technology use.

The Anxiety UK study found that over half of respondents who regularly use social networking sites saw their behaviour change negatively. Further investigation revealed factors such as negatively comparing themselves to others, spending too much time in front of a computer, having trouble being able to disconnect and relax, as well as becoming confrontational online, thus causing problems in their relationships or job.

The study also found that 45 per cent of people who are not able to access their social networks or email feel worried or uncomfortable as a result. And perhaps most surprising, 60 per cent of respondents said that they felt the need to switch off their mobiles/computers/Smartphones in order to have a break, with one in three of them saying they switched off several times a day.

“We were surprised by the high proportion of people who found that the only way to ensure a break from the demands of life was to switch off their phone or computer, as they were not capable of simply ignoring them,” explained Nicky Lidbetter, chief executive of Anxiety UK.

“If you are predisposed to anxiety it seems that the pressures from technology act as a tipping point, making people feel more insecure and more overwhelmed. Our findings, as well as those reported in The Telegraph, suggest that some may need to re-establish control over the technology they use, rather than being controlled by it.”

If you are feeling overwhelmed or are experiencing anxiety and stress and would like support, please ring the Anxiety UK helpline on 08444 775 774 to find out how Anxiety UK can help.

page 29

Podiatry Review Vol 71:2

HEALTH ARTICLE

43498 Podiatry Rev Mar 20/02/2014 15:43 Page 30

AWARENESS INFORMATION

Podiatry Review Vol 71:2

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PRESS RELEASE

43498 Podiatry Rev Mar 20/02/2014 15:43 Page 32

Please se www.ioc e website calend p.org.uk a for late e r ntries

March 2014 2

12

20 22

27

Cheshire North Wales, Staffs and Shropshire Branch Meeting 10.00am - The Dene Hotel, Hoole Road, Chester, CH2 3ND Presentation to be confirmed Tel: 0151 327 6113

Hants and Dorset Branch Meeting 8.00pm - Crosfield Hall, Broadwater Road, Romsey SO51 8GL Lecture: Steroids and their actions - Brian Quilty – Consultant Rheumatologist.

Tel: 01202 425568

Sheffield Branch Meeting 7.30pm - SWD Sports Club, Heeley Bank Road, Sheffield S2 3GL Tel: 01246 477725

Southern Area Council Seminar – Details to follow Southend University Hospital Education Centre Carlingford Drive, Southend on Sea SS0 0RY Tel: 01704 546141 (Head Office)

6

7 13

13

13 26

27

Cheshire North Wales, Staffs and Shropshire Branch meeting 10.00am - The Dene Hotel, Hoole Road, Chester, CH2 3ND Presentation to be confirmed Tel: 0151 327 6113

Essex Branch meeting 2.00pm - Southend University Hospital Education Centre Carlingford Drive, Southend on Sea SS0 0RY Tel: 01702 460890

West Middlesex Branch AGM 7.30pm - The Harvester, Croxley Green, Rickmansworth WD3 3RX Tel: 0208 903 6544 Devon and Cornwall Branch meeting 10.30am - Exeter Court Hotel, Kennford, Exeter EX6 7UX CPD Lecture by Langer Biomechanics Tel: 01803 520788 email mrkjoanne@aol.com

Western Branch Meeting 12.00 noon - 4.30pm - Blair Bell Education Centre, Room 1, Liverpool Women’s Hospital, Crown Street, L8 1SS Lectures and trade stands TBA for all meetings.

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

North of Scotland Branch Meeting Belvedere Hotel, 41 Evan Street, Stonehaven AB39 2ET. A further meeting will be held in either September or October. Please phone for details Tel: 01382 532247

Leicester & Northants Branch meeting 10.00am - Kilsby Village Hall – refreshments and reg 9.45 CPD Workshop: Joint Mobilisation Tel: Sue 01530 469816

DIARY OF EVENTS

North West Branch Meeting St Joseph’s Parish Centre, Harpers Lane, Chorley PR6 0HR Tel: 01257 411272

May 2014 11

11

12

April 2014 6

29

South Wales and Monmouth Branch meeting 10.00am - Meeting room at Asda Store, Coryton, Cardiff CF14 7EW First Aid refresher with autoclave servicing (please book) Tel: 01656 740772

18

30/31

Nottingham Branch Meeting 10.00am - Feet and Co 85 Melton Road, West Bridgford, NG1 6EN Tel: 0115 931 3492

West of Scotland Branch meeting 11.00am - 1.30pm - Holiday Inn Express, Springkerse Business Park, Stirling FK7 7XH Tel: 0141 632 3283

West Middlesex Branch meeting 8.00 pm - The Harvester, Croxley Green, Rickmansworth WD3 3RX Tel: 0208 903 6544

Hants and Dorset Branch First Aid Course Open to all; members of other branches and non members - Location to be confirmed Further details email juliacdoble@gmail.com Tel: 01202 425568 The Institute of Chiropodists and Podiatrists AGM Workshops and CPD Conference Southport theatre and convention centre The Promenade, Southport PR9 0DZ Tel 01704 546141

June 2014 8

18

19 22 22

26

Essex Branch meeting 2.00pm - Southend University Hospital Education Centre Carlingford Drive, Southend on Sea SS0 0RY Tel: 01702 460890

Hants and Dorset Branch Meeting 8.00pm - Crosfield Hall, Broadwater Road,Romsey SO51 8GL Lecture: Lymphoedema – Raksha Peters Tel: 01202 425568

Sheffield Branch Meeting 7.30pm - SWD Sports Club, Heeley Bank Road, Sheffield S2 3GL Tel: 01246 477725

South Wales and Monmouth Branch meeting 2.00pm - Meeting Room at Asda Store, Coryton, Cardiff CF14 7EW Tel: 01656 740772

Western Branch Meeting 12.00 noon - 4.30pm - Blair Bell Education Centre, Room 1, Liverpool Women’s Hospital, Crown Street, L8 1SS Lectures and trade stands TBA for all meetings.

Tel: 01745 331827 Birmingham Branch meeting 8.00pm - Red Cross Centre, Vine Street, Evesham, Worcs Tel: 01905 454116

Podiatry Review Vol 71:2

page 32

43498 Podiatry Rev Mar 20/02/2014 15:43 Page 33

July 2014 13

Wolverhampton Branch meeting 9.30am - 4 Selmans Parade, Selmans Hill, Bloxwich, W53 3RN Tel: 0121 378 2888

14

West Middlesex Branch AGM 8.00pm - The Harvester, Croxley Green, Rickmansworth WD3 3RX Tel: 0208 903 6544

20

Leicester & Northants Branch meeting 10.00am - Kilsby Village Hall (refreshments 9.45am) CPD Lecture: Understanding Ultrasound therapy Tel: Sue 01530 469816

September 2014 8

West Middlesex Branch AGM 8.00pm - The Harvester, Croxley Green, Rickmansworth WD3 3RX Tel: 0208 903 6544

9

North West Branch Meeting St Joseph’s Parish Centre, Harpers Lane, Chorley PR6 0HR Tel: 01257 411272

14

West of Scotland Branch meeting 10.00am - 4.00pm - Holiday Inn Express, Springkerse Business Park, Stirling FK7 7XH Tel: 0141 632 3283

22

Essex Branch meeting 2.00pm - Southend University Hospital Education Centre Carlingford Drive, Southend on Sea SS0 0RY Tel: 01702 460890 Includes a First Aid Course

October 2014 1

Devon & Cornwall Branch will be meeting in October. Please telephone Mark Smith 01803 520788 for details.

1

Hants and Dorset Branch Meeting 8.00pm - Crosfield Hall, Broadwater Road,Romsey SO51 8GL Canonbury will be available to answer questions and display various products of interest with discounts.

Tel: 01202 425568

2

Birmingham Branch meeting 8.00pm - Red Cross Centre, Vine Street, Evesham, Worcs Tel: 01905 454116

5

North West Area Council Seminar – Details to follow

12

Wolverhampton Branch meeting 9.30am - 4 Selmans Parade, Selmans Hill, Bloxwich, W53 3RN Tel: 0121 378 2888

19

Cheshire North Wales, Staffs and Shropshire Branch meeting 10.00am - The Dene Hotel, Hoole Road, Chester, CH2 3ND Presentation to be confirmed Tel: 0151 327 6113

26

Leicester & Northants Branch meeting 10.00am - Lutterworth Cricket Club (Refreshments 9.30) CPD Lecture: Wound care – TBC Plus Autoclave service by MDS – reservation required as limited places.

Tel: Sue 01530 469816

page 33

November 2014 16

West of Scotland Branch meeting 10.00am - 4.00pm - Holiday Inn Express, Springkerse Business Park, Stirling FK7 7XH Tel: 0141 632 3283

14

Western Branch Meeting 12.00 noon - 4.30pm - Blair Bell Education Centre, Room 1, Liverpool Women’s Hospital, Crown Street, L8 1SS Lectures and trade stands TBA for all meetings.

Tel: 01745 331827

23

Essex Branch meeting 2.00pm - Southend University Hospital Education Centre Carlingford Drive, Southend on Sea SS0 0RY Tel: 01702 460890

23

Leicester & Northants Branch meeting 9.00am - Lutterworth Golf Course (refreshments 8.45am) CPD Lecture: TBC Trade Stands to be arranged.

Tel: David 01455 550111

December 2014 5

Hants and Dorset Branch Christmas Social event.

Details to follow Tel: 01202 425568

2015

January 11

Western Branch AGM & Meeting 12.00 noon - Blair Bell Education Centre, Room 1, Liverpool Women’s Hospital, Crown Street, L8 1SS Tel: 01745 331827

11

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

13

North West Branch AGM St Joseph’s Parish Centre, Harpers Lane, Chorley PR6 0HR Tel: 01257 411272

15

Birmingham Branch AGM 7.30pm - Red Cross Centre, Vine Street, Evesham, Worcs Tel: 01905 454116

18

Essex Branch AGM 2.00pm - Southend University Hospital Education Centre Carlingford Drive, Southend on Sea SS0 0RY Tel: 01702 460890

18

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

25

Leicester and Northants Branch AGM Lutterworth Cricket Club Starts 10am with refreshments at 9.45am Contact Sue 01530 469816

Podiatry Review Vol 71:2

DIARY OF EVENTS

43498 Podiatry Rev Mar 20/02/2014 15:43 Page 34

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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

Contact us on 02085190044 or www.chiropodydrillrepair.co.uk

RECRUITMENT US: friendly, modern, dynamic YOU: HPCP registered, reliable, excellent routine podiatry skills, positive attitude and interpersonal skills, work independently and as part of a team WHAT NEXT: visit www.solebodysoul.com for more information Send CV & covering letter to recruitment@solebodysoul.com

Basingstoke, Hampshire

HCPC registered Podiatrist wanted to work Fridays and Saturdays at a well-established clinic within a multi-disciplinary setting. Working independently on a self-employed basis, previous private practice experience preferred but not essential. Applicants must have excellent clinical skills inc general chiropody and biomechanics, as well as good interpersonal skills and excellent reliability. Near immediate start required.

If interested or for more information please email info@overtonfootclinic.co.uk or call 07887 368899

To advertise in this section and on our website Call: 01704 546141 or email: bernie@iocp.org.uk 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 ALL YOUR STATIONERY NEEDS

Situation Vacant

Torquay, Devon - Retirement Sale

Surgery and Domiciliary.

Established 25 years.

Income £16K over 3 days.

Plenty of Scope for expansion.

Price £11K Telephone 07739 041919

QUATAR U.A.E

Full time Podiatric Consultant wanted for Hamad Medical Corporation.

We are Quatar’s leading healthcare provider to more than two million expatriates and Quatari nationals living and working in Quatar.

We would like to hear from Consultants of Podiatric Medicine with at least 5 years’ experience who would like the opportunity to work in our very supportive and progressive modern department.

Excellent working conditions. Tax free salary; 35 – 50 days paid annual leave plus local holidays (approx. 10); one round trip annual leave ticket; educational support for children; relocation support; housing allowance; subsidised healthcare for all the family plus additional benefits.

For further details and an informal discussion in the utmost confidence please email John Shorland john.shorland@ae.ibm.com

Podiatry Review Vol 71:2

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Mechanical watches for a humanitarian cause

NOMOS Glashütte from Germany is now launching a limited edition of classic mechanical watches to support Doctors Without Borders/Médecins Sans Frontières (MSF) and their relief operations worldwide.

Every year, millions of people around the world are caught in catastrophic events such as armed conflicts, epidemics, malnutrition, or natural disasters. They are in need of urgent humanitarian assistance. The town of Glashütte, the center of fine watchmaking in Germany, is by contrast a peaceful place. But just because we are far off the beaten path, does not mean that we are cut off from the world outside. This is why we are producing limited editions of classic NOMOS watches to support the work of the Nobel Peace Prize winning international medical humanitarian organization.

NOMOS Glashütte first launched a campaign to support Doctors Without Borders in Germany, producing an initial batch of 2,000 watches in March 2012. Now the successful charitable initiative is being repeated and going international at the same time: from June, special models of the NOMOS Tangente benefiting Doctors Without Borders will be available in the United Kingdom and the United States.

What makes these hand-wound watches extra-special is a red twelve, the name “Doctors Without Borders” on the white silverplated dial and an engraving on the back referring to the international medical humanitarian organization. In addition, these special models have black oxidized hands instead of the Tangente’s usual tempered blue ones. And you can watch the NOMOS Alpha movement at work through the sapphire crystal glass back.

NOMOS Glashütte is now making 1,000 of each special model to support Doctors Without Borders—namely the NOMOS classics Tangente and Tangente 33 in the UK, Tangente 38 and Tangente 33 in the United States. One hundred pounds or dollars respectively from the sale of each watch go directly towards helping those most in need. However, customers pay no more than they normally would for a regular Tangente, as both NOMOS Glashütte and the retailers are waiving a share of their margin. “We’ll be delighted if a large number of watch enthusiasts opt for the best of both worlds: to help and, at the same time, enjoy an excellent timepiece,” says NOMOS General Manager Uwe Ahrendt. “Every look at your watch will also remind you of the people around the world in need of help and who just might get it, thanks to you.”

Further information see http://www.nomos-glashuette.com/en/watches/limitededitionsdoctorswithoutborders/

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Podiatry Review Vol 71:2

DOCTORS WITHOUT BORDERS

43498 Podiatry Rev Mar 20/02/2014 15:44 Page 38

For all things Podiatry!

Supporting Podiatry through research, development and manufacture for over 100 years Below are just a few of our well known brands. For further information on our extensive range of podiatry products available through a countrywide network of distributors visit: www.cuxsongerrard.com

A comprehensive range of paddings and strappings in varying thicknesses and compressions

The dynamic orthotic insole that relieves: Arch Pain, Knee Pain Back Pain, Heel Pain

The elegant, thin and exceptionally strong orthotic that fits all patients shoes

CRYOSPRAY 59 Breathable hypoallergenic adhesive tape, in various sizes for dressing retention

The professional solution for effective Verruca and Wart removal

www.cuxsongerrard.com

The softer way to protect feet. Protects and cushions, whilst moisturising and lubricating