Podiatry review september october 2013

Podiatry Review

ISSN 1756-3291

Volume 70 No.5. Published by the Institute of Chiropodists and Podiatrists as a Peer Review Journal September/October 2013

• Understanding tumours of the foot.

• Peripheral arterial disease explained.

• What is consent?

The Institute of Chiropodists and Podiatrists

NATIONAL OFFICERS

National Officers President

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

Chairman Executive Committee Mrs C Johnston MInstChP BSc(Hons)

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

Chairman Board of Ethics Mrs J. Dillon MInstChP

Chairman Board of Education

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

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

Vice-Chairman Board of Education Miss Joanne Casey MInstChP BSc

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Secretary

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S E P T E M B E R / O C T O B E R 2013 V O L 70 N o.5

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

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

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

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PODIATRY REVIEW

The Institute of Chiropodists and Podiatrists

Contents

Editorial .............................................................................2 Technical Article - Peripheral Arterial Disease Michelle Taylor M.Inst.Ch.P., BSc. .....................................4 Website log-on information ..............................................7 Technical Article - Tumours of the Foot Stephen Willey M.Inst.Ch.P., LCh. .....................................8 Information Article - Consent to Treat ............................11 Information Article - Restless Leg Syndrome...................12 Graduation of Students from Cohort 6 City and Guilds...15 Botox’s target could hold cure for diabetes Heriot-Watt University ...................................................16

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ISSN 1756-3291

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© The Institute of Chiropodists and Podiatrists.

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

Obituary - Ronald Ward...................................................17 Conference Postbag ........................................................18 Interview with David Thomas of MDS Medical ...............20 Information Arthritis Research UK ..................................22 Information Diabetes UK.................................................24 Branch News ..............................................................27-33 Sheffield Branch Seminar Information ............................28 Leicester and Northants Branch Seminar........................29 Diary of Events ...........................................................34-35 Classified Adverts ...........................................................36 Crisis information - volunteers .......................................37

page | 01

EDITORIAL Dear Readers, What a lot of branch seminars we are featuring in the second half of this issue! Well done to all those branches for organising these CPD events on behalf of your members. Please remember to support your branch but also bear in mind that you can attend any branches for CPD. A good attendance is essential to keep the events running on a regular basis. In the office, we hear many complaints from members that CPD venues are too far to travel for them. With CPD events being organised in Wolverhampton, Sheffield, Leicester, Preston, Sussex and

What is consent to treat? Do you know what makes consent valid? If you are hesitating you may like to read the article on page 11, kindly provided by Claire Gallagher. This was actually the subject of a lecture which we have adapted for the Review.

Also, in this issue, we are including the conference postbag although conference now seems such a long time ago and we are busy planning the next, we appreciate your letters and the timing of this year’s event meant they missed the deadline for the July/August issue. Many thanks to all who contributed.

Huddersfield before the end of the year, there must be CPD activity within reasonable travelling distance for the majority of you! I hate to remind you but the HCPC audits will be upon us again before we know it. Please take advantage of your branches!

I hope you will find this issue interesting and if you don’t..........then please supply us with articles; these can be factual, observational or anecdotal - in fact anything you would like to read yourselves.

In this issue: We thank Stephen Willey (Sheffield Branch) for taking the time to write an article on ‘Tumours of the Foot’.

Perhaps Stephen will discover he enjoys writing for the Review as much as Michelle Taylor (Cheshire North Wales Branch) has.

Michelle has written us another article for this issue on Peripheral Arterial Disease and we hear she is beavering away with another.

Many thanks to both and as we keep saying; the more the merrier. Please at least think about writing for your journal.

Finally, we thought you may like to see some photographs of ‘summer in Southport’ courtesy of Pauline Leatherbarrow. We hope you are all enjoying this unusually long hot sunny spell (apologies if it is pouring down or snow is falling by the time this goes to print!)

Bernadette Hawthorn, Editor

Dear Editor,

May I take this opportunity to congratulate our branch members in recently being awarded the branch 'Endeavour Award' and in particular, our Secretary, Mr David Collett, for his tireless work and efforts for

this branch; it is very much appreciated by us all.

Very proud - well done to you all.

Lisa Whitehouse-Foskett Chairman - Wolverhampton Branch

Editor’s Note: Well done Wolverhampton Branch. Can any branch beat them next year? All entries will be considered by the Executive Committee prior to the annual conference.

02 | page

Introducing Your Private Podiatry Team A dedicated team just for you!

Rachael Frank

James Cree

Podiatry Division Manager

Business Development Executive

Rachael manages the private Podiatry Division from our Head Office in Liverpool.

Contact Rachael about anything related to our podiatry marketing, suggestions for new products or any initiatives within your clinic we may be able to help you with.

Appointments can be made for James to visit your clinic to introduce new products, offer unique solutions, give product demonstrations and put together bespoke quotations. Many of you will recognise James from the numerous conferences and branch meetings we attend.

You can contact James on 07713 519 475 or james.cree@algeos.com

You can contact Rachael on 0151 448 1228 or rachael.frank@algeos.com

Vicki Smallwood

Angela Proudfoot

Marketing Executive

Telemarketing Account Manager

Vicki has a great knowledge of our products and the vast library of marketing material that we have produced over the years. You can contact Vicki for any marketing literature or support you may require.

Vicki is also great at getting the team organised during the busy conference times!

You can contact Vicki on 0151 448 1228 or vicki.smallwood@algeos.com

Ava Hughes

Customer Services Executive With a friendly and helpful manner, Ava is a popular member of our Customer Services Department and is your key point of contact when looking to place an order, check the status of an order and for handling any product queries you may have.

You can contact Ava on 0151 448 1228 or ava.hughes@algeos.com

Angela has a wealth of Account Management experience so will ensure we provide the greatest levels of service to our customers.

Angela will make you aware of special offers, new product introductions and handle any account queries you may have.

You can contact Angela on 0151 448 1228 or angela.proudfoot@algeos.com

Service & Delivery Improvements: A Dedicated Team for orders & enquiries FREE Delivery for online orders over £50 (ex VAT) and offline orders over £85 (ex VAT)* Next Day Delivery – we aim to despatch all ‘in stock’ orders placed before 3pm on the same day Upgraded computer systems to improve efficiency Increased despatch speeds ensure fast deliveries *excludes some bulky/heavy items

page | 03

TECHNICAL ARTICLE

Peripheral Arterial Disease Michelle Taylor M.Inst.Ch.P., BSc.

Atherosclerosis in the Western world is a major cause of morbidity, mortality, coronary artery, cerebrovascular and peripheral artery diseases. Circulatory disorders of the lower limb can be classified into:• Arterial (macro vascular) • Capillary (microvascular) • Venous or lymphatic disease.

Arterial disease is clinically the most important arterial disease, due to the threat of limb viability and negative impact on the patient’s quality of life. Arteriosclerosis describes the hardening of the arteries, and is restricted to describing age related changes within the arterial walls. The definition of arteriosclerosis is not widely accepted. It is sometimes used as a generic name to describe the pathological changes associated with arteriosclerosis and atherosclerosis. While atherosclerosis – microvascular disease – describes the thickening of the intima of the medium and large sized arteries. This leads to narrowing of the artery caused by lipid and fibrous deposits (Lorimer, D. et al 2006).

Peripheral arterial disease (PAD) is known as poor circulation or hardening of the arteries. It commonly occurs when the arteries supplying the lower limbs become obstructed.

Obstruction is caused by fatty plaques deposited within the arteries causing stenosis (narrowing of the artery) leading to a reduced blood flow (Smith, L. 2012). This build-up of fatty plaque (atheroma) or scar tissue causes degeneration of the walls of the arteries (Concise Medical Dictionary). Due to the build-up of plaque the tunica intima and media of the arterial wall becomes thickened and fibroses, replacing the smooth muscle and collagen (Lorimer, D. et al 2006).

Progressive narrowing or occlusion of the arteries results in ischaemia of the tissues supplied by the diseased vessels.

Development and progression of the atheroma varies from vessel to vessel. A patient may present with symptoms of ischemia in the lower limbs, heart or brain. Patients presenting with PAD have a 4 to 6 fold increase of dying due to a cardiovascular event (Lorimer, D. et al 2006).

PAD can be defined by anatomical considerations as atherosclerotic disease causing narrowing of the arteries, leading to a mismatch between oxygen demand and supply.

04 | page

This mismatch leads to symptoms of intermittent claudication, exercise limitations or tissue loss. It is thought that a reduction

in oxygen in the surrounding muscles leads to claudication due to a build-up of metabolites. Symptoms are reduced with rest as the muscles are re-oxygenated as the metabolites are cleared away. This definition help’s divide PAD into either asymptomatic or symptomatic disease states. For every symptomatic patient there are at least 6 asymptomatic patients (Dieter, R.S. et al 2002).

Risk factors for developing PAD include smoking, diabetes, hypertension (high blood pressure) and dyslipidaemia (cholesterol) (Menz, H.B 2008). PAD has been described as both being under diagnosed and under treated. In the U.K approximately 20% of people over 60 have being diagnosed with some degree of PAD. It is also a marker for increased cardiovascular morbidity with patients having a mortality rate of approximately 30% after 5 years. PAD is recognised as a contributor to lower limb ulceration and amputation (Fox, M. 2012).

Symptoms of PAD have a gradual onset with a large number of cases being asymptomatic. The classic early signs of intermittent claudication are ischemic induced pain in the calf region – less commonly in the thigh, buttocks or foot. The pain occurs while walking and disappears on rest. In advanced cases of PAD cramping pain may occur in the night – known as nocturnal or night cramps – as the increased temperature while in bed increases the oxygen demand within the muscles of the legs. In order to gain relief the limb is placed over the side of the bed to reduce the temperature of the limb and to increase blood flow (Menz, H.B 2008).

Rest pain is the most severe form of ischaemic pain as this occurs without any physical activity. As this indicates that the arterial supply cannot met even the most basic metabolic needs.

This stage is known as critical limb ischaemia as ulceration/ gangrene may develop. If limb perfusion cannot be improved there is significant risk of limb failure and amputation (Menz, H.B 2008).

A full, detailed medical history can supply evidence of atherosclerotic, ischaemic or cerebrovascular disease, anaemia or blood disorders (Lorimer, D. et al 2006). It can also allow for differential diagnosis to be made which include;

TECHNICAL ARTICLE • Spinal stenosis

• Venous claudication.

• Chronic deep venous thrombosis causing venous claudication.

• Chronic compartment syndrome.

• Osteoarthritis.

• Rheumatologic/ connective tissue disease.

(Dieter, R.S. et al 2002).

Visual observation of suspected PAD includes: • Loss of hair growth.

• Atrophic or shiny skin.

• Dystrophic toenails.

• Limb temperature.

• Palpation of the pedal pulses.

• Buergers test (limb elevation).

• Abnormal sounds detected via stethoscope.

• Paraesthesia (numbness).

Physical examination of suspected PAD patients should

concentrate on the arterial system. The abdomen requires palpation for an aneurysm, abnormal sounds or mummers (bruit) of the heart or large vessels. The femoral, popliteal, posterior tibias, dorsal pedis pulses require palpating and grading using the following system: • Normal pulses 2

• Diminished pulses 1 • Absent pulses 0.

(TASC Working Group 2000).

The most useful clinical observations for detecting PAD have been found to be abnormal pedal pulses, femoral artery bruit, unilateral cool limb and abnormal limb colour (Menz, H.B 2008).

A doppler enables the blood flow through the blood vessels to be heard enabling additional information of the site of the occlusion. Triphasic and biphasic sounds indicate normal flow, while a monophasic sound and or lowering of the sound pitch indicates arterial occlusion (Lorimer, D. et al 2006). The following table can be used to access whether there is PAD present:

Test

Test result indicative of peripheral arterial disease.

Femoral Artery bruit (mummer)

Bruit present.

Abnormal pedal pulses Cool skin

Abnormal limb colour

(Menz, H.B 2008).

Dorsal pedis and posterior tibial artery pulses either absent or 1 present and 1 weak.

Unilateral cool skin.

Pale, red or blue skin.

Burger’s Test is performed by laying the patient down and noting the colour within the foot.

Occlusion of a main artery is noted by pallor of the foot on elevation of the limb, while a flush of colour is noted across the top of the foot when the leg is lowered. There is no such colour change in a non-ischaemic limb (Burger, L 1924). Also by noting how long it takes for the blood to refill the drained vessels enables the degree of ischaemia to be noted; • Less than 15 seconds is normal.

• 20 – 30 seconds indicates moderate ischaemia.

• 40 + seconds indicate severe ischaemia.

Fountaine Classification.

This test is invalid if there is venous incompetence (Lorimer, D. et al 2006).

A low ABPI (ankle brachial pressure index) of less than 0.7 is indicative of PAD; with a reading of greater than 1.3 may indicate that there arteries are heavily calcified. Therefore both the extremes should be seen as advanced atherosclerosis disease and associated cardiovascular risks (Aerden, D et al 2011).

The severity of PAD can be classified using the Fountaine Classification of peripheral arterial disease, with an accurate diagnosis of intermittent claudication obtained using the Edinburgh Claudication Questionnaire. A positive classification of claudication requires the indicated responses to the questions (Menz, H.B 2008).

Stage

Symptoms

2

Intermittent Claudication

4

Severe rest pain with ulceration or gangrene or both.

1

3

(Menz, H.B 2008).

Asymptomatic (without symptoms)

Ischaemic rest pain

page | 05

TECHNICAL ARTICLE The Edinburgh Claudication Questionnaire.

Question

Response

Does this pain ever begin when you are sitting or standing still?

No

Do you get pain or discomfort in your leg(s) when you walk?

Yes (if No stop here)

Do you get the pain if you walk up hill or when you hurry?

Yes

Do you get the pain if you walk at an ordinary pace on level ground?

Yes or No depending on severity of claudication

What happens if you stand still?

Pain gone in less than 10 minutes

Where do you get this pain?

Calf* Thigh# or buttock#

*definite claudication = pain in calf # Atypical claudication = pain in thigh or buttock with the absence of calf pain. (Menz, H.B 2008).

Smoking should be stopped and weight reduction should be encouraged, while diabetes and hypertension requires management. Limbs should be kept warm but direct heat should not be applied, while care of the feet is required to avoid infection and trauma and elderly patients are advised to have regular chiropody.

Regular exercise encouraged to allow the development of anastomotic (the joining of 2 blood vessels) vessel’s (Kumar, P. et al 1994). The lower leg and feet should be inspected for ulcers, fissure’s, callous, and areas of yellowish pigmentation due to the deposit of lipids (xanthoma) (Dieter, R.S. et al 2002).

The use of statins to treat dyslipidaemia and antiplatelet therapy are of benefit to patients with PAD. Walking programmes of at least 6 months duration have shown to increase the distance walked prior to the onset of claudication (Gardiner, A.W et al 1995). Low dose aspirin is of benefit while vasodilators are not required and anticoagulants are of no benefit (Kumar, P. et al 1994). Naftidrfuyl alleviates symptoms of intermittent claudication and improves pain free walking in moderate disease.

Patients require assessing for signs of improvement after 3 – 6 months. Cilostazol is licensed for improving walking distance for patients with intermittent claudication who do not have peripheral tissue necrosis without pain at rest. Patients on this treatment require assessment for signs of improvement after 3 months. This treatment is not recommended for treatment by the NHS in Scotland (BNF Sept 2012).

Surgical management of PAD is considered when intermittent claudication or rest pain is severe enough to affect daily life.

Surgical options include revasculation (bypass of the affected vessel using grafting techniques), angioplasty (stents to expand the affected vessel). If and when revasculation fails, or if there is significant amount of gangrenous or necrotic tissue present amputation is considered as a last resort (Menz, H.B 2008).

06 | page

NICE guidelines (2012) for lower limb peripheral disease (CG147) recommendations include; • That all people with peripheral arterial disease are offered information, advice, support and treatment regarding prevention of secondary cardiovascular disease.

• If PAD is suspected the femoral, popliteal and foot pulses are checked.

• A supervised exercise programme is established and maintained for all people with intermittent claudication

• All people with critical limb ischaemia are assessed by a vascular multi-disciplinary team.

Those patients thought to have symptomatic peripheral arterial disease need to be referred on to a vascular surgical unit, or multi discipline team for further investigation (Fox, M. 2012).

References

Aerden, D. Denecker, N. Keymeulen, B. Van den Brande, P. (2011). Ankle Brachial Pressure Index: A mixed blessing. The Diabetic foot Journal. 14 (4). BNF Sept 2012 Burger, L. (1924). Circulatory disturbances of the extremities. Philadelphia. WB Saunders.

Concise Medical Dictionary. (2002) 3rd ed. Oxford University Press.

Dieter, R.S. Chu, W.W. Pacanoswski, J.P. McBride, P.E. Tanke T.N.E. (2002). The Significance of Lower Extremity Peripheral Arterial Disease. Clinical Control (25) 3 – 10.

Fox, M. (2012). QOF indicators for PAD: have the cavalry finally arrived? The Diabetic Foot Journal 15(2)

Gardner, A.W. Poehlman. E.T. (1995) Exercise rehabilitation programs for the treatment of claudication pain. A Meta – analysis. Journal of the American Medical Association.

Kumar, P. Clark, M. (1994) Clinical Medicine. 3rd ed. Baillier Tindal.

Lorimer, D. French, G. O’Donnell, M. Burrow, J. G. Wall, B. (2006) Neal’s Disorders of the Foot.

7th ed. Churchill Livingstone Elsevier.

Menz, H.B (2008) Foot Problems in Older people. Assessment and management. Churchill Livingstone

NICE Guidelines (2012) Lower Limb Peripheral Arterial Disease; Diagnosis and management.

(CG147) NICE Manchester.

Smith, L. (2012). Identifying and managing peripheral arterial disease. Nursing Times 108 (43) 12 – 14.

TASC Working Group (2000). Management of Peripheral Arterial Disease. Journal of Vascular Surgery (31) s1 – 296.

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Website Information

As some of you might have noticed (hopefully) we now have our new look revamped website and the comments that we've had so far have been really positive.

For those who are not quite sure of how to change their own details, listed below are a few pointers that may help.

1. Log in to members area on top right of home page.

You'll see on the top right 3 areas Public Site Log out

Your details

2. Click on your details, this will bring up your personal settings on the left, surgery details in the centre and insurance on the right.

3. Click on the pencil top right of personal settings column, this is where you can change your personal info including asking to be notiďŹ ed if a posting is made on the forum.

When you've completed this click on save.

4. Click on pencil top right of surgery settings, this is where you can put all of your surgery info and add or remove any towns and post codes you want to include. You can also add your own surgery website link if you wish. Once you've completed again click on save. page | 07

TECHNICAL ARTICLE

Tumours of the Foot

Stephen Willey M.Inst.Ch.P. L.Ch

In my surgery, a new patient; Female, 59 years of age presented with an irregular circular growth on the inside of her left heel measuring approximately 1 cm x 1.5 cm. It was a deep pink colour. On questioning the patient, I was told that the growth was not painful or itchy but she believed it had increased in size over a period of time. My initial diagnosis was an eccrine poroma.

These are generally benign, however, to be on the safe side I referred the patient for a biopsy. It was subsequently confirmed the tumour was indeed that of a benign eccrine poroma and the lesion was excised. The patient was extremely worried and confided that she had delayed asking for professional help out of pure fear as to what she would learn! This led me to explaining some of the different types of tumours to her…….

Mention ‘Tumour’ and people will often equate it with cancer when, in fact, a tumour is derived from the Latin word for swelling (tumor) and generally refers to an unspecified accumulation of tissue.

Fibroma

Fibromas are non-malignant lumps of fibrous connective tissue, which can be found on any region of the body. Generally asymptomatic and not requiring any treatment. They are There are numerous swellings or bumps that can occur in the foot commonly located on the plantar fascia (fibromatosis). region and the chiropodist needs to be vigilant and able to Presentation is generally a firm lump in the arch which may cause recognise the different types in order to provide the correct some pain on pressure extending down to the toes. Should the treatment for his patient. Although most ‘tumours’ will be benign fibromas become troublesome, steroid injections can reduce the and need simple monitoring or removal, a mass albeit temporarily. Orthotics may small amount may prove to be malignant or also help with pain relief by stabilising the Of 196 Foot and Ankle pre-malignant. foot and ensuring even weight distribution tumours 87.2% were away from the fibroma. If the patient It was reported by H M Ozdemir et al 1. in benign and 12.8% continues to have pain it may require their clinical cases of 196 foot and ankle surgical extraction. malignant tumours that 87.2% were benign and 12.8%

malignant. They also reported that the most common tumor was a ganglion followed by plantar fibromatosis, and that they had four cases (2 %) of lipoma in the region.

The following are some of the types of tumour that a podiatrist may encounter.

Benign Tumours Eccine Poroma

Benign eccrine poroma is a common tumour and can appear anywhere on the skin. It is thought to be derived from the intraepidermal sweat glands 2. In the foot it usually occurs as a solitary small lesion, more often on the sole. Multiple tumours are known as eccrine poromatosis.

Both men and women are susceptible but it tends to begin in middle age. The tumour cells are generally sessile and firm with a pinky/reddish colour which can occasionally be pigmented.

Complete surgical excision is necessary to completely remove the tumour. Incomplete removal could lead to recurrence.

08 | page

Ganglion cysts.

A ganglion cyst is a swelling that develops near a joint or tendon.

It is filled with fluid and can range from the size of a pea to the size of a golf ball. Ganglion cysts are harmless and often disappear on their own without any treatment. Painless ganglions need only be observed. If a ganglion is causing pain, generally when it is next to a nerve, it is possible to aspirate using a sterile needle to puncture the cyst. The area is first numbed and the fluid is then drained away. This may not, however, be successful and, therefore, if the cyst is persistent or causing trouble (for example interfering with the wearing of shoes) it may have to be surgically excised either under local or general anaesthetic

It is not fully understood why ganglions form. They can be due to trauma or as they tend to occur close to tendons and joints it is thought that they may be a distention of a weakened portion of a tendon sheath and the surrounding fluid collects and swells beneath the skin. 3 A ganglion cyst is sometimes called a Bible cyst – largely due to

TECHNICAL ARTICLE

the fact that early ‘cures’ involved bashing the bump with a heavy book or object, the Bible being the heaviest book most families had to hand. Today it is not accepted practice!

Bursae

Bursae are hollows in the fibrous tissues and contain a little fluid.

They are normally found where pressure or friction is evident such as the knee or ankle – probably the most common being ‘Housemaid’s Knee’. They are most prominent in our discipline in the first metatarsal phalangeal joint with hallux valgus. This can become infected or inflamed and they can cause a lot of pain although recommended treatment is generally the alleviation of friction e.g. rest or pressure pads. Surgical intervention is generally only required in extreme cases. 4

Glomus

Glomus tumors are soft tissue neoplasms that mostly affect younger adults. The visible characteristics are small, reddish blue nodules of 1-2 cm of the distal extremities, with most cases involving subungual sites. These tumours can be very painful and react to changes in temperature as well as pressure.

Glomus tumors are thought to arise from the glomus body, which consists of an arterio-venous shunt surrounded by a capsule of

connective tissue. This shunt takes blood away from the skin surface when it is cold in order to prevent loss of heat. Most lesions are solitary and whilst the vast majority of glomus tumors are benign, malignant cases have been reported. 5,6

Mucoid Cyst

A mucoid cyst is a soft dome-shaped lesion which is smooth to the touch and often has a translucent appearance. They are slow growing and often irregular.

The cysts are generally asymptomatic but spontaneous discharge can occur and the cyst may disappear of its own accord. Should the cysts become a problem treatment can be through steroid injection or excision.

Lipoma

Lipomas are the most common soft issue neoplasm accounting for almost 50 % of all soft-tissue tumors 7 - however, they are rare on the foot. They are benign, mesenchymal neoplasms occurring in areas of abundant adipose tissue. Many people will probably never know they have a lipoma as most people cannot examine their own feet thoroughly. It is probably only when they visit a chiropodist that they become aware of the fact. Most Lipomas of the foot are generally benign and originate from the soft tissue.

Photographs courtesy of Jeffrey A Oster DPM, My Footshop©

Top L-R Ganglionic Cyst, Mucoid Cyst, Pre-malignant keratosis of the dorsum of the foot – precursor to squamous cell carcinoma.

Bottom L-R Mucoid Cyst, Kaposi’s Sarcoma, Plantar Fibromatosis

Further Information www.myfootshop.com

page | 09

TECHNICAL ARTICLE Malignant Tumours

Malignant eccine poroma

Malignant eccine poroma tumours are extremely rare, reported to account for < 0.005% of EP cases. They look like verrucae but which often bleed with minor trauma. There is a 50% metastasis rate to regional lymph nodes and prognosis is often poor. 8,9

Kaposi’s Sarcoma

There are several types of recognised Kaposi’s sarcoma which include Classic, African endemic, Immunosuppressive Drug Induced and HIV related 4

It is a rare tumour but unlike most types of tumour, it is thought people who develop classic Kaposi’s sarcoma are vulnerable to the HHV-8 virus (Human herpes virus type 8)10. Classic (or sporadic) KS affects more Mediterranean and Middle Eastern people more often males over the age of 60. The African type has similar characteristics but affects all ages. HIV/AIDS associated KS can be extremely aggressive with a limited survival time as metastasis can occur. 11 The initial symptom of KS is the appearance of red or purple asymptomatic lesions on the feet or legs. The lesions are generally slow growing and changes in appearance may be subtle but when fully developed there is a rapid growth of small vessels with spindle shaped cells with spaces. Red blood cells haemorrhage into these spaces. 11

Podiatrists need to be especially aware of KS when treating high risk groups already mentioned. If they present with purplish nodules close to the instep, it may very well be Kaposi’s sarcoma and immediate action could save their lives.

Squamous cell carcinoma

Squamous cell carcinoma (SCC) is relatively rare in the foot.12 It may derive from a precursor lesion or may be secondary. The lesions are usually tender and scaly or crusted.

It is thought that numerous factors can lead to squamous cell

carcinoma including age, skin colour e.g. fair skinned people are generally more susceptible, general health and condition of skin overall e.g Ulcers may lead to SCC. In addition other skin lesions such as Bowen’s disease can be premalignant and lead to SCC. Ultimately exposure to the sun plays a huge part. 3 Presentation can be either as a proliferative or an erosive lesion.

It can start as a red coloured plaque that looks like eczema or dermatitis although the edges would show some irregularity.

Some may ulcerate.

Although most cases are curable, tumors may recur or metastasize. Prevention should be encouraged and constant monitoring of patients at risk for genetic reasons is advisable. In all cases of SCC, surgery is the only option.

References

1. Ozdemir HM, Yildiz Y, Yilmaz C, Saglik Y.Ankara University School of Medicine, Department of Orthopedics and Traumatology, Turkey. cyilmaz@pallas.dialup.ankara.edu.tr

2. Pincus H et al. Eccrine poroma: tumors exhibiting feature of epidermal sweat duct unit. Arch Dermatol 1956; 74:511.

3. McDonald, RE; Mullens, DJ (May 2013). "Ganglion cyst treatment using the ganglion suture technique".

4. Neale’s Disorders of the Foot – Diagnosis and Management 6th edition.

5. Brathwaite CD, Poppiti RJ. Malignant glomus tumor. A case of widespread metastasis in a patient with multiple glomus body hamartomas. Am J Surg Pathol. 1996;20:233-8.

6. Hiruta N, Kameda N, Tokudome T, et al. Malignant glomus tumor: a case report and review of the literature. Am J Surg Pathol. Sep 1997;21(9):1096-103.

7. Myhre-Jensen O: A consecutive 7-year series of 1331 benign soft tissue tumors. Clinicopathologic data. Comparison with sarcomas. Acta Orthop Scand 1981; 52: 287–293

8. Ghislain PD, Marot L, Tennstedt 0, Lachapelle JM. Eccrine porocarcinoma with extensive cutaneous metastasis. Ann Dermatol Venereol 2002; 129(2):225-8.

9. Maeda T, Mon H, Matsuo T et al. Malignant eccrine poroma with multiple visceral metastasis: report of case with autopsy finding. J Cutan Pathol 1996; 53:566-70.

10. Klein et al 1974

11. Lemlich et al 1987

12. Spinosa FA. Squamous cell carcinoma of the plantar aspect of the foot. J Foot Surg 1987. May-Jun;26(3):253-255.

Additional information and photographs courtesy of My Footshop www.myfootshop.com 10 | page

INFORMATION ARTICLE

When should you seek consent for treatment?

Claire Gallagher BSc (Hons)Pod

A lot of confusion has arisen regarding consent and consent forms. Let us look at what consent is? Simply put, consent is when a patient gives permission for a clinician to carry out an assessment or treatment. So, I hear you murmuring, “do I need to obtain a signature?” Not necessarily. Capable patients may indicate their consent by various means. It can be orally “Please can I make an appointment for chiropody treatment?”. Non verbal - by way of action; for example: sitting in the chiropody chair and taking off shoes. It can be in writing also. The one thing that is important is that you are satisfied that the consent you have obtained is valid!

Consent is validated only if the patient is fully aware of what procedure is about to take place and aware of all the risks. The patient must be full competent to make a decision and must not be influenced or forced into making a decision.

To be able to give valid consent a person must be deemed competent. Anyone aged over 16 years and deemed competent can give valid consent but in certain (rare) cases competent minors can consent (as in the case of Gillick v W. Norfold and Wisbech AHA). A competent minor can consent to treatment and a parent cannot override that consent, however, legally a parent can consent if a competent minor refuses. It is recommended, however, that parents or guardians ARE involved in the information and consent process for any minor wherever possible.

The Mental Capacity Act 2005 ruled that health professionals can decide the best interests of a patient in regards to their treatments, therefore if a patient is suffering from dementia, you may still treat in the best interests of the patient. This involves following any known requests or religious and/or cultural beliefs

that they may have once held.

You should seek consent before any assessment or treatment by explaining the procedure fully before hand and asking your patient if he agrees.

For surgical procedures you should give at least 24 hours notice (for reflection) before commencing treatment. It would help to ensure valid consent if you supplied written information about the procedure and obtained a signature at this stage also, in addition to explaining verbally.

One thing to remember is never assume that valid consent has been given!

Written consent is not required for all treatments but it is good practice to do so for the following procedures: • Cryotherapy

• Any verrucae treatments • Any clinical photography • Nail surgery

• When using local anaesthetics

• It is also advisable for biomechanical assessments as the nature of them may mean above the knee assessment.

Finally, please do remember that withdrawal of consent may be given at any stage before or during a treatment and if it is safe to do so a health professional must stop the treatment immediately on request. You may try to ease any fears or concerns but you should not insist on carrying on if the patient does not agree.

References: Department of Health (2008 code of practice: Mental Health Act 1983 Department of Health (2009) Reference guide to consent for examination or treatment 2nd ed. www.dh.gov.uk/publications www.scp.co.uk

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HEALTH ARTICLE

Restless Leg Syndrome Restless legs syndrome (RLS) is a common condition affecting the nervous system, which causes an overwhelming, irresistible urge to move the legs. As many as one in ten people are affected by RLS at some point in their life.

Women are twice as likely to develop RLS as men. The condition is also more common in middle age, but the symptoms can develop at any age, including childhood.

Restless legs syndrome (RLS) typically causes an overwhelming urge to move your legs and an uncomfortable sensation in your legs and sometimes arms, chest and face.

A range of different sensations have been reported by people with RLS, including: • tingling, burning, itching or throbbing • a 'creepy-crawly' feeling

• feeling like fizzy water is inside the blood vessels in the legs • cramping in the calf’s or legs

These unpleasant sensations can often be relieved by moving or rubbing your legs. They can range from mild to unbearable and are usually worse in the evening and during the night.

Some people experience symptoms now and again, while others have them every day. It may be difficult to sit for long periods of time, for example on a long train journey.

Just over half of people with RLS also experience episodes of lower back pain.

Some cases of RLS are caused by an underlying health condition, such as iron deficiency anaemia, or kidney failure. Doctors may refer to this as secondary RLS.

There is also a link between RLS and pregnancy and around one in five pregnant women will experience symptoms of RLS in the last three months (third trimester) of their pregnancy, although it is not clear exactly why.

About four out of five people with RLS also have a condition that is known as periodic limb movements of sleep (PLMS).

If you have PLMS, you will have jerky or twitchy leg movements at night, while you are asleep. The movements are involuntary (you have no control over them) and may occur every 10-60 seconds.

The leg movements of PLMS can be severe enough to wake up both you and your partner. They may also sometimes occur when you are awake and resting.

In many cases of restless legs syndrome (RLS) the exact cause is unknown.

12 | page

There is conflicting evidence about the role of a brain chemical called dopamine with RLS.

Some people benefit from a type of medication called a dopamine agonist which raises the levels of dopamine in the brain. This had led to some people arguing that the condition is related to low levels of dopamine.

The theory is that low levels of dopamine disrupt the nerve signals

sent from the brain to the legs, causing the typical involuntary movements and unpleasant sensations. Dopamine levels naturally fall towards the end of the day, which may explain why the symptoms of RLS are often worse in the evening and during the night.

However a problem with the above theory is that in some people with RLS, dopamine agonists actually make their symptoms worse.

So the link between dopamine and RLS is not as clear-cut as

previously thought.

Another point is that dopamine levels often drop when people are feeling unhappy, so any drop in dopamine levels could be the result, not the cause, of the symptoms of RLS. Further research is required on this matter.

Secondary RLS can occur as a complication of another health condition, or it can develop as a result of another health-related

factor. For example, you may develop secondary RLS if you:

• have iron-deficiency anaemia – low levels of iron in the blood can lead to a drop in dopamine, triggering RLS

• have a chronic (long-term) health condition – such as chronic kidney disease, diabetes, Parkinson’s disease, rheumatoid arthritis, an underactive thyroid gland or fibromyalgia

• are pregnant – particularly during the last trimester (week 27 to birth); in most cases, the symptoms of RLS disappear within four weeks of giving birth

Triggers

There are a number of factors or triggers that do not cause RLS, but can make symptoms worse. These include a number of medications such as: • antidepressants

• antipsychotic medicine

• lithium (used in the treatment of bipolar disorder)

• calcium channel blockers (used in the treatment of high blood pressure) • antihistamines

• metoclopramide (used to relieve nausea)

HEALTH ARTICLE Other reported triggers include:

supplements, and RLS associated with pregnancy usually goes away on its own within four weeks of the birth.

• smoking

If RLS has no obvious cause, then treatment falls into one of two categories:

• caffeine • alcohol

• lifestyle changes

• being overweight or obese

• medication

• stress

Lifestyle changes

• lack of exercise

Diagnosing restless legs syndrome

No single test is currently available for diagnosing restless legs syndrome (RLS). The condition is usually diagnosed based on your symptoms and previous medical and family history.

The International Restless Legs Syndrome Study Group has identified some basic criteria for diagnosing RLS. These are: • an overwhelming urge to move legs, usually with an uncomfortable sensation such as itching or tingling

• symptoms occur or worsen when resting or inactive

• symptoms are relieved by moving legs or rubbing them

• symptoms are worse during the evening or at night

A confident diagnosis can be made if all symptoms are present.

It is usual for blood tests to be carried out to confirm or rule out a number of possible secondary underlying causes. such as anaemia, diabetes and problems with kidney function.

A GP will also want to know the pattern of symptoms, to assess whether it is mild, moderate, severe or very severe RLS.

They may ask:

A number of lifestyle changes may be enough to ease the symptoms of RLS. These include: • avoiding stimulants, such as caffeine, tobacco and alcohol • not smoking

• taking regular, daily exercise – but avoid exercising near bedtime

• establishing a regular sleeping pattern – for example, going to bed and getting up at the same time every day; not napping during the day; taking time to relax before going to bed; avoiding caffeine close to bedtime • avoiding medicines that trigger the symptoms of RLS or make them worse – if you think your medication is causing your symptoms, continue taking it and make an appointment to see your GP.

During an attack of RLS, the following measures may be helpful in relieving symptoms: • massaging legs

• taking a hot bath in the evening

• applying a hot or cold compress to leg muscles

• how often symptoms occur

• how unpleasant the symptoms are

• doing activities that distract the mind, such as reading or watching television

• if sleep is being disrupted, making you tired during the day

• walking and stretching

• if symptoms cause significant distress

Mild RLS can usually just be treated by making lifestyle changes.

Moderate to very severe RLS usually requires medication to bring symptoms under control.

In cases of severe sleep disruption, polysomnography may be recommended.

sleep tests such as

Polysomnography is a test that measures breathing rate, brain waves, and heartbeat throughout the course of a night. This type of test will confirm whether a patient has periodic limb movements of sleep.

If restless leg syndrome (RLS) is known to be linked to an underlying cause, then treating that cause can often lead to a complete cure.

For example, iron deficiency can be treated by taking iron

• relaxation exercises such as yoga or tai chi

On this last point a small medical trial carried out in 2011 found that

a type of osteopathic exercise technique called positional release manipulation (PRM) could be of benefit to people with RLS. PRM involves holding different parts of the body in position that has been found to reduce feelings of discomfort and pain. Though larger studies will be required before it is clear that PRM is an effective treatment for most cases of RLS. Medication Levodopa

Levodopa may be recommended for sporadic symptoms due to a high risk that long term it could actually make symptoms worse.

Levodopa can cause nausea, so it is usually combined other medications to reduce the nausea. page | 13

HEALTH ARTICLE Dopamine agonists

Dopamine agonists are usually recommended for more frequent symptoms. They include:

prescribed to relieve any pain associated with RLS.

Side effects of these types of painkillers include: • constipation

• ropinirole

• pramipexole

• feeling sick • dry mouth

• rotigotine

Another medication that can be used to both relieve pain and relieve

These medications do have side effects which can include:-

symptoms of RLS is gabapentin. Side effects of gabapentin include

dizziness and feeling tired and sleepy.

• Sleepiness

Aiding sleep

• nausea

• dizziness

• headache

Another dopamine agonist called cabergoline has proved to be effective in the treatment of RLS but tends only to be used if the medications mentioned above prove ineffective. This is because it can cause a range of serious side effects.

Painkillers

Hypnotics such as temazepam and loprazolam may prove useful short term to aid disturbed sleep patterns however not recommended for longer than a week.

Acknowledgement – The Institute thanks NHS Choices for its help in compiling this article.

For further information go to www.nhs.uk/Conditions/Restless-legsyndrome

A mild opiate-based painkiller such as codeine or tramadol may be

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CERTIFICATES

L-R

Congratulations to

Des McCarthy

Samantha Thaxter

Cheryl Brenkley

Friday 28th June saw me in SheďŹ&#x192;eld where my task was to assess cohort 6 of the City and Guilds course. It was with great pleasure that I was able to pass all three students on their practical work. After cracking open a celebratory bottle of champagne I presented them with their certiďŹ cates and their welcome packs. On behalf of the Executive Committee, I would like to welcome them into the Institute of Chiropodists and Podiatrists as Foot Health Practitioners and wish all of them the best for the future. I am sure that they will succeed in their chosen pathway.

Malcolm Holmes, Institute Inspector

page | 15

HEALTH ARTICLE

Botox’s target could hold cure for diabetes Heriot-Watt University

Scientists believe the proteins that are targeted by cosmetic surgery treatment Botox could hold the secret to treating and even curing Type 2 diabetes.

Dr Colin Rickman said, “The human body has a system for storing glucose and releasing it when the body needs energy. This system

controlled by the release of insulin.

“When a person is obese, which a worryingly high and increasing number of people in the UK are, this system is put under pressure and eventually fails. This leads to Type 2 diabetes.

“We know SNARE proteins are responsible for insulin secretion, but it’s still not understood exactly how they do it.

“Once we can understand how these proteins behave in ‘normal’ circumstances, how they move, how they are arranged in the cell, how they interact with other proteins, we can then compare it with what happens under Type 2 diabetic conditions. This is the first time these proteins have ever been observed in such detail.

“Ultimately this could lead to new methods of diagnosis, prevention of the cells’ failure that leads to diabetes and also treatments for Type 2 diabetes.”

PICTURE 1: The organisation of SNARE proteins in a cell. The position of SNARE proteins is shown in purple with vesicles ready for release shown in green.

A team of researchers at Heriot-Watt University in Edinburgh is using new molecular microscopic techniques on SNARE proteins to solve the mystery of how insulin release is regulated and how this changes during Type 2 diabetes.

SNARE proteins are targeted by Botox treatments, preventing them from helping muscles contract. However, their role goes well beyond the cosmetic realm, such as their work in the human pancreas.

Dr Colin Rickman and his team are observing SNARE proteins in pancreatic beta-cells, the highly specialised cells that release insulin. Within the cells are SNARE proteins, which are the machinery that helps the beta-cells release the insulin to try and stabilise blood glucose levels.

In 2012, the NHS described diabetes as ‘... one of the most prevalent and serious chronic conditions currently affecting the UK population’[1].

From 1996 – 2012, the number of people diagnosed with diabetes increased by 1.5 million. It is estimated that five million people will have diabetes in the UK by 2025, due in part to an ageing population and a dramatic increase in the number of overweight and obese people[2].

Dr Rickman and his team are funded by the Medical Research Council and the Edinburgh Super Resolution Imaging Consortium (ESRIC), a joint initiative between Heriot-Watt University and the University of Edinburgh.

Type 2 diabetes occurs when the beta-cells can’t cope with the prolonged high glucose levels of some obese patients and so secrete less insulin. The beta-cells lose both mass and function, but the reasons for this have always been unclear.

The Heriot-Watt team hopes to answer these questions by observing SNARE proteins in the cell for the first time, pinpointing their exact location in an area equivalent to a ten-thousandth of a human hair.

16 | page

PICTURE 2: A small cluster of SNARE proteins pinpointed using superresolution microscopy. Each spot marks the position of an individual molecule.

OBITUARY

Ronald Leo Ward 1924 – 2013

Ronnie was born in Stretford, Manchester on December 29th 1924. He had one younger brother. A keen DIY man, he always

had to be doing something for somebody. His mother often said that even as a toddler he would take charge as he proclaimed “I’ll show you”.

Ronnie attended Sale High School (a branch of Manchester Grammar) for most of his education and finished it at Manchester Grammar. His father owned a number of cinemas, and after leaving school Ronnie started working with him. This early career was short lived as he joined the Navy at a young age and served on aircraft carriers repairing the planes. He became a Petty Officer and served much of his time in India.

When he was 21, Ronnie met Peggy and they married in 1949.

Peggy and Ronnie moved in with Peggy’s mother and looked after her

for 20 years, during which time he returned to the cinemas for a number of years doing numerous jobs. He was instrumental in turning some of the cinemas around Lancashire into night clubs when cinema audiences began to fall.

He found it upsetting. After witnessing one of his cinemas becoming a petrol station, he felt he needed to move on and embarked on a three year degree course in chiropody at Salford University.

In 1976 Ronnie and Peggy moved to Grange-on-Sands in the Lake District and soon became chief chiropodist for South Lakes.

He loved the area and never tired of saying that he couldn’t imagine living anywhere else, and was looking forward to enjoying his retirement life in the Lakes.

He loved being involved with Age UK, especially his job on the lunch club at the Pheasant.

Sadly he became ill shortly after retiring and suffered for a long time. He was taken to hospital but he did not want to die in hospital. Even though the hospital he was in wasn’t keen to discharge him from intensive care, we managed it! Peggy took responsibility for his safety on the journey home.

The song that typifies Ronnie the most is Frank Sinatra’s “I did it my way”.

Rest in Peace my friend.

Bryan Massey North West Branch

A note from Ronnie’s wife Peggy Ward

I would like to thank Bryan for his epitaph for Ronnie and also to thank the staff at Barrow, and Blackburn hospitals together with the district nurses and Dr Golding.

The Queen, in one of her speeches, referred to Prince Philip as her rock! I know just what she meant. I shall miss my ‘rock’ but am really thankful for all the loving friends I have around me. page | 17

CONFERENCE LETTERS Dear Editor,

Once again I have returned from another conference after having a truly enjoyable experience. I have met up with friends and acquaintances that I only see once yearly. Top of the list are the fabulous head office staff who guide us all though so many things such as worrying issues like an HCPC audit or litigation.

They, not only hold your hand, but help you to fill in the paperwork correctly! As we live in an increasingly litigious world if your insurance is via the institute they are there like the “foot prints in the sand” ( I'm sure you all know the verse, but this would be a good time to read it again ) They are also there for minor problems including locating delegates who get waylaid at the trade stands!!!! So thank you all again. I would like also to thank personally the members of the Executive Committee, who have for many years given their time voluntarily to guide and direct us in the Institute.

I have made some new friends and met up with some old.

The ‘new’ was the student of the year, Sue Rylance who I met at dinner. Sue has now joined us and is the new blood our Institute badly needs. The ‘old’ (in the politest of terms) - the one and only Mr Currie, the printer, who is larger than life and twice as friendly! I have been doing business with Des for over 25 years!

Our ex-Secretary, Mrs Kirkham was looking very well; mind you that could be the air in Southport!

Sadly there were faces missing from the gathering for various reasons. Some I will never see again. Some I hope to see next year, God willing. Sadly many members have never been to a conference and had the pleasure of meeting their peers and dipping into the wealth of talent and experience our Institute encompasses. Not only is it a legal tax expense, you cannot put a true value on being able to rub shoulders with peers and the traders. I could try and put it into words but I guess you will have to “suck it and see”.

I was at the 25th anniversary of the Institute and the 50th.

Soon it will be the 60th (Diamond) so let us all pull together in the same direction for a great future.

Michael Franklin, South Wales Branch

Dear Editor,

I would like to thank Malcolm Holmes and the head office staff for the AGM and Conference at Southport. The workshops and lectures were again excellent. This has now become the usual standard that is expected at the conference. The trade stands were offering lots of bargains this year and it was nice to catch up with colleagues from around the country.

It was an enjoyable evening of the Friday night.

Congratulations to everyone who won an award. The sun was very welcome and sitting on the beach later in the day was like 18 | page

being on holiday. For those who did not attend you missed a lovely weekend.

Denise Willis - Chester N Wales Staffs and Shrops.

Dear Editor,

Location, location, location - that is a big consideration when I choose to go to a conference or do some CPD learning. Southport seems to have it all – the conference centre being situated near the water front alongside the hotel. A brisk walk or a stroll along the pier or promenade after a day’s lectures and workshops is invigorating. Take a different direction and visit the shops on Lord Street where the head office is.

The weather was glorious and an exotic ice cream was enjoyed sitting outside!

According to the Mayor of Sefton Southport has only been a town for 200 years and is still reclaiming land and developing as can be seen.

Learning was taking place in all the areas of the conference, always good to see something new and gain confidence. A time of change for the Institute I felt but ways forward are being found.

Since joining the Institute in 2007, I have gained invaluable CPD at Nottingham branch and gained my degree in 2011. I have had support all along even when I was ill. Members have become friends.

Kind Regards,

Val Dannourah, Nottingham branch Hi Bernie

Just a quick letter to say thank you for another great Conference, I can only say what a vast improvement in workshops and lectures. This is due to the hard work of the girls in head office and Malcolm Holmes. They are trying their best for us members. It is a pity that even more members did not attend.

I was disappointed that no one from Wolverhampton attended the awards dinner to collect their 'branch endeavour' award but that is a small moan in what was a very good weekend. I thought the dinner was excellent!

Christine Carrington, Cheshire North Wales branch

Dear Editor,

This year’s conference seemed to be one which brought clarity and I hope unity to the membership.

The tombola and book stall raised an amazing amount for the Benevolent Fund and Diabetes UK this year. Mum and Martin would like to thank all of you who supported it.

At the dinner dance, which was really well attended, there

CONFERENCE LETTERS were a few special awards given out, well done to all the recipients. I would like to say a big thank you again to the people and trades who donated prizes and look forward to seeing you next year.

Kind regards,

Linda Pearson, Western Branch Dear Editor,

Thank you to Colette who presented my "Record of Achievement" book, which signified the end of my school life at Rhyl High School. I wasn't able to attend the school ceremony as I was at the Institute’s Conference in Southport.

Afterwards I was pleasantly surprised and honoured to receive a certificate of honorary membership from Robert. It was a really memorable evening and it was lovely to see so many friendly faces.

Best wishes,

Martin Pearson Dear Editor,

Malcolm and the ‘girls’ in the office you did it again with another good conference in Southport. Three years on the trot now, Malcolm, you’ve managed to source some great workshops and lectures, as well as having to put up with me assisting you again! Thanks for keeping me in check.

It was lovely to see so many new and old faces both on the trade stands and delegates. It was also lovely to catch up with some people from the training school when I worked at Scholl.

It was nice to know I hadn’t changed that much in the intervening years.

For those of you that were in Robert’s nail surgery workshop; Angela’s toenail is looking great! Robert I’ll give you 9 out of 10 for a good job………. You could have got 10 out of 10 if you’d parted with the last remaining £40 in your wallet for the Benevolent Fund, but thanks for both yours and Malcolm’s large donations.

I would also like to thank Chis Carrington for requesting donation prizes from the traders and both Joyce and Martin for manning the stall for me. I couldn’t have done it without your help. Thank you.

Roll on next year.

Michelle Taylor, Cheshire North Wales Branch Dear Editor,

I would like to extend my thanks for another slick and well organised Southport conference. The head office team and all

others involved once again did an excellent job.

In my view, the venue works well for our event. There is enough space to make moving around all the trade stands easy, and immediate access into the conference hall itself. The location in a seaside town means that there are plenty of places to stay.

Hotel staff were helpful and friendly. They seemed genuinely pleased to see us back for a second year!

If the event moves to another part of the country it is always going to be more accessible for some but further for others.

Congratulations to all who were involved.

Norman Hodge, Leeds/Bradford Branch Dear Editor,

Thank you again to all Institute staff, delegates, helpers, visitors and attending members for making my wife Diane and I so welcome at your AGM and trade show. Diane and I treat this as a weekend away, which although we work during the daytime, gives us a couple of nights off for eating out, shopping and exploring.

Southport is not renowned for geological features such as fossils or mineral deposits but strangely enough I came back home with an interesting slab of unusual mineral! Diane and I visited many parts of the beach areas between Southport and Liverpool, examined many dry stone walls and checked out every patch of ornamental gravel we came across. We found nothing of particular interest except around Friday teatime when we left our B & B and wandered into the busy outskirts of the town centre. An enterprising lady had pulled all the furnishings from her second hand shop and had them displayed in a cul-de-sac lane. A few of her associates/friends from the pub next door had settled into her armchairs and were philosophising on the problems of the world; the local council and the escalating prices of both tobacco and alcoholic beverages! Noticing me listening, they brought me into their discussion and after about five or six minutes I realised that Southport, Consett and Newcastle’s problems mulled over and argued about on a Friday night over a pint or two are exactly the same!!

Meanwhile, Diane had spotted a funny looking piece of stone on a shelf beneath the table, it was a slab of some sort of veined mineral priced at £3 but sold to me for £2. One of the best moments of the weekend! – my very own chunk of Tiger’s Eye weighing 2 or 3 pounds. If any chiropodists have unwanted fossils or mineral samples looking for a new home; simply bring them with you to Southport in 2014 when I hope that I will again be invited to attend. Actually, of course, the trade show is much, much more exciting and much, much better than old fossils!!!!

Des Currie, Currie International Printers, North East

page | 19

INTERVIEW

Interview with David Thomas of MDS Bernadette Hawthorn H.M.Inst.Ch.P

There does seem to be a large choice of autoclaves available on

the market and we are often asked for our opinions.

At

conference this year, I asked David Thomas of MDS Medical Ltd

to give his overall view.

BH: I notice you only sell vacuum autoclaves. Why is this?

DT: We believe the best way to sterilise instruments is in pouches

or out of pouches, as everything should come out dry. If water is

present, it is a good trap for bacteria to start to grow. Under the

HTM 01-05 recommendations, unopened sterilised pouched instruments can be put on the shelf for up to one year before use.

BH: Who designed the machines you sell?

DT: I did! I designed these machines with help from out great

team of engineers. I cannot produce a machine at the right price

in this country which means I have had to go over to China, where we have a factory. We are in a partnership in China where we

discuss

how

best

to

design

machines

to

suit

the

Podiatry/Chiropody market. It isn’t just the UK market, it is the

European market, as all MDS Medical machines are CE marked

under the Medical Devices and the European Directive which is very important.

A vacuum machine is the best machine you can use for any

sterilisation. That is why hospitals, pharmaceuticals and

laboratories will only use vacuum machines for pouched

instruments. If you go into a hospital where the instruments are

wrapped for an operating theatre they will only use vacuum

autoclaves. ‘Pouched instruments’ is where you are using a

vacuum to remove the air and to dry the load at the end of the cycle. That is what we do.

BH: Your autoclaves have two tanks for water. Why is this?

When the spores are sterilised they are cultured on a culture plate to see if any grow relative to the unsterilised spore strip, and the difference should be that the latter will grow into a fungus whereas the former will not. Laboratories use this as a test.

Stearothermophilus is very hard to kill. It will live in the ground for ten even twenty years. It is a bacterium that lives in a shell and the shell has to be broken for the bacteria to be killed. The shell fragments and on the lining of the shell you have a thing called endotoxin which is dead bacteria as a protein. The older autoclaves used to exhaust all the steam and condensate back into the water. By doing that you are putting dead bacteria into that water. Consequently, what you are doing is increasing the endotoxin level within that water. The next time you go to sterilise, you are putting endotoxin into your chamber and onto your instruments. The Health Technical Memorandum states that you should not be having any more than a very small endotoxin level in your water (0.25 endotoxin level).

With our autoclaves, we have two tanks, and can exhaust the steam and condensate into a separate tank so that it never contaminates the clean tank. The clean water will always be pure water and we can drain off the dirty water. If the endotoxin were to go into the blood stream it could cause a fever and in turn septicaemia. Even though Podiatry/Chiropody is, in the mainstream, not an invasive procedure, when it is, you don’t want endotoxins present. By sterilising your instruments with our autoclaves, you will guarantee with spore testing that you won’t have any bacterial contamination. Also, on the next cycle, because we are always using clean water you will never have any endotoxin build up. We have two tanks built into the autoclave so it saves space as well.

DT: The old type autoclaves required that a chamber was filled

BH: If somebody doesn’t have an autoclave with twin tanks would they need to change their water daily?

degrees Celsius. They could go up to 137 degrees Celsius but not

DT: Not only daily, but every single time they use it.

with water, which was heated into steam and taken to 134 drop below 134 for a time of 3 to 4 minutes. We know, as

sterilise your instruments. To test these temperatures and time

BH: Your autoclaves come in various different sizes to suit different clinics dependant on their needs. What can you tell me about this?

is live on a strip and we would place a certain amount of spores

DT: We do an eight litre as a basic model which sells for £1,200

engineers, that at that temperature, for that time, it would

we use a spore strip that contains stearothermophilus. The spore

in the chamber of the autoclave, with some kept out of the autoclave.

20 | page

and a twelve litre, the next size up, for £1,500. We find these two

are the most popular for Podiatrists/Chiropodists. Both these

INTERVIEW models have printers as standard. The higher spec 12L autoclave

has a printer and USB port so you can download all your information. It is like a data logger you can plug into your computer

for all your records. These are a little bit more expensive and the

twelve litre starts at £2,250. The eighteen litre is £2,500 and the twenty two litre is £2,900. All these prices are exclusive of VAT.

These are all vacuum machines. If you are not pouching your

instruments you can still put your instruments into these autoclave

and the instruments will come out sterile and dry.

BH: You also offer maintenance?

DT: In the first twelve months you would have a full twelve months warranty, parts and labour and after the first twelve months we can offer a service contract. If somebody just wanted

a one off service once a year we offer within that a Written Scheme of Examination which is law and it comes from the Health and Safety Executive under the Pressure Safety Regulations 2000.

BH: Does this require the use of consumables?

David Thomas: Perhaps every two years you would want to

change your filters. Those filters would be roughly about twenty pounds for each carbon filter and around forty pounds for each

polishing filter.

BH: Distillers burn a lot of electricity. The reverse osmosis is cold isn’t it? Would it save on electricity.

DT: There is no electricity used at all and it all works by mains

water pressure. It costs £290 with a £95 fitting charge (depending

where you are in the country). Or your local plumber can fit it.

BH: Would you be prepared to attend branches to do training?

DT:

I would be prepared to attend branches or speak to

individuals. I don’t know it all and I am learning all the time but

Each machine should have a written scheme of examination every

I have been in sterilisation for thirty years. I’ve learned an awful

steam.

sterilisers and sterilisation, I would be pleased to talk about it and

fourteen months as it is a pressure vessel and a generator of

BH: From the interview, it is clear that the correct water should be used in an autoclave.

DT: For years, in our clinic, we have used a distiller to make our own purified water suitable for putting into our machine. Tap

water is not acceptable and an alternative for us was to buy

water, which is really expensive. Here I spoke to David Thomas

about an RO system that we could easily have fitted in our clinic

that, despite initial set up costs, could leave us with a considerable saving over a short time.

BH: Tell me about the RO system. I know nothing about it. You

said my distiller was more expensive.

DT: Your distiller will give you a litre of water every two hours

which is like having a kettle on for two hours, because it is using 750 watts of electricity. Imagine your kettle being on for two hours and only producing a litre of distilled water.

There are three types of water you can use; distilled water, deionised water and RO water, which is reverse osmosis. With RO

we sell a device which filters and then polishes the water. It goes

through two carbon filters and a polishing filter. In this way we

can produce three litres every thirty minutes with a tap that sits

on your sink unit and you can have RO water on tap. You can use

that water for your autoclave and ultrasonic bath.

lot. If you need to be trained and need somebody to talk about

take any questions that people fire at me. If I don’t know the answers to any questions I will always go and find out.

BH: If somebody wanted you to do a workshop for a group of Podiatrists, say, half a dozen, what would it involve? Would this

be a full day?

DT: No. I know how busy Podiatrists are and we should be looking at doing this as an evening course or at a Podiatrist/Chiropodist

training centre.

Thank you David, I am sure our readers will find the information

most helpful.

If any branches wish to book David for their branch meetings

please contact him direct.

David Thomas, MDS Medical Ltd. Ringstead Business Park, 2-3 Spencer Street, Ringstead, Northants, NN14 4BX Tel: 01933 462636 Mob: 07979 553295 Email: autoclaves@mdsmedical.co.uk www.mdsmedical.co.uk Based in Northamptonshire, with a factory unit in Corby and offices in Ringstead, MDS Medical Ltd offer a range of autoclaves that can fit into any clinic and at prices that are reasonable.

page | 21

ARTHRITIS RESEARCH UK

New national research centre to reduce the risks of sports injuries Researchers at the new Arthritis Research UK Centre for Sport,

at reducing the incidence of injuries in professional footballers –

Hospitals and The Universities of Nottingham and Oxford, aim to

habilitation’.This will involve developing ways of improving

Exercise and Osteoarthritis, led by Nottingham University develop better injury treatments and screening tools to predict an individual’s risk of developing osteoarthritis following sports

injury.

Centre director Professor Mark Batt, consultant in sport and

exercise medicine at Nottingham University Hospitals, explained: “Regular exercise is vital to keep your joints healthy and the longterm benefits of exercise far outweigh the risk of injury."

Our centre aims to keep people of all sporting abilities active and

injury-free by developing definitive, evidence-based advice and information to minimise the consequence of injury and recommend effective treatments to reduce long-term damage.

“This is the first time in Europe that specialists in sports medicine

a concept known in the sports medicine world as ‘pre-

training and warm-ups to reduce the incidence of injuries such

as pulled muscles and tendons, to ensure that players use their

muscles correctly and don’t overload their joints during matches

and in training. They hope their research will enhance current FIFA (F-Marc: Football for health) and 11-plus guidelines on

warming-up.

Rickie Lambert, the Southampton FC striker who has experienced

hip pain but has managed it successfully through exercise,

supports the new centre. He said: “Hip pain is one of the most common injuries amongst footballers, and lots of players have to

retire early if they don’t get the correct treatment. I’ve been very lucky at my club; I’ve got certain exercises I do that have helped

me and improve the problems I’ve had. Making sure young

and osteoarthritis are combining their expertise to understand

footballer get the right treatment in their teens is massively

and whether we can prevent or slow down degeneration of the

game. If these problems can be picked up early by automatic

why some sports injuries will go on to develop into osteoarthritis,

joints.”

An injury to the joint is one of the main risk factors for osteoarthritis, along with ageing and obesity. Approximately 8 million people in the UK are affected by osteoarthritis, which is the most common form of joint disease.

A poll carried out by Arthritis Research UK in 2011 found 40% of

active people were worried about limited mobility and joint

problems in the future*

Young footballers are at particular risk from a potentially career-

ending form of groin injury called femoroacetabular impingement

(FAI).The cause is not known but over-training as the bones are developing may play a role. In FAI the head of the thigh bone rubs

against the socket, leading to intermittent groin or hip pain in the

short term, and potentially osteoarthritis of the hip in the longer term.

Arthritis Research UK researchers will scan young footballers aged

nine from a number of professional football academies, using state-of-the-art MRI, every two years. They will be compared to

two other same-age groups – ordinary schoolboys and also young

elite athletes from other sports. The sophisticated MRI scans will be able to pick up holes or cracks in cartilage and metabolic

changes to cartilage and bone, so training movements could be modified or avoided to prevent injury occurring. The researchers

will also design a range of targeted training programmes aimed

22 | page

important and will improve their chances of succeeding in the

testing, the better for everyone. On behalf of all professional footballers I would like to show my support for the new centre’s research.”

Gary Lewin, the current permanent first-team physiotherapist for

the England national football team added:"Physiotherapists

recommend regular physical activity to maintain good general

health. It is therefore encouraging to see this investment in

research to better understand the nature and impact of common

sporting injuries. The learning from this work will help people

exercise safely and keep active."

Other activities being investigated in the research include rugby, Olympic Games, horse racing and athletics.

The Arthritis Research UK Centre for Sport, Exercise and

Osteoarthritis has the backing of leading sports organisations

including the International Olympic Committee, Rugby Football

Union, the Chartered Society of Physiotherapy, UK Athletics, the FA and the Professional Footballers Association. The centre is a

consortium of seven universities led by Nottingham University Hospitals and the Universities of Nottingham and Oxford, and

involving the Universities of Southampton, Bath, Loughborough, Leeds and University College London.

*Survey of 3,000 members of the public who took the Arthritis Research UK ‘Taking the pain out of sport’ survey in 2011.

If you are interested in taking part in the research contact centre

administrators: Joanne.bartram@nuh.nhs.uk or lis.ahlstrom@ndorms.ox.ac.uk

ARTHRITIS RESEARCH UK

Several factors influence decision to seek care for low back pain A person's beliefs about low back pain may influence whether or not they decide to seek medical care for the condition, new research suggests.

Back pain can often be treated effectively through a combination of lifestyle interventions and physiotherapy, yet many people do not seek help for this common problem.

It is therefore important to determine the factors that influence individual patients' decisions over whether or not to visit their GP.

Researchers at the Schulthess Klinik in Zurich sent questionnaires to 2,507 people who were participating in a study on musculoskeletal health.

Patients were asked to complete a number of questions relating to back and fear avoidance beliefs, as well as providing information on sociodemographics, their experiences of low back pain, and whether or not they had visited a specialist, GP or physiotherapist in the last month.

Analysis revealed that 43 per cent of participants had low back pain at the time of the survey and just 28 per cent of these had sought care.

experienced back pain regularly or intensely, were limited in their ability to carry out daily activities or were in poor general health.

Fear-avoidance beliefs were also associated with an increased tendency to seek back pain care.

Publishing their findings in the journal Spine, the study authors concluded: "That the odds of seeking care are higher in fearavoidance individuals - even when controlling for other established predictors - emphasises the importance of addressing such beliefs during the consultation."

Arthritis Research UK has developed a new approach to treating people with low back pain that targets the most intensive physiotherapy treatment at those who need it most. Crucially, those patients at highest risk of their back pain becoming longterm - because they were afraid that exercise would make it worse, for example - benefited from a more intensive approach that addressed their specific worries.

The STarT Back screening tool is now being rolled out around the UK and is already having a substantial benefit where it is being implemented, making a big difference to patients.

People were more likely to seek advice on their back pain if they were female, older, did not have a full-time job, had a low income,

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

Arthritis Research UK has awarded researchers at University College London (UCL) and the University of Nottingham a grant of £800,000 to develop new treatments for severe arthritis pain.

the development of new drug treatments which are more effective in fighting arthritis pain.

London and Nottingham researchers awarded funding for new severe arthritis pain study

The research could be of benefit to the millions of people with arthritis around the world who experience disability and distress as a result of their pain.

Research teams at UCL and the Arthritis Research UK Pain Centre at the University of Nottingham will use the funds for a four year study to look at the role of the proteins and molecules involved in causing severe pain in people with osteoarthritis and rheumatoid arthritis.

Currently people experiencing pain associated with osteoarthritis and rheumatoid arthritis are offered pain relieving drugs such as steroids or ibuprofen which work by blocking the disease inflammation. Although these drugs work well for people experiencing low level pain, they can have little impact for people experiencing severe pain.

The team, led jointly by Professor David Walsh, director of the Arthritis Research UK Pain Centre at the University of Nottingham and Professor John Wood from UCL hope their findings may lead to

Professor Wood said: “We know that many people with arthritis experience disabling pain every day, quite often brought on by carrying out simple activities such as walking or standing.”

Professor Walsh added: “Pain remains the biggest issue for people with arthritis, even after they have been using currently available treatments to their best effect.

We’re looking at whether arthritis is less painful when specific molecules are missing that are known to convert mechanical stimuli (e.g., touch, pressure, etc.) to nervous impulses to give us mechanical sensation.

“From this we will be able to tell which specific molecule or molecules are mediating arthritis pain, so that we can develop and test drugs to those specific molecules as potential new treatments for arthritis. None of the painkillers that are currently available specifically block pain transmission in response to mechanical stimuli.”

Full story http://www.arthritisresearchuk.org/news

page | 23

DIABETES NEWS

Essential Kidney Checks for people with Diabetes A quarter of people with diabetes are not getting an annual check

that is vital for picking up the early signs of kidney failure, according to a new analysis by Diabetes UK.

According to the analysis, based on National Diabetes Audit data, 25 per cent of people with diabetes in England were not recorded

as having the urine check (called a urinary albumin) during

2010/11. The situation is only slightly better in Wales, where 21.6

per cent did not get a check during the same period.

"Devastating impact" on quality of life Barbara Young, Chief Executive of Diabetes UK, said, "It is really worrying that a quarter of people with diabetes are missing out

on a simple check that could identify kidney problems early

enough to slow their progression.

"Kidney failure might not worry people with diabetes as much as other complications such as blindness and amputation, but it can

have an equally devastating impact on quality of life. All those

Timely warning

people who are not getting this check are at increased risk of

the urine for the presence of a protein called albumin can give an

number of people with diabetes getting these checks, we can

Kidney failure is common in people with diabetes, but checking

early warning of kidney damage, allowing people to be given

treatment to help stop it getting worse. Unless people get this

urine check, they are unlikely to find out they have kidney damage until it has already developed into an extremely serious

health issue.

Annual checks

The urine check is one of the two checks people with diabetes

should have every year to screen for kidney complications. The

other part of the screening is a blood test to show how well the

kidneys are working – the percentage of people with diabetes who have the blood test is much higher than for the urine test.

Increased risk of kidney failure

needing dialysis and ultimately of dying early. By increasing the help ensure they get treatment for any kidney problems early

enough to give them the best possible chance of delaying

progression.

"This, as well as reducing people’s risk of developing problems in

the first place by supporting them to keep their blood glucose and blood pressure at healthy levels, could make a real difference

to the number of people with diabetes whose lives are devastated by kidney failure.

Unanswerable case "As well as being tragic for the person involved, kidney failure is

also extremely expensive to treat, and the high level of diabetes-

related kidney failure is one of the reasons diabetes costs 10 per

We are concerned that the large number of people not getting

cent of the entire NHS budget. This means that for both people

to 750,000 people – are at increased risk of serious kidney failure.

pressure, the case for increasing the number of people getting

the urine check – and a quarter of people with diabetes equates

Rates of diabetes-related kidney failure at now at record levels:

9,753 people with diabetes in England and Wales needed renal replacement therapy during 2010/11.

We want people with diabetes to make sure they receive both

with diabetes and for an NHS that is under severe financial

these kidney checks is unanswerable.

Understanding the seriousness "Healthcare professionals need to make sure people with

the urine and blood tests, and to be aware of kidney disease and

diabetes understand the seriousness of kidney failure, increase

to the appointment: people forgetting to bring one is thought to

quickly on any problems they identify. It is also important that

how to reduce their risk of it. A urine sample needs to be taken be one of the reasons so few people are getting them.

We are also calling on the NHS to be more proactive in offering

the checks, and in reminding people about the need to bring a

urine sample. Many GP practices are already giving the urine

check to over 90 per cent of people with diabetes, and there is no reason the NHS cannot achieve this across the country.

24 | page

awareness of why the urine sample is so important and then act people with diabetes make sure they take a urine sample with

them to their appointment – doing so could literally save their

life."

Having an annual urinary albumin is one of Diabetes UK’s 15

healthcare essentials, which sets out the care everyone with

diabetes should be getting.

DIABETES NEWS

More about Kidney Nephropathy Kidney disease can happen to anyone but it is much more common in people with diabetes and people with high blood pressure. Kidney disease in diabetes develops very slowly, over many years. It is most common in people who have had the condition for over 20 years. About one in three people with diabetes might go on to develop kidney disease, although, as treatments improve, fewer people are affected.

What is kidney disease?

The kidneys are the organs that filter and clean the blood and get rid of any waste products by making urine. They regulate the amount of fluid and various salts in the body, helping to control blood pressure. They also release several hormones. Kidney disease (or nephropathy to give it its proper name) is when the kidneys start to fail.

What happens if I have kidney disease?

If the kidneys start to fail they cannot carry out its jobs so well. In the early stages of kidney disease this can mean there are changes in blood pressure and in the fluid balance of the body.

This can lead to swelling, especially in the feet and ankles. As kidney disease progresses, the kidneys become less and less efficient and the person can become very ill. This generally happens as a result of the build up of waste products in the blood, which the body cannot get rid of. Kidney disease can be a very serious condition, which is why it is very important to detect it at its earliest stage.

Why are people with diabetes more at risk?

As with many of the other complications of diabetes, kidney disease is caused by damage to small blood vessels. This damage can cause the vessels to become leaky or, in some cases, to stop working, making the kidneys work less efficiently. It is now known that keeping blood glucose levels as near normal as possible (between 4 and 6 mmol/l before meals, and less than 10 mmol/l two hours after food) can greatly reduce the risk of kidney disease developing as well as other diabetes complications. It is also very important to keep blood pressure controlled (130/80mmHg or less).

How does my doctor check for kidney disease?

Everyone with diabetes should have at least an annual check up, which should include a urine test for protein. One of these tests looks for tiny particles of protein in the urine, called 'microalbuminuria'. These appear during the first stages of kidney disease, as the kidneys become 'leaky' and lose protein. At this stage kidney disease can often be treated successfully, so this test is very important.

I had protein in my urine but now the test is negative. How can this happen?

Kidney disease is not the only reason for protein to appear in the urine. If you have a urinary tract infection (UTI) this can lead to protein being passed out in the urine. People with poorly controlled diabetes can be more prone to urinary tract infections because glucose in the urine provides a perfect breeding ground for bacteria. This might need treatment with antibiotics. In some cases, if the infection persists, it can cause damage to the kidneys, so it is very important for people with diabetes to visit their doctor if they develop a urinary tract infection.

What sort of treatment might be recommended?

This very much depends on the individual, the type of diabetes and other factors, such as blood pressure. Keeping blood pressure under control is extremely important and tablets for lowering blood pressure are often used. An increasingly common form of treatment for people with diabetes are 'ACE inhibitor' drugs or Angiotensin II receptor antagonists (AIIRAs). These are particularly successful as they not only lower blood pressure but also help protect the kidneys from further damage. These drugs are also sometimes used therefore in people who have normal blood pressure, due to their protective effect on the kidneys. Your doctor should discuss any treatment with you before starting you on it, explaining what it does and how it will help.

What if kidney disease gets worse?

There are many ways of treating kidney disease if the kidneys are no longer able to function properly. You may need to limit certain foods in your diet, such as protein foods or foods high in potassium, phosphate or sodium. This aims to prevent waste products building up in your body. As there may be a number of different things to consider, the diet can be quite complicated to follow. If you need to make any changes to your diet, you should receive detailed advice from a registered dietitian. Controlling blood pressure is also very important. If the kidneys have been damaged, the filtering and cleaning of the blood cannot be done normally. In some cases, dialysis might be needed to do this job for the kidneys. There are various types of dialysis and your doctor will discuss with you which one would be best for you.

Who can I contact for more information about kidney disease?

In the first place, it is sensible to talk with your diabetes team.

They should be able to answer most of your questions about kidney disease and the treatments available.

If you would like some more information, especially about the later stages of kidney disease, the National Kidney Federation produces leaflets on this topic and can put you in touch with a local group.

They can be contacted at National Kidney Federation, The Point, Coach Road, Shireoaks, Worksop, Nottinghamshire S81 8BW (telephone: 0845 601 0209 or see their website) page | 25

DIABETES NEWS

National Diabetes Inpatient Audit highlights "shocking" failings in hospital care Hospital in-patients with diabetes are developing potentially lifethreatening complications at a "shocking" rate, according to a report published today.

The National Diabetes Inpatient Audit (NaDIA) found that, in a fiveday period, more than 60 people with diabetes developed diabetic ketoacidosis (DKA), which results from a severe shortage of insulin.

Medication errors

The report also found that the majority of hospitals in the survey made medication errors, with more than a third of inpatients experiencing a medication error during the period of the study.

In addition, NaDIA found that, of the inpatients who should have seen a specialist diabetes care team, only three in five actually saw one. In the same period, one in five patients experienced a mild hypo, and one in ten experienced a severe hypo.

Health and Social Care Information Centre

NaDIA is based on data collected over a five-day period in September 2012 from hospitals in England and Wales. The study involved 13,410 patients with diabetes in 136 trusts in England and six local health boards in Wales. Over this period, 15.3 per cent – around one in seven – of inpatient beds were occupied by people with diabetes.

NaDIA is managed by the Health and Social Care Information Centre, working in collaboration with Diabetes UK and commissioned by the Healthcare Quality Improvement Partnership.

"Serious questions about basic levels of care"

Bridget Turner, Director of Policy and Care Improvement, Diabetes UK, said, "It is appalling that some people with diabetes are being so poorly looked after in hospitals that they are being put at risk of dying of an entirely preventable life-threatening condition.

"Even a single case of DKA developing in hospital is unacceptable

because it suggests that insulin has been withheld from that person for some time. The fact that this is regularly happening raises serious questions about the ability of hospitals to provide even the most basic level of diabetes care.

Profoundly disturbing picture

"But the small minority of people who become seriously ill through neglect is just the tip of the iceberg. In every aspect of hospital diabetes care that this report examines, the picture that emerges is profoundly disturbing. Medication errors are being made with alarming regularity, large numbers of people are not getting foot checks that we know can help prevent amputation, while one in 10 people’s blood glucose level is dropping dangerously low during their hospital stay.

"Put together, this adds up to a situation where in too many cases hospitals are doing people with diabetes more harm than good. This is a scandal and the really shocking thing is that it’s a scandal we have known about for some time but which there has never been any serious focus on bringing to an end.

One in seven inpatients

"People with diabetes are crying out for diabetes care in hospitals to improve and the Government has a key role in showing the leadership to make this happen. Firstly, we need to see diabetes inpatient specialist nurses in every hospital, and all medical staff in hospitals need a basic understanding of how to look after people with diabetes. After all, people with diabetes account for over one in seven hospital inpatients.

"These are the kind of changes that could make a real difference to ensuring that people finally start getting the care they are entitled to, which in turn could have a significant impact on the number of people with the condition who die before their time."

Meningitis Awareness Week – 16-22 September 2013

Meningitis Awareness Week is being held from 16-22 September 2013. The week's timing coincides with an increase in meningitis and septicaemia as we move into autumn and winter.

The Meningitis Research Foundation are targeting teenagers and young adults and urging them to “Get The Message”.

Fourteen to twenty-four year olds are one of the most at-risk groups. It is vital that everyone understands meningitis causes, meningitis effects and can look out for signs of meningitis.

Meningitis is a swelling of the brain and spinal cord lining. A number of symptoms associated with it include vomiting, severe headache, stiff neck and aversion to bright lights.

Septicaemia is a blood poisoning caused by the same germ as meningitis. A sufferer might have one or both of the diseases at the same time. Symptoms such as confusion, a rash anywhere on the body, and intense sleepiness are shared with meningitis. Muscle pain, cold hands and feet, and breathlessness are all specific to septicaemia.

If you wish to find out more or make a donation please go to the Meningitis Research Foundation Website

www.meningitis.org

26 | page

BRANCH NEWS

Western Branch Seminar On 23rd June, 18 Western branch members attended a very interesting meeting at the Women's Hospital in Aintree, Liverpool. We started with an excellent insight into acupuncture by our own member Loreto Sime, who has this year qualified in the subject and finds it compliments her podiatry clinic brilliantly, by also treating some stubborn foot conditions. Loreto also gave us a talk on the complicated condition Reynauds and how she would treat patients with circulatory, stressful and addictive conditions by using acupuncture. She then did a demonstration and talk on the very popular therapy reflexology. I have to say she had a very willing guinea pig in Linda Pearson!

Ben Stead from Canonbury gave up his Sunday afternoon to talk about and demonstrate how to use Kiniseo strappings and then

showed us new podiatry products which he thought we could

adapt to our private practice and lastly Michelle Weddell and

James Cree from Algeos demonstrated and helped the members do a practical workshop on the use and moulding of silicones in

podiatry practice.

I'm sure all members in attendance would like to thank all those

involved. The next Western branch meeting is on Sunday 22nd

September.

Next Branch Meeting Sunday 22nd September in Seminar Room 1, Blair Bell Education Centre, Women's Hospital Crown Street, Liverpool 12 - 1 1- 1.15 1.15 2.15 2.30 3.20 3.40

Branch Meeting Break and Raffle with trade exhibitors Chiropody Express and Prossor Uniforms Lecture "Tissue Donation" by NHS Liverpool Blood Nurses Break and trade shows Lecture "Honey Dressings" by Gemma Glen (Advancis Medical) Lecture "Sterilisation and Good Practice" by David Thomas (MDS) TBC HCPC Group Profile Discussion

PLEASE DO COME ALONG!

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lp yourself and n y ou r tieents. Apply ^ >q to e sulcus and gently ease ck the skin, repeat then ng the ultra slim in gro owing nippers remove the offending nail parts.

With patience - a clean and painless experience!

Hilary Supplies, 34A Halstead Road, Mountsorrel. Leics. LE12 7HF Tel: 0116 230 1900 Local rate 0845 3451678 Fax: 0116 230 3363 eMail: soniak@hilarysupplies.co.uk page | 27

BRANCH NEWS

! ! SEMINAR !

SHEFFIELD BRANCH ! !

! ! ! !

Sunday 22nd September 2013 ! ! !

9:45 –! 15:00

! ! ! ! ! ! !

Sheffield Works Department Sports & Social Club ! ! ! ! ! !

Heeley Bank Road,! Sheffield S2 3GL !

SPEAKERS: !

!

D

• Cold ! Related!Harm and ! Ill !Health: ! findings ! from the Keeping Warm in Later Life study

!

!

!

! !

!

Angela Tod !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!+0Q5F2!RH1!

Angela is professor of Health Services Research " ! at! Sheffield Hallam ! ! University ! ! ! ! ! !

!! !

! !

!

• What Treatments are available for the patient ! with chronic kidney disease?

!

! !Plant ! !

Mandy Mandy! is Matron of ! Renal Services ! at the Northern General Hospital Sheffield

!

!

!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!.2013!OF207!

9 ! ! ! ! ! ! ! • Third !lecture TBC !

! !

! !

!

!

28| page

!

DLT Trade Stand present throughout ! the day ! with ! products for sale at discounted prices

!

!

£50 Including!Buffet Lunch

!

!

!

!

!

!

To book a place contact Debbie !Straw on ! 01623 452711 or email debbie.straw1@ntlworld.com ! ! ! ! !

Only 30 places available on a first come first served basis! ! ! ! ! ! ! ! ! ! ! ! ! !

!

! !

!

BRANCH NEWS

page | 29

INFORMATION

30 | page

BRANCH NEWS

NORTH WEST AREA COUNCIL 15th ANNUAL SEMINAR at

The University of Central Lancashire, Preston on

Sunday, 13th October, 2013

PROGRAMME 9:30 a.m.

10:00 a.m.

Registration; tea; coffee and biscuits

Lecture: Podiatric Surgeon: Criteria for the Management of Hallux Valgus Lecturer T.B.C.

11:00 a.m.

Tea, coffee & biscuits

11:30 a.m.

Lecture: The Effects of Medicine on Blood Pressure Lecturer Dr. Emma Allison MBBs.Hons

12:30 p.m.

Lunch, tea & coffee and trade stands

3:00 p.m.

Prize Draw & CPD Certificate Issue and Close of Seminar

2:00 p.m.

Lecture: To be confirmed

If you plan to attend please send your details and a cheque made payable to:

‘IOCP North West Area Council’ for £65.00 (This includes all refreshments and cooked lunch)

Send to: Mr. Bryan Massey, 104, Gillbent Road, Cheadle Hulme, Cheshire, SK8 6NG For more information please contact David Topping (Secretary) 01772 615769

✁ ✁ -----------------------------------------------------------------------------------------------------------------------------------------------Booking Form

NWAC 15th ANNUAL SEMINAR 2013

I enclose a cheque for £65 made payable to the IOCP North West Area Council

Name:.....................................................................................................................................................................

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

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

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

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

page | 31

BRANCH NEWS

SUSSEX BRANCH

At the Bent Arms, Lindfield, Nr Haywards Heath, West Sussex RH16 2HP Sunday 15th September 2013 at 9 am for 9.30 am start

Sussex Branch is delighted to present a Study Day

With well-known Biomechanics Specialist Robert Isaacs

‘Biomechanics for Everyone’ – an informal, practical and fun day of learning to include:

•

•

•

Evolution of biomechanics with practical anatomy

What to do when a patient tells you their foot hurts – assessment techniques

Optional mid-afternoon workshop for those wishing to know more on prescribing and casting orthotics in Private Practice

Also Belinda Longhurst (Private Practitioner) will be kicking off the day with an informal and informative discussion on the aetiology and latest treatment of verrucae pedis

And Canonbury will be there on the day with their trade stand!

Cost of the day is £40 to include a delicious buffet lunch and refreshments.

If you would like to attend please complete the booking form below and return by early September. Or for further information call Valerie Probert-Broster on 01273 890570 or email IOCPSussexBranch.live.co.uk EVERYONE WELCOME!

Booking Form

Biomechanics Study Day with lunch and refreshments on Sunday 15th September 2013 at the Bent Arms, Linfield, RH16 2HP

9 am for 9.30 am start

Name…………………………………………………………………………………………………………………………………………………..………..…

Address ………………………………………………………………………………………………………………….…………………………..………..… ………………………………………………………………………………………..………Post Code………………………………………….………..…

Branch…………………………………………………………………………………………………………….…………………………………..………..…

Tel…………………………………………… Email …………………………………………………………………………………………...………..….…

Please send a cheque for £40 made payable to IOCP Sussex Branch and send to Valerie Probert-Broster, The Rectory, Plumpton, Lewes BN7 3BU by early September.

32 | page

page | 33

DIARY

What’s on in your area?

September 2013 1

1

6

West of Scotland Branch Meeting 11 a.m.

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

East Anglia Branch Meeting 10.00 a.m. for 10.30 a.m. prompt With autoclave servicing (contact Julie Garwood garwoodjulie@yahoo.co.uk or 01473 310155) Barrow Village Hall, Bury St Edmunds IP29 5DX Tel: 01992 589063

9 West Middlesex Branch Meeting 8 p.m.

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

14 Southern Area Council Meeting 1 p.m.

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

17 North West Branch Meeting 7.00 p.m.

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

Tel: 01992 589063

Tel: 0161 486 9234 Includes CPD Presentation

20 Birmingham Branch Meeting 8 p.m.

British red Cross Centre Evesham, Worcs.

Tel: 01905 454116 22 Sheffield Branch Meeting 10.00 a.m.

SWD Sports Club, Heeley Bank Road, Sheffield S2 3GL

Tel: 01623 452711 N.B. This replaces the meeting scheduled for 18th October

22 Western Branch Meeting 12.15 p.m.

Blair Bell Education Centre, Liverpool Women’s Hospital, Crown Street, Liverpool Presentation: “Tissue viability” and trade stand.

Tel: 01745 331827 27/ Executive Meeting Head Office 28 150 Lord Street, Southport PR0 0NP

Tel: 01704 546141

29 Essex Branch Meeting 2 p.m.

Southend University Hospital Education Centre Carlingford Drive, Southend on Sea SS0 0RY Tel: 01702 46089

34 | page

29 Nottingham Branch Meeting 10.a.m.

Willow Tree House, Main Street, Little Hurnby, Grantham NG33 4HW

Tel: 0115 931 3492

29 South Wales & Monmouth Branch Meeting 2 p.m.

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

October 2013 2

6

Hants and Dorset Branch Meeting 7.45 p.m.

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

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

The Dene Hotel, Hoole Road, Chester Tel: 0151 327 6113

6

Leeds Bradford Branch Meeting 10 a.m.

Oakwell Motel, Leeds WF17 9HD

7

Surrey and Berkshire Branch Meeting 7.30 p.m.

Pirbright Village Hall, Pirbright, Surrey Tel: 0208 660 2822

27 Northern Ireland Branch Meeting Lagan Valley Hospital

Tel: 01924 475338

Tel: 028 9446 2423

27 Wolverhampton Branch Meeting 9.30 am 4 Selman’s Parade, Selman’s Hill, Bloxwich, Walsall, WV3 3RN

Tel: 0121 378 2888

27 Leicester and Northants Branch Meeting Kilsby Village Hall, Hall Lane, Kilsby CV23 8XX Tel: 01234 851182

DIARY

November 2013 3

Leeds Bradford Branch Meeting 10 a.m.

Oakwell Motel, Leeds WF17 9HD

3

Scottish Area Council Meeting

3

3

14 North West Branch AGM 7.00 p.m.

St Joseph’s Parish Centre, Harpers Lane, Chorley, Lancs Tel: 01924 475338

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

The Village Hotel, Coryton, Cardiff CF1 7EF Tel: Esther 01656 740772 West of Scotland Branch Meeting 11 a.m.

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

11 West Middlesex Branch Meeting 8 p.m.

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

13 London Branch Meeting 7. 30 p.m.

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

24 Essex Branch Meeting 2 p.m.

Southend University Hospital Education Centre Carlingford Drive, Southend on Sea SS0 0RY Tel: 01702 460890 24 Leicester and Northants Branch Seminar Lutterworth Golf Club Tel: 01234 851182

December 2013

Leeds Bradford Branch Meeting 10 a.m.

Oakwell Motel, Leeds WF17 9HD

6

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

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

Tel: 01924 475338

January 2014

Leeds Bradford Branch AGM 10 a.m.

Oakwell Motel, Leeds WF17 9HD

15 Hants and Dorset Branch AGM 7.45 p.m.

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

16 Birmingham Branch AGM 8 p.m.

British Red Cross Centre Evesham, Worcs.

Tel: 01905 454116

17 Sheffield Branch AGM 7.30 p.m.

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

17 East Anglia Branch AGM 10.30 a.m.

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

19 Essex Branch AGM 2 p.m.

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

19 West of Scotland Branch AGM 11 a.m.

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

25 Southern Area Council AGM 1 p.m.

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

Tel: 01992 589063

26 Leicester and Northants Branch AGM Kilsby Village Hall, Hall Lane, Kilsby CV23 8XX Tel: 01234 851182

1

5

Tel: 0161 486 9234

Tel: 01924 475338

11 Surrey and Berkshire Branch AGM 1.30 p.m.

Greyfriars Centre, Reading Berkshire Tel: 0208 660 2822

12 Western Branch AGM 12.15 p.m.

Blair Bell Education Centre, Liverpool Women’s Hospital, Crown Street, Liverpool Tel: 01745 331827

28 London Branch AGM 7. 30 p.m.

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

February 2014 2

Northern Ireland Branch AGM Lagan Valley Hospital

2

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

Tel: 028 9446 2423

March 2014

21 Sheffield Branch Meeting 7.30 p.m.

SWD Sports Club, Heeley Bank Road, Sheffield S2 3GL Tel: 01623 452711 page | 35

CLASSIFIED

Classified Section PRACTICES FOR SALE RETIREMENT SALE - WREXHAM.

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

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

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

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

TORQUAY, DEVON - RETIREMENT SALE

Surgery and Domiciliary Established 25 years Income £17k over 3 days. Plenty of Scope for Expansion. Price £15K Telephone 01803 211616

SOUTH WEST DUBLIN

Podiatry/Chiropody Business For Sale Business located in prime demographic area. Very modern premises and facilities well suited to medical uses and expansion. Located in area with little competition. Excellent opportunity and huge potential evidenced by accounts.

Please call 00353 8724 82798.

CHESTER For sale a Podiatry Clinic on the outskirts of Chester. Turnover of 68k per annum.

The practice has a large customer base and the sale includes all equipment. The leased clinic is currently open 4 days per week and has two treatment rooms.

A business overview and valuation document is now available.

Email scgriffiths@me.com Telephone 01244 303215 / 07920 864797 To advertise in this section and on our website Call 01704 546141 or email bernie@iocp.org.uk 36 | page

RECRUITMENT WARWICKSHIRE Podiatrist required to join busy, expanding practice on self employed basis.

For more information contact Kate on 07762 038201.

SOUTH NOTTS

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

Podiatrist with excellent interpersonal skills, a minimum of 2yrs post grad with experience of private practice. Successful candidate to be employed as part of a professional and friendly forward thinking team.

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

Chiropodist/podiatrist wanted

for central London clinic. Every other Saturday 9am till 2pm. Salary negotiable.

Please send CVs to bernie@iocp.org.uk

EQUIPMENT/SUPPLIES FOR SALE

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

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

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

CLASSIFIED

And finally, we hate to mention the ‘C’ word …….. but Crisis at Christmas are desperate for your help.

If anybody feels like they would like to volunteer please get in touch direct.

B

t eer a t n u l o V ea

Chr is t m

as

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

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

“Crisis are always looking for donations of socks as well as all sorts of other food and clothing for use during the Christmas ǁĞĞŬ͕͟ ƐĂLJƐ ŽƐLJĨĞĞƚ͛Ɛ <ĂƚŝĞ ,ŽƵƐĞ͘ ͞tĞ͛ƌĞ ĚĞůŝŐŚƚĞĚ ƚŽ ďĞ ĂďůĞ ƚŽ ŚĞůƉ͘͟ Cosyfeet make a wide range of socks including extra-roomy and seam-free socks for those with swollen or sensitive feet, complementing the company’s range of extra-roomy footwear.

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

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

Need Stationery?

Supplies?

Uniforms?

Don’t forget to visit our on-line shop at LinkUP Ltd

www.linkupltd.com/iocp Telephone David 01252 343127 page | 37

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