Podiatry Review January/February 2012

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ISSN 1756-3291

Podiatry Review

Volume 69 No.1. Published by the Institute of Chiropodists and Podiatrists as a Peer Review Journal January / February 2012

Southport AGM Information Design of A Clinical Audit New Waste Disposal Rules

INSTITUTE OF CHIROPODISTS AND PODIATRISTS

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JANuARY/FEBRuARY 2012 VOL 69 NO.1

The Institute of Chiropodists and Podiatrists Editor in Chief Roger Henry FInstChP, DChM Academic Editor Robert Sullivan MInstChP, Bsc(Hons)Pod, PGDip, TP Surg Editorial Assistant Bernadette Willey bernie@iocp.org.uk Editorial Committee Mrs F H Bailey MInstChp Mr W J Liggins FInstChp, FPodA, BSc(Hons) Mrs A Yorke MInstChP Mrs J A Drane MInstChP Advertising Please contact Julie Aspinwall secretary@iocp.org.uk Published by The Institute of Chiropodists and Podiatrists 27 Wright Street, Southport Merseyside PR9 0TL 01704 546141

Printed by Mitchell & Wright Printers Ltd, The Print Works, Banastre Road, Southport PR8 5AL 01704 535529

ISSN 1756-3291 Annual Subscription

PODIATRY REVIEW

Contents Design of A Clinical Audit................................................04 Anne Todd BScPod,MInstChP, RMT, MCThA The Treatment of stubborn plantar warts using topical 5% imiquimod cream ................................06 Ivan Bristow, University of Southampton and Christine Styles, Private Practitioner Statin Therapy ................................................................09 Judith Barbaro-Brown MSc, BSc(hons), PGCE, DpodM, MChS Podiatry as a Profession: My path to becoming a Podiatrist and my experience as a newly Qualified Practitioner Part 2 ..........................................15 Deirdre O’Flynn BSc Pod 2012 Waste Pre-Acceptance Audits – what you need to know ..................................................16 Damian Murray - Podiatry Waste Specialist An Evening with Kylie......................................................19 Beverley Wright MInstChP, BSc(hons) PGCE,PGDip Homeopathy and the treatment of arthritis and rheumatism - A personal journey with RA ..............20 Lauren Vaknine Rambling Roads ..............................................................23 Branch News ..................................................................24 Book Review ..................................................................32 Dates for your Diary........................................................34

£30 UK £45 Overseas

© 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.

Classified Advertisements ..............................................35 National Officers ............................................................37

EXECUTIVE COMMITTEE L-R Julie Dillon, Colette Johnston, Joanne Casey, Martin Harvey, Heather Bailey, Bill Liggins, Jacquie Drane, Robert Sullivan, David Crew, Valerie Dunsworth, Michele Allison, Ann Yorke page | 01

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EDITORIAL Dear Reader, I hope that you all had a very enjoyable Christmas. It is now the start of another year and I wonder what the future has in store for us all? A mountain was deliberately chosen for the front cover of Podiatry Review.

We all have our own mountains to climb. As Beverley Wright said in her article [see page 19] whether you are a student, chiropodist, podiatrist, or health professional, by undertaking new learning you can achieve something positive in your life, in addition to gaining a certificate, diploma or degree for your efforts.

On page 6 you will see the treatise “The Treatment of stubborn plantar warts using topical 5% imiquimod cream by Ivan Bristow, University of Southampton and Christine Styles, Private Practitioner Marlborough. I asked my old friend Ivan for permission to publish the article and he readily agreed.

I went to a Conference recently and met Lauren Vaknine and her mother and we were discussing Homeopathy. She told me that she is the youngest ever trustee of the British Homeopathic Association, and that she has written a book “My Enemy, My Friend”. It is available to buy on Amazon. Lauren was diagnosed with Juvenile Rheumatoid Arthritis aged 2 she is now 27 years old. After having been severely disabled and wheelchair bound for many years, Lauren turned it all around with the help of Holistic therapies, especially Homeopathy. [see page 20] We, in the Institute, once again thank Judith Barbaro-Brown for her informative article on statin therapy [page 9] There are plenty of seminars and opportunities for learning which I am quite happy to give advance notice of. Southern Area Council has a Seminar on Saturday 24th March 2012 at Anglia Ruskin University.

Midland Area Council has a seminar on Sunday March 11th 2012 at the

Village Hotel, Shirley, Birmingham.

Leeds and Bradford branch hold their Seminar on Saturday 3rd March 2012 at the University of Huddersfield with many interesting speakers.

We in the Institute are looking forward to our national AGM, lectures, workshops, trade show and dinner dance, to be held at the prestigious Conference and Exhibition Centre, Southport Merseyside. The dates are Friday 27th and Saturday 28th April 2012.

The Ramada Plaza Hotel is interconnected next door. The Premier Inn Hotel is two minutes away and there is an abundance of hotels and guest houses to suit all pockets and budgets. Amongst the lectures are workshops on various subjects including padding and strapping, diabetic assessments, Insurance, manual lymph drainage, nail surgery, pharmacology, and cautery of troublesome skin lesions and verrucae using hyfrecaters.

The annual social event [tickets £35 ] commences at 7pm with the President’s Reception followed by a three course dinner and dancing to the hugely popular Northern All Stars 17 piece swing band. Should be quite an event!

It only remains for me to thank Mrs Willey [Bernie] in the office for all her hard work with the review during the last year and to wish you all a prosperous, but above all a healthy New Year.

Roger Henry Editor in Chief Podiatry Review

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ARTICLE

Design of A Clinical Audit Anne Todd MInst ChP BSc Pod RMT MCThA Title “An audit of missed appointments in a multi-chair podiatry clinic within NHS Lothian”.

Introduction For this audit protocol, we have chosen a prominent podiatry clinic in Edinburgh as the location in which it is to be conducted - a multi-chair clinic encompassing both community and student clinics, the latter being used for teaching purposes for students in years 1 to 3 (with some level 4 students on occasional short term placement). Its quite central location is one where a good cross-section of the population of the capital city is represented, with a host of patients with differing health concerns – varying from low maintenance treatment requirements to that of more convoluted care due to having chronic medical conditions, therefore being classed as high risk patients. It is estimated that 80 patients a day in the student clinic are treated (18 chairs) and around 23 (3 chairs) in the community clinic. We have identified a need for audit to address the issue of patients who did not attend appointments (DNAs) as it is a very costly problem, for the NHS particularly, and it’s monitoring is part of cost effectiveness and quality assurance. Two other concerns appropriately highlighted within the subject are that of loss of qualified practitioners’ time, and concerns for further health deterioration in the patient themselves, along with the possibility of subsequent further impact on their required treatment time if they miss scheduled appointments. The standard desired minimum patient attendance time in the NHS has been mentioned as 80%, with variations in acceptable standards seen in different texts, according to what health board or trust is reporting. This NHS local practice does have a strategy in place, it is ascertained that a “3 strikes and you are out” standard policy is used, but as Improving NHS Scotland (2011) points out, each practice should be checking that this policy is being adhered to and asking themselves what an acceptable level of DNAs is.

Further justification in detail for the areas explored in this audit will follow in the form of a literature review, having used CINAHL and MEDLINE mostly as databases to find relevant research or previous audits which addressed the subject of missed appointments routinely throughout NHS departments.

Aims To discover if DNA rates are above the overall NHS suspected national average of 20%.

To identify areas where non-attendance may be reduced.

To minimise loss of NHS funding.

To improve services to patients.

Literature Review A compelling issue with DNA patients is the cost – a paper by Murdock et al (2002) tells of an estimated annual cost of £300 million, based on DNA rates of 12%. More recently, Davies and 04 | page

Craddock (2006) report a figure of close to half a billion pounds to the NHS in general, breaking it down to between £50-150 per appointment. Their study, which focused solely on podiatry, found that one primary care trust in England was above the national average of 20%, therefore with even more cost implications. An American study (Silberstein 2008) similarly told of an estimated annual loss of $30000, a significant loss in revenue in a private podiatry practice.

On the 2nd issue of wasting practitioners’ time, Silberstein (2008) raises the issue of staff not being productive, emphasising the problem of having too much time to catch up, and then to face the possibility of making staff cuts. Armistead (1997) gave statement - with regards to physiotherapy patients - about the need to maximise use of the practitioner’s time in order to certify an effective throughput of patients, thereby actively helping management of waiting lists, cost effectiveness, as well as meeting patients’ needs. She also stated the need for the problem of non-attendance to be studied more in combination with internal audit. Murdock et al (2002) states that failure to attend appointments results in manpower and equipment being under used, whilst possibly increasing the time that other people must wait for treatment.

Lastly, there is much report around the subject of patient health – Murdock et al (2002), argues that a delay in conferral and diagnosis, or incomplete checking of chronic conditions, would make patients more likely to develop otherwise avoidable additional health problems. Davies (2006) points out clinical nonattendance as being a particular problem in the elderly, continuing to illustrate that most of the general podiatry caseload is contained of the elderly, with the number of older people increasing. Moreover, Lyon and Reeves (2006), accent failure to attend as part of non-compliance, going on to highlight the link between patient compliance and good communication and optimum clinical outcome. The fact that patient waiting times are likely to be increased as a result of missed appointments by a minority shows a further effect on clinical treatment available for all concerned, also arguably questioning waiting times as appropriate measures for NHS achievement (Davies 2006).

Ethical Considerations There are no issues of an ethical nature to accommodate, as data collected does not involve naming of individual patients.

Methodology Firstly, a proposal registration form will be completed for approval by the appropriate quality improvement team prior to starting the project, involving contacting the Midlothian Community Health Partnership (CHP). A letter for permission to undertake the audit, on a quiet day, has also been prepared for sending to the manager at Inchkeith House. With these obtained, one Band 4 admin and clerical staff member, with basic Excel skills, would be employed to compile the data and use the programme’s functions to display totals/percentages for presentation to the podiatry team, who will then meet and subsequently disseminate the findings to the appropriate audience.

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ARTICLE Resource requirements would be that of a requisitioned laptop with a recent Microsoft Office programme. Therefore the audit would be costed in terms of the hours it would take for this member of staff to complete the tasks – at an hourly rate of £7.11(assuming point 1 on band scale) this would equate to £53.32 gross on the basis of 1 full day’s work (7.5 hours). Each incident of non-attendance is to be recorded in the data collection sheet with monthly figures for all columns totalled.

Monthly statistics for attended/missed appointments are available electronically; these would be obtained and included in the Excel sheet prior to entering the reception/office area to start the file gathering component of the task. Firstly, appointment diaries from the selected dates would be consulted to give names/CHI numbers of all patients booked in on that month, their cards then pulled from the filing system in order to track the record of appointments/ DNAs on their cards.

We have chosen the years 2006-2008 and months of March and November to record a snapshot of data as these months represent the 2 clinics working at their highest capacity with students and staff included, whilst excluding the problem of unusually bad weather in the past 2 winters. Exclusion criteria is that of any patient who has not been attending the clinic for at least 12 months, taken into consideration is the fact that patients who DNA and do not then make contact are placed in a separate, accessible, filing system (until they do initiate contact and another appointment is made) - along with those who have not been treated in over 1 year. Only if a patient fails to attend after 3 events in a 12 month period is contact made by the clinic – this may involve a phone call but more commonly a letter stating that they have now missed 3 appointments and they will need to be re-referred by their GP (so they will once again join the live system) or they will be otherwise considered as discharged (thus archived). The sending of this letter is recorded on their card.

“Health Statistics Quarterly”, in conjunction with the Office for National Statistics, or any other journal that has relevance to UK Health and Social Policy.

References Armistead, J. 1997. An evaluation of initial non-attendance rates of physiotherapy. Physiotherapy. 83 (11) November, pp. 591-596.

Davies, K. 2006. Patient non-attendance in podiatry. Podiatry Now. November, pp.19-23.

Improving NHS Scotland. 2011. [online] Available from: http://www.improvingnhsscotland.scot.nhs.uk/tools/Pages/DN As.aspx [Accessed April 4 2011] Lyon, R. and Reeves, P. J. 2006. An investigation into why patients do not attend for out-patient radiology appointments.

Radiography. 12 pp. 283-290.

Morrell, C. And Harvey, G. 1999. The clinical audit handbook – improving the quality of healthcare. London: Elsevier.

Murdock, A., Rodgers, C., Lindsay, H., and Tham, T. C. K.2002.

Why do patients not keep their appointments? Journal of the Royal Society of Medicine. 95 pp.284-286.

Silberstein, N. 2008. Reducing No-Shows. Podiatry Management. October, pp. 71-74.

Data Analysis Using Excel’s calculator functions, we can see how much individuals are missing appointments (once, twice, or 3 times or more) and obtain an idea of how much the podiatrists’ time is being lost, as well as what percentage of these individual missed amounts are presenting on the spreadsheet. These figures will go some way to identify if the DNA rate is above 20% overall, we can also see if those who receive letters continue to DNA or start to attend regularly, and indeed, if those who DNA 3 times are contacted and then their cards filed appropriately, checking that no-none is in the live system who is not complying with the policy.

Comparisons may be made between the 2 clinics to flag up either being more under-used than the other.

Conclusion The results of the study will be used to monitor and improve existing practice, as is required of clinical audit (Morrell and Harvey 1999), with the ultimate aim of ensuring that such processes are put in place throughout relevant organisations, in line with quality assurance. With this in mind, findings would certainly be circulated through peer reviewed professional journals involving podiatry and the allied health professions.

Another possible pathway to display these findings would be page | 05

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ARTICLE

The Treatment of stubborn plantar warts using topical 5% imiquimod cream

By Ivan Bristow, university of Southampton Christine Styles, Private Practitioner, Marlborough Introduction Plantar warts (verrucae) continue to be a stubborn problem for both patients and practitioners alike. A systematic review of the numerous treatment modalities has highlighted the lack of evidence and consistent results from published studies 1-3. A qualitative study of patients’ views has also emphasized the patient’s frustrations - many feeling embarrassed, negative and restricted in their normal daily activities, in addition to the disappointing outcome of the various treatments 4.

Imiquimod (Aldara® - 3M Pharmaceuticals) is a prescriptiononly, topical imadazoquinolone, currently licenced in the UK for the treatment of genital warts, actinic keratosis and superficial basal cell carcinoma. Introduced in 1997, the drug has demonstrated itself as a safe and effective treatment for external genital warts. A number of case studies have been published since, documenting its off-licence use in the treatment of cutaneous warts including verrucae 5-15. This paper discusses two cases of resistant plantar warts successfully treated using the drug.

Case Report 1 Mrs A was a married, 43-year-old woman with a history of cardiac arrhythmias and viral carditis. At her initial podiatric consultation she presented with a two-year history of multiple cutaneous warts on both feet, hands, lower legs and right thigh (figure 1). A review of her medical history suggested no apparent immunesuppression.

Previous podiatric treatments had included cryosurgery, trichloracetic acid with silver nitrate, salicylic and monochloracetic acid and oral zinc sulphate.

Following an assessment, in view of previous Figure 1: Patient 1 showing typical treatments, it was decided lesion on plantar area of right to commence a course of foot at presentation. topical 5% imiquimod to 06 | page

treat the verrucae. The drug was obtained by private prescription from the patient’s general practitioner. All foot lesions were debrided and the patient was instructed to apply a thin layer of the cream topically to individual lesions rubbing in until the cream was no longer visible and then cover treated lesions using gauze or similar dressings.

Dressings were left on overnight Figure 2: Patient 1 showing and removed in the resolution at five months. morning, washing off any remaining medicament. This was carried out three nights a week for an initial period of 6 weeks.

Within two weeks, changes were noted in all treated lesions, with reduction in size and flattening. At around six weeks into therapy, improvement continued in all treated lesions but increased vascularity with bleeding was evident from lesions, along with crusting and discomfort. Therapy was continued for a further 2 weeks. The patient was reviewed again at five months (after a total of eight weeks therapy) and all lesions had cleared (figure 2).

Case Report 2 Miss B was an active 15 year old girl with no previous medical history. She presented with numerous verrucae on the plantar surfaces of both feet which had failed many treatments including caustics, thuja, cryotherapy and marigold oil (figure 3). In view of the lesions persistence, imiquimod 5% cream was prescribed by private prescription from the general practitioner. Lesions were treated in a similar manner to the preceding case and reviewed at eight weeks, showing significant improvement in all but one plantar lesion. At 16 weeks following commencement of

Figure 3: Patient 2 (right foot) before treatment.

Figure 4: Patient 2 (right foot) at sixteen weeks showing significant improvement

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ARTICLE treatment, there was significant improvement with a few tiny remnants of lesions remaining with the majority having resolved (Figure 4). No further treatment was instigated and at one year after starting treatment, one lesion remained without any symptoms.

Discussion The unique mechanism of action of imiquimod has been investigated. Research conducted in the late 1990’s on the innate immune system demonstrated the existence of a family of receptors present on the cell membrane and within the cell 16.

They function as sensors for particular structures present on bacteria, fungi, virus and protozoa and are most numerous on cells of the immune system as well as endothelial and epithelial surfaces such as the skin. These receptors are called Toll-like receptors (TLRs). To date, ten TLRs have been discovered in humans, each one with a different antimicrobial sensing ability allowing the immune system to recognise and respond to a diverse range of pathogens appropriating the correct chemical response. TLR 7 and 8 have been shown to respond to the presence of nucleic acids and single stranded RNA found in many viral infections.

Imiquimod has been discovered to be a ligand for the TLR 7 site 17 and therefore is able to mimic the presence of such a viral infection. The resultant effect of TLR 7 stimulation is the release of a number of pro-inflammatory cytokines including TNF-α, IFNγ, IFN-β and IL-1 and IL-618. These mediators in particular facilitate the Th1 pathway – an important immune defence mechanism against viral infections and tumours. In addition, TLR 7 activation enhances Langerhans cell delivery to lymph nodes to enhance antigen presentation. Thus, the drug does not directly destroy the virus or its host cell but causes wart regression by inducing a localised, natural immune response.

Initial studies of the drug on 311 patients with external genital Author Hengge7 Sparling12 GrussendorfConen5 Housman8 Yesudian13 Harwood6

Year 2000 2001

Notes 50 cases (36 hands and feet) 2 cases (periungual and plantar)

2002 2002 2002 2005

Leong9 Mitsuishi11 Atorzi15 Micali10

2007 2009 2003 2003

Zamiri14 Harwood6

2003 2005

Leong9 Mitsuishi11

2007 2009

18 cases (paediatric study) 3 cases (2 plantar, 1 hand) 1 case (hands and feet) 15 immuno-suppressed patients – (hands and feet) 1 case (plantar) 2 cases (plantar) 1 case (dorsum) 15 cases (recalcitrant sub- and peri-ungual warts) 2 cases (plantar) 15 immuno-suppressed patients – (hands and feet) 1 case (plantar) 2 cases (plantar)

warts demonstrated a success rate of 51% versus 11% placebo19.

As the topical cream could be safely self-administered by the patient its advantages over more traditional treatments such as cryotherapy and other destructive therapies was clearly evident.

The use of imiquimod in the treatment of plantar warts has been previously documented in a number of papers (table 1) 5-14.

Consistent with other published studies, typically the treated lesions respond with some irritation around the lesion, gradual erosion and flattening13, 20. Some authors report that irritation is often a good sign indicating stimulation of the immune response and a predictor of a positive outcome21 whilst others report clearance without any such response14. Consistent with other reports, recurrence with this therapy was not encountered13, 14.

Compared with other modalities this is an advantage. It has been hypothesized that the application of imiquimod to the surrounding tissue has an accumulative effect, stimulating keratinocytes to release cytokines to destroy latent virus in adjacent cells, which is often missed when using physical methods such as laser or excision.

Methods of application between reports also vary – ranging from direct application of the cream without occlusion12, 13, to those with occlusion6, 9, 14. In addition some authors have used a pre-treatment; such as salicylic acid 3-5 days prior to commencement of therapy9, 10, scalpel debridement11 or a single freeze thaw cycle of cryosurgery8, 12. During imiquimod therapy two studies included regular filing of overlying hyperkeratosis by the patient6 or the on-going use of over-the-counter salicylic acid preparations8. Hengge7 in his study dosed the regime every day for five consecutive days arguing that the 3 times a week recommended for genital warts is insufficient to penetrate thicker epidermis on non-genital lesions. Harwood and colleagues 6 initially began with a 3 day a week dosing but if no improvement was observed it was increased to a daily regime. Treatment duration time with imiquimod for warts is recommended to a maximum of sixteen weeks, although neither of the two cases required therapy to this length. All reviewed studies worked to this timeframe.

Its routine use in the management of verrucae is yet to be formally tested although the above successes offer some hope.

In addition, the treatment is safe enough for the patient to use at home and not to affect their daily activities. Adverse reactions with this drug are low and often localised to the topical treatment area – itching, burning, pain and soreness.

Conclusion Topical imiquimod has been successfully used in the treatment of recalcitrant plantar warts within a podiatric setting. Currently this prescription only medicine is unlicensed for use on plantar warts and may have to be obtained by private prescription. The authors stress, like most other wart treatments, it is not a universal panacea but can be safely applied by the patient with minimal side effects and impact on daily activities with a response rate comparable to most other current treatments.

Table 1: Previous reports of successful use of 5% imiquimod cream in the treatment of plantar or foot warts.

page | 07

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ARTICLE References 1. Gibbs S, Harvey I, Sterling J, Stark R, editors. Local treatments for cutaneous warts. Oxford: Update Software; 2002.

2. Kwok CS, Holland R, Gibbs S. Efficacy of topical treatments for cutaneous warts: a meta-analysis and pooled analysis of randomized controlled trials.

Br J Dermatol. 2011.

3. Gibbs S, Harvey I. Topical treatments for cutaneous warts. Cochrane Database Syst Rev. Chichester, UK: John Wiley & Sons, Ltd; 2006.

4. Ciconte A, Campbell J, Tabrizi S, Garland S, Marks R. Warts are not blemishes on the skin: A study on the morbidity associated with having viral cutaneous warts. Br J Dermatol. 2003; 44: 169-73.

5. Grussendorf-Conen EI, Jacobs S. Efficacy of imiquimod 5% cream in the treatment of recalcitrant warts in children. Pediatr Dermatol. 2002; 19(3): 263-6.

6. Harwood CA, Perrett CM, Brown VL, Leigh IM, McGregor JM, Proby CM. Imiquimod cream 5% for recalcitrant cutaneous warts in immunosuppressed individuals. Br J Dermatol. 2005; 152(1): 122-9.

7. Hengge UR, Esser S, Schultewolter T, Behrendt C, Meyer T, Stockfleth E, et al. Self-administered topical 5% imiquimod for the treatment of common warts and molluscum contagiosum. Br J Dermatol. 2000; 143(5): 1026-31.

8. Housman TS, Jorizzo JL. Anecdotal reports of 3 cases illustrating a spectrum of resistant common warts treated with cryotherapy followed by topical imiquimod and salicylic acid. J Am Acad Dermatol. 2002; 47(4, Part 2): S217-S20.

9. Leong C-M, Tarbotton J, Hibma M. Self applied treatment of persistant plantar warts with 5% imiquimod cream. N Z Med J. 2007; 120(1259).

10. Micali G, Dall'Oglio F, Nasca MR. An open label evaluation of the efficacy of imiquimod 5% cream in the treatment of recalcitrant subungual and periungual cutaneous warts. J Derm Treat. 2003; 14(4): 233-6.

11. Mitsuishi T, Wakabayashi T, Kawana S. Topical imiquimod associated to a reduction of heel hyperkeratosisfor the treatment of recalcitrant mosaic plantar warts. Eur J Dermatol. 2009; 19(3): 268-9.

12. Sparling JD, Checketts SR, Chapman MS. Imiquimod for plantar and periungual warts. Cutis. 2001; 68(6): 397-9.

13. Yesudian PD, Parslew RAG. Treatment of recalcitrant plantar warts with imiquimod. J Derm Treat. 2002; 13(1): 31 - 3.

14. Zamiri M, Gupta G. Plantar warts treated with an immune response modifier: a report of two cases. Clin Exp Dermatol. 2003; 28 Suppl 1: 45-7.

15. Atzori L, Pinna A, Ferreli C. Extensive and recalcitrant verrucae vulgares of the great toe treated with imiquimod 5% cream. Journal of the European Academy of Dermatology and Venereology. 2003; 17(3): 366-7.

16. Iwasaki A, R. M. Toll-like receptor control of the adaptive immune responses. Nat Immunol. 2004; 5(10): 987-95.

17. Hemmi H, Kaisho T, Takeuchi O, Sato S, Sanjo H, Hoshino K, et al. Small antiviral compounds activate immune cells via the TLR7 MyD88-dependent signaling pathway. Nat Immunol. 2002; 3(2): 196-200.

18. Gibson SJ, Imbertson LM, Wagner TL, Testerman TL, Reiter MJ, Miller RL, et al. Cellular requirements for cytokine production in response to the immunomodulators imiquimod and S-27609. J Interferon Cytokine Res. 1995; 15(6): 537-45.

19. Edwards L, Ferenczy A, Eron L, Baker D, Owens ML, Fox TL, et al. Selfadministered topical 5% imiquimod cream for external anogenital warts.

HPV Study Group. Human PapillomaVirus. Arch Dermatol. 1998; 134(1): 25-30.

20. Hengge UR, Cusini M. Topical immunomodulators for the treatment of external genital warts, cutaneous warts and molluscum contagiosum. Br J Dermatol. 2003; 149 Suppl 66: 15-9.

21. Liota E, Smith KJ, Buckley R, Menon P, Skelton H. Imiquimod therapy for molluscum contagiosum. J Cutan Med Surg. 2000; 4(2): 76-82.

originally published in Podiatry Now 14(10):14-16.

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ARTICLE

Statin Therapy Judith Barbaro-Brown MSc BSc(hons), PGCE, DPodM, MChS Statins are a group of drugs used to lower cholesterol levels by inhibiting the activity of the enzyme HMG-CoA reductase (3Hydroxy-3-methylglutaryl coenzyme A reductase), which plays a central role in the production of cholesterol in the liver. Raised levels of cholesterol are associated with an increase in cardiovascular disease, and statins are therefore used in the prevention of these diseases. They appear to be most effective in individuals already suffering from cardiovascular disease (CVD), and as such are a form of secondary prevention. However, they are also advocated and used extensively in those without previous CVD but with elevated cholesterol levels and other risk factors, such as diabetes and high blood pressure.

Statins currently available are : • Atorvastatin (Lipitor, Torvast) – the most widely used, and probably the best-selling pharmaceutical agent in history.

• Fluvastatin (Lescol) • Lovastatin (Mevacor, Altocor, Altoprev) • Pitavastatin (Livalo, Pitava) • Pravastatin (Pravachol, Selektine, Lipostat) • Rosuvastatin (Crestor) • Simvastatin (Zocor, Lipex).

Some of these agents occur naturally, such as in some

mushrooms and red yeast rice, others are fermented from bacteria, whilst some are purely synthetic. Some of them are also combined with other agents, such as niacin (Vit B3), amlodipine, or ezetimibe – referred to as Combination Therapy.

The beneficial effects of statins are usually attributed to their capacity to reduce endogenous cholesterol synthesis by competitive inhibition of the principal enzyme involved – HMG CoA reductase. Since mevalonate, the product of HMG CoA reductase reaction, is the precursor not only for cholesterol, but also for many other nonsteroidal isoprenoidic compounds, use of statins to inhibit this key enzyme may result in pleiotropic effects, i.e. actions other than those forwhich the drug/agent was specifically developed. Some of these beneficial effects include improvement of endothelial function by the upregulation of endothelial synthase (eNOS), decrease in vascular smooth muscle cell proliferation and macrophage proliferation, reduction of platelet activity, stabilisation of atherosclerotic plaques, and antioxidant, anti-inflammatory and immunomodulatory effects.

Mechanisms of action of statins Dyslipidaemia and hypercholesterolemia are controlled by the liver cells. Hepatocytes take up around 50% of LDL cholesterol from the circulation. An increase in take-up in hepatocytes would be an efficient method to decrease plasma LDL cholesterol level.

Inhibition of HMG CoA reductase Statins target hepatocytes and inhibit HMG-CoA reductase, the enzyme that converts HMG-CoA into mevalonic acid, a

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ARTICLE cholesterol precursor. The statins alter the conformation of the enzyme by binding to its active site, thereby preventing HMGCoA reductase from attaining a functional structure. This ability to change conformation at the active site makes these drugs very effective and specific. Binding of statins to HMG-CoA reductase is reversible.

The inhibition of HMG-CoA reductase results in the reduction of intracellular cholesterol, which then induces the activation of a protease which separates the sterol regulatory element binding proteins (SREBPs) from the endoplasmic reticulum. The SREBPs are translocated at the level of the nucleus, where they increase the gene expression for LDL receptor. Therefore, the reduction of cholesterol in hepatocytes leads to the increase of hepatic LDL receptors, which then bind to the circulating LDL, reducing its’ levels and that of it’s precursors - intermediate density lipoproteins (IDL) and very low density lipoproteins (VLDL). All statins reduce LDL cholesterol in a dose dependent fashion, and are effective after administration of a single daily dose. Their effect on triglyceride reduction parallels LDL cholesterol reduction.

Direct effects of HMG CoA reductase inhibition Statins inhibit hepatic synthesis of apolipoprotein B-100, causing a reduction of the synthesis and secretion of triglyceriderich lipoproteins and an increase of receptor production for apolipoproteins B & E. This explains why atorvastatin and simvastatin are capable of reducing LDL in patients with homozygous family hypercholesterolemia where LDL receptors are not functional. Statins have a small effect on HDL increase, and no influence on lipoprotein concentration.

Isoprenoids Metabolism of mevalonate ultimately leads to the synthesis of

10 | page

isoprenoid metabolites, which serve as lipid attachments for a number of intracellular signalling molecules. By inhibiting mevalonic acid synthesis, statins also prevent the synthesis of other important isoprenoid intermediates of the cholesterol biosynthetic pathway, such as farnesylpyrophosphate (FPP) and geranylgeranylpyrophosphate (GGPP). These intermediates serve as important lipid attachments for the post-translational modification of a variety of cell-signalling proteins. Protein isoprenylation permits the covalent attachment, sub-cellular localisation, and intracellular trafficking of membrane-associated proteins. Members of the Ras and Rho GTPase family are major substrates for post-translational modification by isoprenylation and may be important targets for inhibition by statins.

Inhibition of RhoA by statins increases endothelial nitric oxide synthase (eNOS) expression and has been shown to decrease severity of cerebral ischemia in ischaemic stroke experimental models. Similarly, statins also increase the expression of tissuetype plasminogen activator and inhibit the expression of plasminogen activator inhibitor-1 and endothelin-1 by mechanisms involving inhibition of geranylgeranylation.

Because Ras and Rho also regulate the cell cycle, they are, in addition, likely targets for the direct anti-proliferative effects of statins. Statins inhibit vascular smooth muscle cell proliferation in transplant-associated arteriosclerosis and may have clinical benefits in inhibiting certain breast cancers.

Inhibition of Rac1 geranylgeranylation and Rac1-mediated NAD(P)H oxidase activity by statins attenuates angiotensin II– induced reactive oxygen species production in vascular smooth muscle cells and cardiac myocytes. These cholesterolindependent antioxidant effects of statins lead to the inhibition of hypertrophic responses in these tissues.

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ARTICLE Reduction of LDL susceptibility oxidation At least 4 mechanisms were proposed to explain statins’ antioxidant properties.

1. The hypocholesterolaemic effect, resulting in reduced lipoprotein cholesterol, and thus, reduced level of oxidation substrate.

2. The decrease of cell oxygen production, by inhibiting the generation of superoxide by macrophages.

3. The binding of statins to phospholipids on the surface of lipoproteins (fluvastatin and lovastatin bind to LDL phospholipids) preventing the diffusion towards the lipoprotein core of free radicals generated during oxidative stress.

4. The potent antioxidative potential of the metabolites (i.e. atorvastatin and fluvastatin metabolites) also results in lipoprotein protection from oxidation.

Beneficial effects of statins Effects on cholesterol esterification and its accumulation in macrophages Experimental studies in mouse macrophages have shown that fluvastatin and simvastatin, but not pravastatin, inhibit cholesterol esterification induced in cells by acetyl LDL. The efficacy of fluvastatin in inhibiting cholesterol esterification is more increased in cholesterol loaded cells than in normal ones, an effect that might be explained by the fact that the HMG CoA reductase is already inhibited in lipid-loaded cells, as compared with unloaded ones.

Effects on endothelial cell function Endothelial dysfunction represents an early event in the initiation of an atherosclerotic lesion induced by hypercholesterolemia.

Nitric oxide (NO) regulates the anti-atherosclerotic function of the endothelium. Hypercholesterolemia reduces the capacity of endothelial cells to produce NO (probably due to the reduced availability of L-arginine, the physiologic substrate of NO synthase) and determines an increased degradation of NO. Cholesterol reduction by statins leads to a significant increase in endothelial function. The effect of statins on the endothelial function can be partially independent of the reduction of the lipid level. Activation of eNOS (endothelial nitric oxide synthase) by statins takes place post-translationally and is prevented by the isoprenoid derivatives mevalonate and geranylgeraniol.

Effects on the inflammatory process Adhesion to the endothelium and transendothelial diapedesis (cells moving out of blood vessels into the surrounding tissue space) of circulating monocytes and of T-lymphocytes, represent key events in formation of an atherosclerotic. Cytokines secreted by macrophages and lymphocytes can modify endothelial function, smooth muscle cells (SMC) proliferation, collagen degradation and thrombosis. Statins can reduce the expression and function of molecules on the leukocyte’s surface. In addition, statins are able to inhibit transendothelial migration and chemotaxisis of neutrophils, which can explain the antiinflammatory effect of these compounds. A further antiinflammatory effect of statins on monocytes and macrophages is decreased expression of intercellular adhesion molecule-1 and the secretion of interleukine-6 (IL-6).

Effects on proliferation, migration and apoptosis of arterial SMC All statins, except for pravastatin, reduce aortic SMC proliferation.

Mevalonate, trans-farnesol and trans-geranylgeraniol prevent the inhibitory effect of statins on SMC proliferation, suggesting that this effect derives from the inhibition of the mevalonate pathway.

Fluvastatin, simvastatin and cerivastatin, but not pravastatin, inhibit arterial SMC migration induced by fibrinogen. Preclinical observations and in vitro studies suggest that apoptosis can modulate the arterial wall in proliferative lesions where SMC are dominant.

Effects on the stability of the atherosclerotic plaque Coronary events are the result of unstable atherosclerotic lesion rupture and thrombus formation. The plaque instability, manifested as ulceration of the fibrous cap, the rupture of the plaque and internal haemorrhage, are characteristics of plaques with numerous lipid deposits and macrophages in the cap.

Recently, it was demonstrated that statins (fluvastatin, simvastatin) can inhibit the gelatinolytic activity of metalloproteases, as well as their secretion by macrophages, reducing the chance of atherosclerotic cap breakdown.

Angiographic studies showed that statins reduce the progression and induce the regression of coronary atherosclerosis, and reduce the formation of new lesions and the incidence of coronary events.

Effects on platelet activation Hypercholesterolemia is associated with hypercoagulability, as well as with increased platelet activation. An increased level of LDL determines an increase in platelet reactivity, associated with an increased thromboxane A2 biosynthesis. In addition, plateletdependent-thrombin generation is increased in hypercholesterolaemic subjects, and pravastatin treatment determines a restoration of thrombin formation. Statin therapy is accompanied by a reduction of platelet aggregation induced by ADP, collagen or fibrinogen, as well as a reduction of thromboxane production, in parallel with LDL cholesterol reduction.

Other beneficial effects of statins The fact that mevalonate plays a key role in cell proliferation and that many malignant cells present an increased HMG-CoA reductase activity, suggests that a selective inhibition of this enzyme could lead to a new chemotherapy for cancer management. Results obtained in vitro have shown that statins can inhibit tumour cell growth, a fact confirmed by some in vivo experiments also. The obtained reduction of sterols synthesis by statins, suggests that inhibition of tumour cell growth can be related to the reduction of isoprenoid compounds. This effect can influence Ras protein farnesylation, thus inhibiting Rasdependent tumour cell growth. Recent experimental evidence supports a role for the mevalonate pathway in murine and rabbit osteoclast formation and bone resorption. In addition, it was demonstrated in vitro and in vivo in rodents that statins enhance new bone formation. Statin administration is associated with a decrease of bone fracture risk in subjects over 50 years, probably because of the increase of the mineral density of the bones.

Therefore, subjects with hyperlipidaemia known to present increased risk for osteoporosis (mostly post-menopausal women) may benefit from statin therapy.

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ARTICLE Adverse effects of statin therapy Statins are generally well tolerated. The most important adverse effects are liver and muscle toxicity. Myopathy can happen if inhibitors of cytochrome P450 (CYP) or other inhibitors of statin metabolism are administered together with statins, causing an increase in their blood concentration. An example of a group of drugs which may do this are the azole antifungals.

Fibrates and niacin (VIT B3) enhance myopathy risk by a mechanism not involving increased statin blood concentration.

Other risk factors are: hepatic dysfunction, renal insufficiency, hypothyroidism, advanced age and serious infections.

Myopathy and Rhabdomyolysis Rhabdomyolysis is the rapid breakdown of skeletal muscle.

Breakdown products of damaged muscle cells are released into the bloodstream and some of these, such as myoglobin, are harmful to the kidneys and may lead to kidney failure. The severity of the symptoms, which may include muscle pains, vomiting and confusion, depends on the extent of muscle damage and whether kidney failure develops. The damage may be caused by physical factors such as a crush injury, extreme strenuous exercise, medication such as statins, drug abuse, and infection.

Statins are associated with muscle complaints ranging from muscle weakness and cramps to myalgia with and without elevated creatine kinase (CK) levels, mild CK elevations, or myositis and rhabdomyolysis. Myalgia is the least severe but most common presentation of muscle toxicity. Rhabdomyolysis and potential renal failure are the most severe but least common presentations. Rhabdomyolysis results from sarcolemmal injury that causes release of skeletal myocyte contents (myoglobin, CK, uric acid, and electrolytes) into the circulation. It can have a number of causes other than statin therapy. Fortunately the development of myopathy and rhabdomyolysis is relatively uncommon for all of the currently available statins Although the precise mechanism for statin-induced myopathy is not fully understood, inhibition of the production of one or more precursors in the cholesterol biosynthetic pathway is likely to be involved, leading to a ubiquinone (co-enzyme Q10) deficiency.Since ubiquinone is an essential intracellular energy component in the mitochondria, cellular respiration may be affected.The isoprenoids farnesol and geranylgeraniol are involved in post-transcriptional modification of proteins (e.g., ras proto-oncogen, Rho-related proteins) that mediate pivotal cellular functions leading to cell signalling, differentiation, proliferation, and, ultimately, apoptosis. Statins can reduce circulating ubiquinone levels. However, their effect on levels in skeletal muscle is unclear, and the role of coenzyme Q10 supplementation in reducing the risk for myopathy remains controversial.

The most common risk factors for statin-associated muscle syndromes are: • • • •

Increased aged (over 80 years) Female Small body frame and frailty Multi-system disease - diabetes, liver disease, chronic renal failure, hypothyroidism,

12 | page

• • • • • • • •

Peri-operative period Major trauma Hypothermia Electrical disturbances Metabolic acidosis Hypoxia Viral and bacterial infection Consumption of large quantities of grapefruit juice (2 pints/1100 mls) which suppresses CYP 450 Enzymes • Alcohol abuse • Concomitant drug abuse involving drugs interacting with CYP enzymes Most myopathic syndromes associated with statins appear to occur in patients who have one or more of these risk factors.

Caution should be used when starting statin therapy in patients with more than one risk factor (e.g., elderly with poor renal function). Patients should be informed about the risk of myopathy and advised to report any unexplained muscle discomfort or weakness that is not associated with physical exercise or other trauma to muscles. If muscle symptoms cannot be explained based on history and physical examination, then creatine kinase(CK) levels should be established. If the patient has symptoms of myopathy and CK is significantly increased, then statin therapy and other lipid-lowering therapy should be discontinued. While the hallmark of myopathy is CK elevation

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ARTICLE with muscle symptoms, patients with biopsyproven myopathy without CK elevation have been reported.

Conclusions Statins are widely used for the treatment of hypercholesterolemia. They inhibit HMG-CoA reductase competitively, reduce LDL levels more than other cholesterol-lowering drugs, and lower triglycerides levels in hypertriglyceridaemic patients.

Statins have anti-atherosclerotic effects which correlate positively with the decrease in LDL cholesterol. In addition, they can exert anti-atherosclerotic effects independently of their hypolipidaemic action. Because mevalonate metabolism generates a series of vital isoprenoids for different cellular

functions, from cholesterol synthesis to the control of cell growth and differentiation, HMG-CoA reductase inhibition has beneficial pleiotropic effects. Consequently, statins significantly reduce the incidence of coronary events, both in primary and secondary prevention, being the most efficient hypolipidaemic compounds that have reduced the rate of mortality in coronary patients.

Statins are well tolerated and have an excellent safety record.

Independent of their hypolipidaemic properties, statins interfere with events involved in bone formation. In addition, it has been demonstrated that HMG-CoA reductase inhibitors impede tumour cell growth.

Important changes for all businesses with employees As members of the Institute of Chiropodists and Podiatrists we know you are dedicated professionals providing high standards of care. We know you care about your patients and for those of you who employ staff, you care about your staff too.

According to the Health & Safety Executive, 1.2 million working people were suffering from a work-related illness in 2010/2011 and an estimated 603,000 workers had an accident at work in 2010/11.

The Employers’ Liability Tracing Office (ELTO) is an independent body that has been created to help those individuals who have suffered injury or disease in the workplace to trace their employer’s insurer quickly and efficiently.

At the core of the initiative is a centralised database that will contain a record of all new and renewed Employers’ Liability (EL) policies as well as old EL policies that have new claims registered against them. The database will be published on a website (www.elto.org.uk) and will allow individuals to search against the name of their current and former employers to identify with whom their EL cover was arranged.

The database will use a unique number to identify each employer. This is known as the Employers Reference Number (ERN) or more commonly referred to as an Employer PAYE Reference. This should be easy for you to locate as all UK businesses employing one or more people are required to have an ERN (the only exemption is where the employer pays all their employees below the PAYE threshold).

The initiative will have a positive benefit on you as an employer. Employers can waste valuable time and manpower tracking down historic insurance records when faced with a potential claim from a current or former employee. Also, where there are long delays, employees can be faced with uncertainty which can often exacerbate the condition they are suffering.

From 1st April 2012 all insurers will begin to capture this information from all policyholders either directly or via an insurance intermediary (depending upon how the EL cover has been arranged). Insurers will also be capturing the name of all subsidiary companies within your company structure which are covered under your EL policy. Please be prepared to provide all the information required when requested to do so.

For further help or guidance on matters relating to ELTO or Employers’ Liability insurance, contact Gallagher Heath Insurance Services on 01384 822201.

1. www.hse.gov.uk/statistics. Health and Safety statistics. Key annual figures 2010/11.

2. www.hse.gov.uk/statistics/causinj/index.htm. Workplace injury

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ARTICLE

Podiatry as a Profession: My path to becoming a Podiatrist and my experience as a newly Qualified Practitioner Part 2 Deirdre O’Flynn BSc, Podiatry Having recently graduated as a Podiatrist from the Queen Margaret University I have learnt so much in the few months since working at Midleton Foot Clinic which is based in Cork but also services Clinics, Nursing homes, Hospitals and Convents in other areas. I visit these on a regular basis also.

Every Wednesday I attend St Patrick’s Hospital in Cork City. This hospital provides respite and continuing care for the elderly.

Marymount is one of the wards in the hospital which provides Specialist Palliative care for people diagnosed with cancer. On my first week at the hospital I treated an elderly lady for routine podiatry. This lady had poor circulation with varicose eczema present, cold feet and capillary refills of more than five seconds. It was also difficult to palpate pulses. I trimmed this ladies nails and assessed both feet for any cuts or abrasions. I completed her record card and continued treating the rest of the patients. The following week I was surprised to see this lady was put back on my list of patients to be seen again. One of the staff nurses advised me she had an infected right toe and she wanted me to have a look at this.

My first reaction was I had done something wrong the previous week because I was so new at the job I felt slightly unsure. On examination and through discussion with the patient I learnt she had banged her toe off a bed a few days previous. The patient appeared to have Paronychia. The area near the cuticle was red, swollen and causing the patient pain. I dressed the toe with iodine and a dry dressing. I advised the staff nurse and she was also put on a course of antibiotics. Over the following few weeks the infection did not clear. It concerned me because she now had two different antibiotics and the toe was being dressed every three days.

I spoke with the staff nurse and I advised a bacterial swab should be taken. When the results of the bacterial swab came back from the laboratory, it showed that she had the contracted the Superbug MRSA which is resistant to the penicillin group of antibiotics used to treat Staphylococcal infections. This explained why the bacterial infection in my patient’s toe refused to heal. This enabled the doctor to prescribe a different type of antibiotic which would respond better to the MRSA. Within a week of taking this antibiotic the bacterial infection in my patient’s toe was completely healed. It was a great learning experience for me it enabled me to think outside of the box when treating a patient.

My working week is varied, every second Thursday I visit a Clinic in a small country town called Lismore in Co. Waterford. I drive about 45 minutes in my car through windy, bumpy roads to get there. I bring along with me a domiciliary bag and my nail drill. I practice from a room in the clinic along with other Health Professionals. At first when I started in Lismore I was apprehensive and felt somewhat out of my comfort zone. I was to run this clinic on my own for my employer. I didn’t have the cushion of the lecturers to guide me through my day. This was scary but presented a fantastic opportunity for me. It enabled me to build up my

confidence working alone as a Podiatrist.

A patient came into the clinic one day with two social workers.

Initially I felt uneasy because they looked quite stern. Although I felt nervous on the inside, on the outside I maintained Confidence and Professionalism. The patient was a 16-year old boy who had been in trouble with the police and was being cared for by the Social Services. The boy was wearing tattered and worn runners and was of a heavy build. When the teenager timidly removed his shoes and socks, it became apparent why the social workers were stern. His socks were wet and dirty. The teenager was ashamed at the condition of his socks and feet. The teenager had not been taking care of his personal hygiene. Upon examination of his feet, I observed white, soggy, pitted and wrinkled skin around both heels.

He had explained that it was causing some discomfort for him. I asked him a series of questions about his medical history and his general care of his feet. After a thorough examination I diagnosed the teenager with Planter Hyperhidrosis. I explained to him and to his carers that to eliminate this problem he would have to wash his feet on a regular basis; change socks frequently and wear sandals or leather breathable shoes. I also gave him a foot powder called Anhydrol Forte which contains aluminium chloride hexahydrate.

This product is an antiperspirant which would stop the excessive sweating. I advised him to apply the powder before going to bed and wash off in the morning.

When the teenager left the room one of the social workers had a brief discussion with me. She explained that he was not taking care of himself and that, hopefully, he would take advice from someone who was a Health Care Professional. She had asked him on several occasions to take more care of his personal hygiene but felt she was not getting through to him. The teenager was advised to return in two weeks so I could review his progress. The social worker said he may not turn up.

Two weeks later I was back treating patients in Lismore. The teenager arrived on time for his appointment. He took off his shoes with a smile on his face. I was delighted to see the Planter Hyperhidrosis had completely cleared up. I congratulated him on the good work he had achieved over the previous two weeks. I advised him to keep up his routine and to not fall back to his old ways. I felt satisfied that I was able to help the teenage boy who needed some guidance and advice on the appropriate care of his feet. If this had been left untreated, he could develop a fungal infection or much worse.

Every single patient is individual and every foot that is presented in front of me is a new learning experience. I have learnt you always have to be mindful of the patient and the situation they are in. Some patients are so nervous coming in to see me that they are physically trembling. When I sit in my room in the clinic waiting for the next patient to arrive, my mind is always thinking ‘what the next foot challenge will be for me’.

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INFORMATION

2012 Waste Pre-Acceptance Audits – what you need to know Damian Murray Podiatry Waste Specialist - PODWASTE ABSTRACT From July 2012 the Environment Agency has imposed a new legal requirement to ensure that podiatrists (chiropodists) carry out audits of their clinical waste before it can be accepted at disposal sites.1 In response to this new requirement the aim of this article is to revise current clinical waste classifications, update practitioners clinical waste procedures and prepare them for the forthcoming pre acceptance audits.

PODIATRY WASTE CLASSIFICATIONS Clinical Waste Clinical waste is fully defined in the Controlled Waste Regulations 1992.2 With direct reference to podiatry practice, clinical waste is any waste that consists of: • • • • • •

human tissue; blood or other bodily fluids; swabs or dressings; syringes, needles or other sharp instruments; pharmaceutical products; or any other waste arising from medical, investigation, treatment or care which may prove hazardous and /or may cause infection to anyone coming in contact with it.

Hazardous and Non-hazardous Clinical Waste The relationship between hazardous and non-hazardous waste within podiatry practice can be differentiated by whether the waste is deemed as infectious (hazardous) or non-infectious (nonhazardous).3 Only the producer (podiatrist) can classify their waste as hazardous or non-hazardous as they are the only person with knowledge of the health status of the patient, the medicaments and materials used in their treatment and the waste generated from their care. It is presumed, however, that podiatry as a healthcare activity will generate some hazardous / infectious waste. Waste can only be classified as non-hazardous / non infectious following a professional assessment of the patient(s) being treated.

Further classification guidance can be obtained from the Department of Health – Safe Management of Healthcare Waste – March 20113 and WM2 on the interpretation of infectious waste.4 A free waste assessment tool is available from www.podwaste.com.

Waste Segregation Podiatrists that produce both hazardous and non-hazardous clinical waste should adopt the practice of segregating their wastes. Failure to segregate infectious from non-infectious waste will mean that the entire waste stream will need to classified as 16 | page

Fig 1.1 charts the colour coding of podiatry waste streams, their contents, EWC codes and frequency of collection. infectious (hazardous) and consigned for appropriate treatment recovery and disposal.4 This will lead to an increase in cost to the producer and an inappropriate method of disposal.

WASTE DISPOSAL PROCEDuRES As waste producers, podiatrists have a legal Duty of Care to take all reasonable steps to keep waste safe. Under the Duty of Care the producer must provide the person who takes your waste with information that includes, the type and quantity of waste, the European Waste Catalogue Numbers (EWC), how it is packed and the substances in the waste.5 The Duty of Care applies to everyone involved the in the handling of waste.

Fixed Location Procedures Podiatrists working from a clinic / practice or other fixed location should: • have a contract or agreement with a ‘suitably registered’ waste disposal contractor; • regularly record and update clinical notes of the patients they treat to monitor the likelihood of introducing infectious waste into their waste streams; • segregate, record and transfer of their waste as outlined in fig 1.1 • store their waste in a lockable cupboard or external lockable yellow bin that cannot be removed or tampered with by a person or animal.

• not transport their waste from one fixed location to another; • keep copies of the Waste Transfer Notes and / or Consignment Notes for at least 3 years.

Waste Transfer Note (WTN) A waste transfer note is a document that details the type and volume of waste transferred from the transferor (podiatrist) to the transferee (waste disposal company) and must be kept for a

35439 Chirpody 40pp 19/12/2011 17:19 Page 19

INFORMATION minimum of 3 years to prove that the waste has been managed safely, kept secure and disposed of by a authorised company.

WTN can be issued at every transfer or an annual transfer note may be used to cover all the movements of regular transfer of the same non-hazardous waste between the same parties.3 Consignment Note (CN) Consignment notes are issued at every transfer of hazardous waste and contain the same details as a waste transfer note albeit for hazardous and / or infectious waste. As with WTN these notes must be kept for a minimum of 3 years. It is common practice for waste disposal companies to charge for WTN and CN (see fig 1.2).

Domiciliary Procedures No specific guidance exists with direct reference to the waste procedures of community based podiatrists. The closest guidance is contained in the Safe management of healthcare waste- March 20113 within the section guiding community nursing.

With reference to hazardous / infectious waste, the practitioner must: • regularly record and update clinical notes of the patients they treat to monitor the likelihood of introducing infectious waste into their waste streams; • segregate, record, store and transfer of their waste as outlined in fig 1.1 • remove infectious waste, sharps and disposable instruments; • transport waste in a yellow, clearly marked lockable receptacle;6 • store at a site for collection by a registered waste disposal company and retain copies of the WTN and CN’s.

Where the practitioner is working in a medical, healthcare or nursing premises then the infectious waste can be disposed of through their clinical waste streams with prior written consent of the appropriate management.

With reference to non- hazardous / non- infectious waste, the practitioner can dispose of the waste in the domestic refuse (with the householder’s permission) where it should be wrapped in an opaque sac. The wrapping should not be yellow or orange.3 PRE-ACCEPTANCE AuDITS Background Since April 2010 the Environment Agency has imposed a restriction on companies authorised to incinerate, treat, dispose or facilitate the disposal of hazardous clinical waste without obtaining a pre-acceptance audit from healthcare waste producers.

copy is held by the producer and a copy or copies are distributed to the company or companies who transfer and dispose of your waste.

How and When to Audit Firstly, you should ascertain whether you are exempt from the pre-acceptance audit by assessing whether you produce hazardous / infectious waste. As members of the Institute of Chiropodists and Podiatrists you can benefit from a free online tool that will classify your waste ahead of the pre-acceptance audit. The weblink can be accessed by emailing: exempt@podwaste.com . Paper copies can also be requested by calling 0800 988 7897.

If you are known to produce hazardous / infectious waste then you have two options: 1. You may undertake the audit and collect the data yourself.

However, the procedure is complex and the Environment Agency recommends that you understand what is required before doing so as it may not be sufficient and not accepted at a site in accordance with its environmental permit.3 2. Or, you can use a clinical waste company to provide you with an online or paper audit tool that will simplify and guide you through the process. Pre-acceptance audit tools are available from most clinical waste companies and charge is made for this service (see fig 1.2). The audit is valid for 5 years.

It is important to note that, you do not have to use your current waste disposal company to provide this audit. Members of the Institute of Chiropodists and Podiatrists can benefit from using the podiatry pre-acceptance audit provided by PodWaste.

For members, the audit has been discounted from £50 to £15 and can be accessed at www.podwaste.com/audit or by calling 0800 988 7897.

Any further information regarding podiatry waste procedures and/or the forthcoming pre-acceptance audits can be obtained by emailing your question(s) to info@podwaste.com REFERENCES 1. Environment Agency – Clinical Waste Pre-Acceptance Producer Update – October 2010.

2. Controlled Waste Regulations 1992 3. Department of Health – safe Management of Healthcare Waste – March 2011 4. WM2 5. Clinical Waste Pre-Acceptance – Producer Update October 2010 6. www.PODWASTE.com/DomBox

To date: hospitals, medical practices, research laboratories, veterinary and dental practices have all undertaken preacceptance audits. From July 2012 all podiatrists that produce hazardous / infectious clinical waste will have to produce a preacceptance audit prior to the removal of their waste.

The Audit The audit must be carried out by the producer of the waste. It is commonly an online audit in the form of a detailed questioner (paper copies are also available). On completion of the audit, a

Fig 1.2 Correct at time of print. Price exc. VAT

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35439 Chirpody 40pp 19/12/2011 17:19 Page 20

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35439 Chirpody 40pp 19/12/2011 17:19 Page 21

NEWS

An Evening with Kylie Beverley Wright MInstChP, BSc (Hons) PGCE, PGDip The first week of October, 2011 was graduation week at Anglia Ruskin University’s Chelmsford campus. There were hundreds of graduating students from the Faculty’s within the University being awarded their Certificates, Diplomas and Degrees. There was also in total, 11 honorary awards presented to various individuals in recognition of their outstanding achievements. Amongst some of the distinguished names receiving honorary degrees were novelist Jilly Cooper, fashion designer Anya Hindmarch and swimmer Mark Foster.

Lord Ashcroft KCMG, Chancellor of Anglia Ruskin University, who presided over the graduation ceremonies said: "We make honorary awards to individuals of extraordinary talent who have made an outstanding contribution to their chosen field of endeavour. We hope that the recipients of these honorary awards will serve as examples to our graduates."

On the evening of October 5th, I had the good fortune to attend singer and actress Kylie Minogue OBE’s graduation ceremony where she was awarded an honorary degree alongside 224 students, and two other honorary award recipients; education author Mary Jane Drummond and economist Kate Barker, who was formerly the Chair of Governors at Anglia Ruskin.

I was really delighted to attend Kylie’s (and earlier Mark Foster’s graduation) ceremony, being part of the Chancellors and Vice Chancellor’s academic procession. It is always exciting to be involved in a graduation ceremony, either as a graduant or academic; especially when you get a chance to honour the student’s achievement and meet some very interesting and inspirational people.

More importantly, I am always impressed and inspired, by the graduating student’s sheer determination and years of dedicated hard work to succeed. The student’s efforts culminate towards one ceremonious moment in front of their peers, families and friends, when they finally receive their awards, which will certainly justify their position in future life. There are always many happy and nervous faces waiting to come across the stage to be greeted by the Chancellor and/or Vice Chancellor, to be acknowledged and confirmed with their individual awards. As was the case for Kylie too, who told us before the proceedings how nervous she was. There were no dress rehearsals on this occasion for her stage appearance, no prepared singing or dancing routine, just an impromptu speech to fellow graduates, their family and friends:

Ruskin University, who are currently researching blood markers that could eventually help with the early diagnosis of breast cancer.

Kylie impressed upon me (despite her nerves), what a brave and astonishingly talented (petite) woman she is. Particularly, when I think of the many remarkable and equally brave men and women I have treated, living with and surviving cancer at the Helen Rollason Cancer Centre. It is certainly an inspiration to me to see anyone with cancer rise above and beat the disease. Cancer survivors find their experience challenging, as well as changing their lives forever, where they continue to find ways to make a difference in their own and other people’s lives.

So, when you consider what can be accomplished by these exceptional individuals, it makes you realise anything is possible.

Much could be said the same of students, Chiropodists, Podiatrists, Health Professionals, or anyone in fact, who by undertaking new learning can achieve something positive in their lives; in addition to gaining a Certificate, Diploma or Degree for their efforts. These days it is as equally important to get an attendance certificate in any Branch meeting, Continuing Professional Development (CPD) course or seminar, which should not to be sniffed at, because it is still a badge of honour; to show you have achieved another step along the road of life long learning.

Particularly, in view of the Health Professions Council (HPC) registration process that takes place every other year and will once again be upon us in July, 2012.

Kylie was conferred with an honorary award, not by passing a multitude of academic assignments, exams or tests, but by making people aware of living and achieving the best out of life, as in her case being a ‘Pop Princess’, an actress and overcoming cancer. So whether or not you are fighting a life threatening disease, or studying; these are not lessons in futility, but continual milestones in your life.

Please, never look a gift horse in the mouth! When opportunities arise - grab them! Do not miss a moment of life - enjoy each and every moment to the fullest, good or bad; make every one of them count! This makes us who we are and we are rewarded with the best achievement award of all - life experience, which you cannot get without living life itself. I know I try to grab opportunities when I can, and on this special occasion I got to spend an evening with Kylie!

"I never went to university so my dad will be very proud when he sees the pictures. I am here partly for the work I do promoting breast cancer awareness. When you are diagnosed yourself it becomes a lot more real and you appreciate at first hand the hard work that goes on to support patients through it."

Kylie received the honorary Doctor of Health Sciences award, for her work promoting breast cancer awareness. Kylie was of course diagnosed with the disease herself in 2005 and underwent surgery and chemotherapy in order to overcome it.

After the ceremony Kylie remarked: "I was incredibly honoured by today's ceremony and it was an inspiration to be amongst the graduates at Anglia Ruskin University."

"Hopefully my award will help to inspire both the researchers into breast cancer and those affected by it."

Photograph courtesy of Anglia Ruskin University - Press Office (2011)

Kylie refers to the many Scientists around the world. This includes the Scientists at the Helen Rollason Research Laboratory, based at Anglia

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35439 Chirpody 40pp 19/12/2011 17:19 Page 22

HEALTH

Homeopathy and the treatment of arthritis and rheumatism - A personal journey with RA Lauren Vaknine Biog: Lauren Vaknine, now 27 years old, from Edgware, North West London, was diagnosed with Juvenile Rheumatoid Arthritis aged 2. After having been severely disabled and wheelchair bound for many years, Lauren turned it all around with the help of Holistic therapies, especially homeopathy. In 2010, she published a book about her experiences with the disease and how she used homeopathy and power of the mind to turn her negative experiences into a positive outcome. She now acts as patient spokesperson for the Royal London Hospital for Integrated Medicine and is the youngest ever trustee of the British Homeopathic Association. Her book, ‘My Enemy, My Friend’ is now available to buy on Amazon.

Modern medicine is ground breaking, innovative and sometimes completely necessary. But what if the other options caused less long term side effects? If you have a chronic, long term illness, your immune system is shockingly low anyway, so if you are taking medications that make your body even weaker, how can it possibly fight a chronic illness? Maybe, as is becoming more and more evident, it can’t. What if these medications are actually causing more harm than good, but doctors are not giving patients any other options, and those who are so sick and looking for a quick fix to get better, give in. Here, I will be taking a look at two case studies; two people diagnosed with the same illness at the same age. One went the conventional route, the other went the holistic route. Who do you think, twenty years later, turned out to be the healthier of the two?

Homeopathy in arthritis. A true story of why homeopathy should no longer be considered ‘the alternative option’: “My name is Lauren Vaknine, and before I talk to you about why I’m here today, I’d just like to tell you a quick story about a friend of mine, Hannah. Hannah was diagnosed with Juvenile Rheumatoid Arthritis a few months before her 2nd birthday. The doctors advised her parents that she should be put on large doses of steroids, and her parents, who were so scared that the illness would get worse than it already was, agreed as there were no other choices. So how does the mind of a parent of a sick child 20 | page

work? Let me explain; there are three main emotions within the first year. Firstly, guilt. Is it my fault? What did I do wrong as a parent? What could I have done to stop it?

Second, denial. There is no way she’s going to have this for the rest of her life, it’s just a blip and we need to do all we can to stop it straight away. The third is fear. The fear that actually it might be here for the rest of her life and there is absolutely nothing you can do to stop it except listen to what the doctors are telling you. That said, these parents are going to listen to you, the healthcare professionals, and take on board nearly everything you say as if it were set in stone. For this reason, there needs to be more than one option for how to treat a child with a chronic illness.

At the time Hannah was diagnosed, there was only one option. Top paediatric rheumatologists were suggesting that the best way to treat JRA was with very large doses of steroids, this should, in effect, knock it on the head. Or so they thought at the time. The only problem was, time was passing and these children were not getting any better, in fact, they were now becoming so dependent on these drugs that coming off them could make them even sicker than they already were.

Then new drugs came out such as Methotrexate, Infliximab, Humira, Enbrel, Sulphasalazine. There were literally no other options. It was a case of ‘give your child these drugs or she will get sicker and sicker.’ So the parents had no choice but to put their child on even more drugs to control a seemingly uncontrollable disease. Of course each drug had its own side effects so the child who was diagnosed with arthritis now had bone problems, numerous deficiencies, growth and hormone problems, liver and kidney complications, low immune system, rash’s, ulcers, sickness… the list is endless.

Hannah’s parents were no different. Hannah’s RA was deteriorating rapidly and so they took the advice of their doctors and put Hannah on any medication that was available.

At 18, Hannah is shorter than her 14 year old sister. She needs hormone injections to help move along the process that the steroids damaged. She has quit college and the dream of becoming a journalist. Most girls in Hannah’s situation have never kissed a boy, been on a date, or simply gone shopping on their own. It is not just the arthritis that has ruined her life, it is the side effects of the medications too.

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HEALTH You’re probably wondering why I’m talking to you about someone else’s life with JRA. Well, let me introduce myself properly. My name is Lauren, I am 27 and believe it or not, I was diagnosed with Juvenile Rheumatoid Arthritis a month before my second birthday.

in 5 joints – my knees, ankles and one finger in my left hand. Fast forward to 10 months after starting Methotrexate: the arthritis had spread to every joint in my body, literally from my jaw right down to my toes, I lost half of my hair, my liver was damaged and I was now in a wheelchair.

I could give you a whole picture show of my life, but I’m sure you’re smart enough to see how different my story is to Hannah’s.

I know there will be sceptics among you but how many of you think this is a coincidence? Unfortunately it was no coincidence.

When I was diagnosed, we were offered the same options as Hannah’s parents, but my parents felt that steroids were too strong to put into a 2 year olds body so they looked around for other options and came across homeopathy after extensive research. I started seeing a dietician and a homeopath straight away and it quickly became apparent that the most important thing was to keep my weak and vulnerable body as healthy as possible.

As the years went on I wasn’t arthritis free at all, but we started noticing a visible difference between me and the other children in my weekly hydrotherapy group. They were all slowed down by the steroids, their faces were puffy, and, their symptoms were no better than mine, in fact, most of them were worse than me, which makes you wonder; what was the point of the medications? Who was benefitting from them? If they had have been so much better off than me in terms of joint mobility and swelling, I may have understood but they weren’t, so for the remainder of my childhood, my parents knew they were doing the right thing and never once thought about changing our course of action.

As with most children with JRA I had uveitis in my right eye and this was controlled by steroid eye drops. Of course it would have been too dangerous to not have used these at all, and seeing as it was localised to the eye, it wasn’t too much of a problem. It did cause nose and ear problems later in life but I won’t go into that now. But there is a reason as to why this is a very significant part of my story. When I was 17 my ophthalmologist noticed that there was a cataract growing in my eye, caused by years of inflammation and steroid eye drops. They could not remove it because there was too much activity in the eye and it would be dangerous. It was kind of a catch 22; the cataract was keeping the flare high and the flare meant it was impossible to operate. Well of course, the doctors had a solution – 3 guesses what it might be? They suggested I take Methotrexate – a drug I was actually asked to be a guinea pig for when I was 9 but my parents said no. I was 17 by this time and took for granted all that the homeopathy had done for me over 15 years. It was just the norm for me and I never asked any questions about it. I didn’t realise how lucky I was to be so much healthier than all the other kids we’d met with arthritis. Being an ‘adult’ I wanted to make my own decisions and against my mothers’ advice, I decided to try the methotrexate.

Now let me paint a little picture, as far as you can see right now, there appears to be nothing wrong with me, but before the age of 17, it was even better. For 15 years I’d only had arthritis

The drug had had a bad effect on my body and caused every side effect imaginable, and ones that weren’t anticipated, like the arthritis suddenly spreading. Even through this very visible change in my health, the rheumatologist still suggested I stay on it for the full year, but I couldn’t bear it anymore and I came off it after 10 months.

Tired, in pain, wheelchair bound and with my eye no better than it was before, I expected my rheumatologist to understand and try to do all she could to help, but all I got from her was ‘It works for 70% of people and for 30% it doesn’t. You fall within the 30%.’ I decided right there that I was not a statistic, I was a human being and deserved better treatment than to be ignored by a doctor who was supposed to be looking out for my best interests. So to my mothers’ delight, I went back on homeopathy and had to find ways to get myself healthy again.

It took a long time but I got there in the end. Homeopathy isn’t a quick fix, it’s not going to work over night and those who want to give up on it because it doesn’t work straight away are going to be disappointed. I have to work hard to keep myself healthy every single day. I have to do exercises, take remedies, oils, tinctures, special baths, physio, hydro, special diets and every few weeks I have to go back to my homeopathic rheumatologist and change my remedy if it needs adjusting. I have to see a dietician, a physio, a hypnotist, a womens health specialist and ophthalmologist. I see a homeopathic rheumatologist – Dr Fisher who spoke here last year, and a homeopathic podiatrist – Dr Khan who is here today, as well as a rheumatologist and podiatrist in my ‘conventional’ hospital.

But isn’t all this worth it for me to be able to stand up today and tell how well I’m now doing? Isn’t it worth it for me to be in the position I am in and not the position Hannah is in?

What I realised, is that if you have a chronic illness, especially an autoimmune disease like arthritis, your body is weak and your immune system is low as it is, so anything that brings that down even more can’t be good. What if instead of using the medications that attack the immune system to ‘fight’ the disease, we work on improving our immune systems through natural sources instead of chemicals. Sounds simple enough right? Well it is, and this is where homeopathy comes in.

I can imagine the word ‘placebo’ running around some of your technically minded heads right about now and my answer for that is always the same – I was 2 when I started homeopathy, how can you explain placebo to a 2 year old?

I am no doctor, I cannot tell you how or why homeopathy works better for me than conventional medicine, and I’m in no page | 21

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HEALTH way saying that this is the case for everyone, each individual has to do what is right for him, but what I am saying is, it is an option.

An option as viable as all the other options, as opposed to a last resort. In some cases, joint damage and other forms of damage caused by long term medications are irreversible, like in Hannah’s case. She will never grow taller than she is now and her deformities are severe but who is to say it is ever too late for anyone?

I met a lady at the Royal London Hospital for Integrated Medicine a few months ago who, after having RA for ten years and treating it with conventional medicine, became severely disabled and had many deformities. She persevered for a long time but eventually decided to try the RLHIM and within two years she is out of the wheelchair and her quality of life has improved vastly. She comes all the way from Scotland once a month to get treated, but like I said earlier, and just like anything in life, it’s worth the hard work if you’re going to see the results.

I met another lady at the hospital who has Brittle Bone Disease with the same story and a lady who had cancer did a talk at the hospital a few months ago on how homeopathy helped her get through cancer and most importantly, she explained how although she quite clearly needed chemotherapy, it was the homeopathy that got her through the side effects of the conventional medicine that was crucial. That is why it is called ‘complementary’. It proves that it is not just for cuts and bruises but for chronic, long term or even life threatening illnesses too.

As with every case study I have given you, I have my own story to back it up. When I first started seeing Tariq Khan 3 years ago, I was for the first time ever displaying slight deformities. My toes had started to curl and I was very worried. After all, no matter what I’d been through, I always looked normal and this was important to me. I am sure that most of you have heard about Dr Khan’s Marigold treatment. For those who haven’t, I urge you to look into it. A year after starting the Marigold treatment, my toes are now straight – so what is to say that it is ever too late to help people who are many years into a chronic illness?

Last year I wrote and published a book documenting my life with arthritis, how it had affected me and how homeopathy helped along the way. It has been a great way of sharing my story and telling other people that there are other options and how to go about them. Although it is a story, not a book of facts, it has helped patients and parents of children with illnesses to see the long term benefits of complementary medicine, and indeed, to see how an illness like RA affects you throughout your life, emotionally as well as physically. The book is called ‘My Enemy, My Friend’ and is available on Amazon.

I know modern medicine is all about science and facts and proof. But some things work whether we believe in them or not.

I’m not someone that looks up every symptom or remedy on the internet. Most of the time, I don’t even ask what is in the remedies I’m being given or how it works, I just go with it. Why do we need solid scientific proof for everything we do? As far as I’m aware, it hasn’t worked out so well for us in the past when 22 | page

the top rheumatologists thought high doses of steroids in young children was the way forward, then 15 years later saw what a mistake they’d made. They weren’t the ones living with the side effects. Or when the brightest minds in the world thought the atom was the smallest thing. And how about Thalidomide?

Thalidomide was sold in a number of countries across the world from 1957 until 1961 when it was withdrawn from the market after being found to be a cause of birth defects in what has been called "one of the biggest medical tragedies of modern times".

It is not known exactly how many worldwide victims of the drug there have been, although estimates range from 10,000 to 20,000.

I’d also like to remind you all that the scientists complaining that homeopathy is not proven, have still not found a cure for cancer, diabetes, AIDS or arthritis. But I stand before you today, 26 years into a disease, trying to get you to see just how much homeopathy has helped me.

In 1906, William Osler delivered an oration on “The growth of truth” and stated: “Truth may suffer all the hazards incident to generation and gestation and all scientific truth is conditioned by the state of knowledge at the time of its announcement.” This certainly rings true with what I have just spoken about.

Scientific theories are always considered to be “works in progress.” No scientist worth his or her salt is ever going to say, “This is a FACT” to be carved in stone forever. So how is homeopathy any different?? And despite all of this, please don’t forget that randomised controlled trials HAVE been taken out using homeopathy AND placebo, and the patients who were put on homeopathy showed more improvement than the patients receiving placebo.

Please don’t get me wrong, science is an amazing thing and thanks to modern medicine, my friends twins who were born 3 months premature are fighting fit today, and a friend of mine who had cancer aged 19 is now 24 and in remission. I believe in it and respect it, I’d just like homeopathy to be respected in the same way.

So, what should you take away from what I’ve spoken about today? When you walk into your practices on Monday morning what do I hope stays with you? What I ask from you, the healthcare professionals, is to understand that people with chronic illnesses, and parents of children with these illnesses, are vulnerable and believe every single thing you say. For them it is as truthful as the bible and they will not question it, so please, give them other options. Let them know there are other options out there and that if they choose to go down this route you will still support them regardless because the patient is the priority. She is not a statistic or a number. She is a person with feelings and hope for a future better than the one that has been drawn out for her. And with the help of people like yourselves, there is a chance that in 20 years from now, the majority of arthritis sufferers will have a story like mine instead of a future like Hannah’s.

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FEATuRE

Rambling Roads Achilles Hele A great deal of information from ‘New Scientist’ this month Unhappy with the NHS? After reports of failings in Stafford and elsewhere the situation must be improved. However, spare a thought for those patients in the USA. In the 12th November issue it is reported that a survey of 11 industrialised nations by the New York based Commonwealth Fund, found that chronically and seriously ill patients fare worse in the United States than in any other ‘rich’ nations. 42% of Americans polled couldn’t afford the treatment they needed, at least twice the comparable rates elsewhere.

Another article by Linda Geddes details a scientific breakthrough which could have a profound effect on the treatment of trauma and various conditions. For the first time, ‘artificial’ red blood cells have been successfully injected into a human volunteer. Luc Douay and his team at Pierre and Marie Curie University extracted haematopoetic stem cells from bone marrow. These were then cultured using growth factors to form red blood cells which were injected back into the same volunteer.

After five days 94 to 100% of the cells remained in the circulation and after 26 days 41 to 63% remained – a figure comparable to that of normal red blood cells; in addition, they behaved like normal red blood cells having an oxygen carrying capacity. In most parts of the world blood banks struggle to keep up with demand and in countries affected by HIV, a ready source of HIV free blood is essential.

More on Stem cell experiment, this time from journalist Chelsea Whyte. Embryonic stem cells have been used to generate the first fullyfunctioning pituitary gland which has been implanted into mice.

Chemicals necessary for growth were first bathed around the stem cells which resulted in the growth of ectoderm. Tissue which mimicked the form of the hypothalamus also grew. These two tissue types spontaneously formed themselves into layers, the ectoderm outer. The ectoderm formed a pouch which pinched off with the hypothalamus cells within. Finally, hormone producing cells formed and spilled out to form the pituitary gland. Yoshiki Sasai of the RIKEN centre in Kobe who developed the technique, freely admits that the mechanics of how the gland is formed is not understood. Research will continue.

The 19th November issue of New Scientist has an article by Linda Geddes which investigates ‘partial wave spectroscopic Microscopy’ (PWS). This technique allows visualisation of structures less than 400 nanometres across which is smaller than the wavelength of light used in normal optical microscopy. PWS examines how a light beam interacts with the structures within a cell be reflection according to density; the resulting pattern is used to view the nanoscale detail within. Chromatin is the package of DNA and proteins within the cell nucleus and a change in the material is one of the first events to occur after exposure to carcinogens. Vadim Backman of the Northwestern University in Illinois has used the method to demonstrate changes in tissue taken from individuals who are apparently healthy but suffer from colon, pancreatic, ovarian and oesophageal cancer. In addition, it has been demonstrated that the changes occur in normal cells as well as those that are, or will suffer carcinogenic changes. Backman used PWS to identify which of 135 tobacco smokers had lung cancer and which were cancer free by analysing cells from the inside of the cheek. Using a similar technique he has preliminary evidence that autoimmune diseases such as IBS and the changes at a cellular level associated with Alzheimer’s disease may be identified.

Johann Auwerx and his colleagues of the Federal Polytechnic School of Lausanne have discovered that eliminating a gene for a protein (Nuclear Receptor Copressor 1) in the muscles of mice Causes the mitochondria to continue working at full rate, resulting in the treated mice running 1,6oo metres in 2 hours, compared to untreated mice which only managed 800 metres in the same time. Eliminating the same gene in fat cells resulted in the mice increasing weight but without developing type 2 diabetes. It is hoped that this latter fact might lead to new treatments for those patients suffering from diabetes or wasting diseases.

The 26th November edition of the journal has a number of items of interest. The first is the excellent news that HIV infections have fallen markedly. UNAIDS, which is the body which coordinates the action against the disease notes that new HIV infections and the incidence of AIDS related deaths have fallen by a fifth since 1997 and 2005 respectively (the peak incidences). The drop in real terms is seen as the effect of antiretroviral drugs (ARTS) which reduce the transmission of the virus. ARTS now reach almost half of the 14.2 million people eligible for treatment in poor countries, and the aim is to reach them all by 2015.

In sub-Saharan Africa new infections have fallen by 26% since 1997 and in South Africa and the Caribbean they have fallen by 33%.

Jessica Hamzelou writes that Alzheimer’s disease can be reversed in some cases by using electrical impulses to stimulate the formix (which carries signals to the hippocampus). It was seen that glucose uptake by the temporal lobe, which had previously reduced, had now increased.

Andre Lozano at the Toronto Western Hospital and his fellow researchers stated that ‘not only did the hippocampus not shrink (in the tested individuals) but got bigger by 5 % in one person and 8% in another. These two volunteers exhibited better than expected cognitive function, although another 4 volunteers did not. It is not fully understood how the treatment works but it is thought that the stimulation may result in the growth of new neurones. A trial of 50 people is now to take place.

Plessey Semiconductors based in Plymouth have announced the development of a new sensor which can continuously monitor heart rate without touching the patient. The Electric Potential Integrated Circuit (EPIC) is an extremely sensitive digital voltmeter which can measure changes in the electrical fields around muscles and nerves. The company says that the product will be integrated into hospital beds where it will provide monitoring of the patients vital signs without the need for electrical wiring or attachments.

Paul Marks writes that one day infections could be diagnosed at the press of a button. The USB sized device would be a disposable ‘lab on a stick’ capable of analysing blood, urine or saliva samples by means of micropumps sending the fluid to reagents capable of analysing disease marker molecules in the fluid. The whole device could be sent for further examination. Even this might not be the limit of possibilities.

Hyun Gyu Park and Byoung Yeon Won at the Korea Advanced Institute for Science and Technology in Daejeon believe that it might be possible for future touch screen telephones to allow a sample of fluid to be placed on a screen where an ‘application’ could carry out the analysis. They took three solutions containing different concentrations of DNA from the bacteria causing chlamydia and applied them to an iphone multitouch screen display. They discovered that the touch sensing electrodes could distinguish between the capacitances caused by each concentration using on 10 microlitres. Harpai Minhas, editor of the journal ‘Lab On A Chip’ says that it is potentially possible; however, NA sequencing is more likely to be necessary for diagnosis than concentration measurement.

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BRANCH NEWS

ACuPuNCTuRE COuRSE ESPECIALLY FOR PODIATRISTS AND CHIROPODISTS tutor is Jennie Longbottom, MSc MMEd BSc FCSP MBAcC. Early booking is recommended as there are a limited number of places for the first course which should be booked direct with: http://www.alied.co.uk/ALIEDPro.html where you will also find more information about the tutor, dates and venue.

This course is open to all HPC registered Podiatrists/Chiropodists.

The IoCP Faculty of Education (FofEd) is working to produce new courses aimed at developing further your clinical skills whilst increasing your earning potential.

Following the request from a member for a course on acupuncture the FofEd has produced a training course designed especially for Podiatrists/Chiropodists.

Working with recognised experts in this discipline a foundation course will begin running in March 2012. The course will be accredited by the University of Hertfordshire and those who wish to enrol with UH will be eligible for 30 APEL points on successful completion of the course. The

The Institute of Chiropodists and Podiatrists

SOuTHERN AREA COuNCIL Spring 2012 Seminar Saturday 24th March 2012 10:00 a.m. – 4:00 p.m.

Registration / Coffee 9:30 a.m. at

Anglia Ruskin university, Bishop Hall Lane, Chelmsford, Essex More details to follow about the guest speakers and workshops Delegate Information The SAC Seminar includes: • Speaker Presentations • Workshops in the afternoon – Seminar delegates will have an opportunity to attend all the workshops • Opportunity to network with like minded professionals – the Seminar is open to all Health Professionals and Chiropodists & Podiatrists from all organisations • Market Place – Trade and information exhibitors • Lunch, refreshments and free parking • Easy to get to by bus, car or train (directions available) • CPD Certificate • Cost: £60.00

Closing date for bookings: 19th March, 2012

Please complete the booking form and return, enclosing a cheque for £60.00 made payable to the IOCP Southern Area Council to: Mrs. Flavia Tenywa (SAC Hon. Treasurer), 96b High Street South, East Ham, E6 3RL. For further information: Tel: 0208 586 9542, Mobile: 07956 980815 or E-mail: fixmytoe@aol.com

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!

SAC Spring Seminar 2012 Name: .....................................................................................

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

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

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

Postal Code:.............................................

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

Dietary Requirements: ...................................................................................................................................................................

Signature: .................................................................................................................

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Date: ........................................................

35439 Chirpody 40pp 19/12/2011 17:20 Page 27

BRANCH NEWS

Cosyfeet are giving away Three Healthy Back Bags, worth £42.00 each Achy back? This giveaway could be for you.

Cosyfeet, the specialists in extra-roomy footwear, socks and hosiery for swollen feet, also supply body comfort products, including the Healthy Back Bag. Developed by a chiropractor, this strong, lightweight bag won't put pressure on your back and neck or drag your shoulders down. The bag distributes weight to minimise stress on your body and prevent chronic pain, so you can carry it comfortably and safely.

Every entrant will receive a free guide to Fitting Footwear For Swollen Feet, by Orthopaedic Footwear Consultant, Gwenda Carter.

If you see patients who need extra-roomy footwear for swollen feet

you can order Cosyfeet catalogues for them by emailing prof@cosyfeet.co.uk For more information on the Healthy Back Bag, or on extra-roomy footwear, socks or hosiery for swollen feet, see www.cosyfeet.com or call 01458 447275.

To enter the draw to win one of three Healthy Back Bags in assorted colours, visit www.cosyfeet.com/backbag The drawer will take place on Friday 2nd March 2012. Winners will be notified by email, telephone or post.

The Institute of Chiropodists and Podiatrists

Leeds and Bradford Branch Seminar Saturday 3rd March 2012

University of Huddersfield 9:00 am 9:15 am 9:30 am 10.30 am 11:00 am 12 noon 1:30 pm 2:30 pm 3:00 pm 4:00 pm

Registration Introduction Rebeka Blenntoft: Lymphoma and Cause Coffee / Trade Stalls Lecture Richard Peck / Sean Dudley, Blood Management Buffet Lunch / Trade Stalls Lecture. Mr Matthew Rothwell, Senio Podiatry Leacturer / Huddersfield University Coffee / Tea break Lecture Miss Liza Dunkley, Senior Podiatry Lecturer / Huddersfield University Finish and Collection of CPD certificates

If you wish to attend, please complete the booking form a.s.a.p. and send to Mrs. I. Shaw, 32, West Oval, Harrogate, HG1 3JW enclosing cheque for £80.00 payable to I.O.C.P. Leeds Branch.

If you require more details contact Martin Hogarth on 01653 697389

The Seminar is open to all Chiropodists / Podiatrists and FHP from all organisations.

All will be made welcome.

Booking Form (BLOCk CAPITALS) Name:.................................................................................................................................................................................................................

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

Telephone No:....................................................................................................................................................................................................

E-Mail: ...............................................................................................................................................................................................................

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BRANCH NEWS

West of Scotland Branch West of Scotland Branch held a CPD day on Sunday 6th November 2011 at the Holiday Inn, Stirling. The event was extremely well attended; I would just like to thank our members for their continued support and to say how delighted we were to welcome some of our colleagues from the North of Scotland Branch on the day.

Our thanks also go to Mr Michael Hooper (Podiatrist) & Mr Sam Wright (Marketing) of the Langer Group who delivered a superb crash course on “Lower Limb Biomechanics” Their presentations were informative and instructive, in addition to gaining an understanding of gait cycle assessment, biomechanical evaluation, casting in foam blocks and prescription writing, we were shown how biomechanics can be a valuable and profitable addition to the services offered in our practices. The lectures were complimented with some excellent practical sessions. The day was as enjoyable as it was educational and was well received by all who attended.

To top it all we received “generous freebies” from the company. Goodie bags packed with information contained not just one but three pairs of Biobasics insoles, these were provided for all present and were most appreciated.

The Langer Group provided a CPD day that I would highly recommend to other branches. Contact Stephanie by email at stephaniek@lbuk.com for further information.

Dear Editor, I am writing to thank the members of Essex Branch for their kind wishes and gift token on the occasion of my retirement.

I have been overwhelmed by the many kind wishes I have received from members of the Essex branch, other branches, members of different chiropody and podiatry associations, health care professionals, patients and suppliers.

As many of you know I recently married Chris who is a dispensing audiologist.

Chris is not ready to

retire yet so I will still be interested in the HPC. Ann Haslehurst-Smith (formerly Baker) Essex Branch

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BRANCH NEWS

Midland Area Council 4th Annual Seminar Sunday March 11th 2012

Village Hotel, The Green Business Park, Dog Kennel Lane, Shirley, Birmingham B90 4GW off Junction 4 of the M42

“Cannot Possibly Diabetes” have

PROGRAMME 9:00 9:20

Registration, Tea, Coffee and Danish Pastries Welcome Address by IOCP President Heather Bailey

9:30

‘LIZARD SPIT

10:45

Jane Sennett, Diabetic Practitioner Overview on Diabetes, New Treatments, Injection Devices, Blood Glucose Monitoring Refreshments and Biscuits

11:15

HANDS ON DIABETIC TESTING

12:45

Gareth Hicks, Podiatrist BSc, Bailey Instruments Practical Workshop on Neurological and Vascular assessment of the Diabetic Foot Lunch and Trade

2:00

SILICONE ORTHOSIS FOR DIABETICS

3:00

Michelle Weddell Podiatrist BSc (Hons) Workshop on how to use silicone putty to make orthosis for your diabetic patients Tea and Coffee

3:20

AN

Y

AND ALL THAT’

ON THE FEET

Jim Osborne Optometrist MSc FCOptom FAAO Can the eyes tell us what is happening to the diabetic foot?

4:30

CPD Certificates and Close of Seminar COST £55 (£5 reduction if booked before 1st January 2012)

!

The seminar is open to Chiropodists and Practitioners from all organisations and all will be made very welcome.

Further information contact Pam 0138647695 or Valerie 01902332847

!

Booking Form NAME (for badge) .........................................................................

Branch ................................................................

Address........................................................................................................................................................................... ........................................................................................................................................................................................

Tel: .................................................................................

Diet Requirements .............................................................

Signature........................................................................

Date....................................................................................

Please complete the form and send with remittance (cheques payable to Midland Area Council) To MAC Treasurer Mrs. Pam Osborne, 8 Andrews Drive, Evesham, Worcestershire, WR11 2JN page | 27

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BRANCH NEWS

28 | page

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BRANCH NEWS

Sheffield Branch Seminar 23rd October 2011 provided yet another superb CPD seminar run by Sheffield branch, at the convenient and easily accessible Sheffield Works Department Sports and Social Club on Heeley Bank Road, Sheffield.

On arrival, freshly brewed coffee and tea was provided while delegates greeted each other and took a peek at the offers at the trade stand. Chiropody Express had very kindly provided trade support and an array of items were on sale at bargain prices!

The first lecture of the day was Infection Prevention and Control in Community Practice by Nottinghamshire Community Health Infection Prevention and Control Nurse Specialist, Diane Churchill-Hogg. Diane was an excellent speaker, not only did she refresh memories and reinforce points which should be (but are not always) plain common sense, she gave new “food for thought” when visiting patients and an insight into better design of clinics The second lecture was something completely different.

Bobbie Drakeford, a Fellow and Director of the International Dance Tutors Association, has devised medically approved exercise programmes at the request of the Metabolic Bone Unit in Sheffield to help in the prevention and alleviation of osteoporosis.

Bobbie didn’t just talk about the exercises, she demanded audience participation, complete with music! Just one session convinced the willing participants that the exercises would be of benefit to one and all.

Following Bobbie was a lovely buffet lunch, provided by the Social Club. It was delicious and there was plenty of choice of selection.

The final speaker was Jenny Roby a Nurse in Diabetic Care.

Diabetes is something all Podiatrists and Foot Health Practitioners encounter constantly and they need to keep totally up to date with progress and development. Jenny’s talk outlining new innovations in diabetic care was of particular interest to the group as a whole.

Thank you to all speakers and I also wish to thank Debbie Straw and Penni Hardy for organising such a successful seminar. If you have never been to one before, please bear in mind that, for value, it cannot be beaten. Three important and informative lectures, CPD certificates, plus refreshments and lunch all (in this case) for £35 can’t be bad!

If you have never thought of attending a Sheffield branch seminar - please consider it for future. You will be glad that you did. They are a very friendly, welcoming, crowd!

Bernie Hawthorn

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The Institute of Chiropodists and Podiatrists

Friday 27th and Saturday 28th April 2012

Lectures, Workshops and Dinner Dance All Chiropodists, Podiatrists and Foot Health Professionals welcome

Delegate Rate Day Only £70!

Includes all Lectures, Workshops, Trade Shows, Lunch and all Refreshments

Next Year, the Institute will be breaking with years of tradition by holding its 2012 Conference and Trade Exhibition in the very prestigious Conference and Exhibition Centre in Southport, Merseyside.

The Centre is in an excellent position, right on the water front, and the fabulous Ramada Plaza hotel is inter-connected. Southport also has an abundance of hotels and guest houses to suit all.

Why not combine a welcome break in Southport with excellent

CPD seminars and

workshops Remember, our profession is due to be HPC audited in 2012. Have you fulfilled your CPD requirements?

Many Trade Houses will be attending with new products for you to look, try and buy. They will happily answer your questions. (Free entry to Trade show only) On the Saturday evening (28th April 2012) we will be holding our annual social event which commences at 7.00 p.m. with the President’s Reception, followed by a three course dinner and dancing to the hugely popular Northern All Stars 17 piece swing band.

Tickets only £35 pp or table of ten - £300 For further details see our website www.iocp.org.uk or telephone Head Office on 01704 546141

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BOOK REVIEW

Book Review Isobel Knight

Despite the fact that my Consultant Rheumatologist suspected I might have flat feet, something related to having Hypermobility Syndrome (HMS), assessments by both a hospital Podiatrist and a Dance-specialist Podiatrist revealed that I actually have very normal and certainly not flat feet. However both Podiatrists did suggest I needed to work on increasing use of my 1st metatarsophalangeal joint and further stretch both calves and Achillies.

The use of footwear was also discussed as it was felt I could wear more lace-up shoes or trainers for greater support of foot.

The hospital Podiatrist further added that she was extremely impressed with my core stability and control, something that she was not used to seeing very often in hypermobile patients.

I then showed her my online blog http://danceinjuryrecovery.blogspot.com/ which she was very impressed by (and has subsequently recommended other patients to look at it), and I told her about my new book (which was not then published) called, “A Guide to Living with Joint Hypermobility Syndrome- Bending without Breaking” which she thought would be invaluable both to other Podiatrists and to their patients. ************************ Hypermobility is about having a larger than normal range of movement (ROM). It is possible to have Generalised Joint Hypermobility (GJH) and be asymptomatic, whilst those who are hypermobile and additionally suffer pain, fatigue and a myriad of other symptoms may be known as symptomatic and possibly having (Joint) Hypermobility Syndrome (HMS). A diagnosis of HMS is made by a consultant Rheumatologist and is dependent upon having a score of greater than 4 (0-3 for those over 50 years old) of the Beighton Score, and a positive affirmation of the Brighton Criteria.

Although the condition relates to joints with a large ROM, HMS per se is a multisystemic condition and owing to the fact it is a genetically inherited disorder relating to abnormal connective tissues, namely collagens which are overly lax. This means that all body systems can be affected- for example, IBS, gut motility disorders, in the digestive system; the lungs affected as in asthma, the bladder might be weakened in this group owing to tissue laxity, not to mention the supporting muscular system which has to work so very hard to support a larger than normal ROM. Muscles frequently fatigue in this group of patients and lack endurance. Patients with HMS are often in pain and can suffer complications such as dislocations because of their tissue laxity.

The condition is related to and has overlaps with symptoms endured by those with Chronic Pain Syndromes, Chronic Fatigue and Fibromyalgia.

32 | page

The mainstay treatment for HMS is physiotherapy because of the need to provide HMS patients with improved core muscular control of their large ROM and improve strength and joint proprioception, which is often impaired in HMS patients. A gradual return to exercise is encouraged as a way of reconditioning the body, and is important in the overall management of the condition itself.

The book goes into detail to explain what HMS is and how it is diagnosed before looking at how HMS affects children, adolescents, dancers and performing artists, with whom the condition is often associated given the prevalence of hypermobility in this population. The book has a chapter devoted to pregnancy as well as other related conditions to HMS including flat feet and the need for podiatry. The book has chapters on psychology and pain management and physiotherapy and a selected range of complementary therapies. The book is partly autobiographical, but is highly academically referenced and includes many patient interviews.

‘What Isobel Knight brings to the literature [on Hypermobility Syndrome] is something appealing and unique... This is a book for anyone who wants to understand the personal impact of Hypermobility Syndrome, as much as its clinical presentation and management without all the medical jargon.’

- from the foreword by Dr Alan J Hakim, Consultant Rheumatologist and Acute Physician, Whipps Cross university Hospital NHS Trust, London uK. The book retails at £12.99 and is a must for anyone working with hypermobile patients. http://www.jkp.com/catalogue/book/9781848190689/review/

35439 Chirpody 40pp 19/12/2011 17:20 Page 35

COURSES2012 COURSES 2012

DLT DL

LLCN CN ICB ROADSHOW ROADS

TOENAIL AILL RECONSTRUCTION R

LOWER LIMB MB B BIOMECHANICS

FULL DAY

COURSE 2012

COURSE 2012

Running SATURDAYS

Running SUNDAYS

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INCLUDES

145 Starter Pack £ + VAT

Starter Pack

Wilde-Pedique - developed exclusively for the restoration, correction and normalisation of toenails.

OPEN TO TO ALL Available A vailable for for delegat delegates de es - Sundays Sundays

ROADSHOW ADSHOW SHOW W

+

Manufactured from 100% EVA, ICB Orthotics can be fully customised by heating and moulding.

+V VAT VA AT

View new products & equipment

Meet our business development managers for up to the minute offers and advice

FREE ENTR ENTRY Y

JUNE Sun 224th 4th HOLIDAY HOLIDA OLIDA AY INN - Eastleigh

HUDDERSFIELD UDDERSFIELD D

DLT DL LT HEADQUARTERS

Stoney Batter Battery y Road, Huddersfield HD1 4TW

APRIL Sun 22nd

SEPTEMBER Sat 15th | Sun 16th BEST WESTERN - W West est Grange Hotel

NEWCASTLE

VILLAGE HOTEL - Newcastle

Cox’s Cox’ ’s Lane, Midgham, Midg Berkshire RG7 5UP

Cobalt Business Park, Newcastle Upon T Tyne yne NE27 0BY

APRIL Sat 28th | Sun 29th

SEPTEMBER Sat 22nd | Sun 23rd

CHESHUNT

DE VERE - Cheshunt

TAUNTON T A AUNTON

HOLIDAY HOLIDA AY INN - T Taunton aunton

Theobalds Park,, Lieutenant Ellis Way Way, W ay y, Cheshunt, Her H Hertfordshire tfordshire EN7 5HW

Deane e Gate A Avenue, venue, Taunton, Taunton, Somersett T TA1 A1 2UA

MAY MA AY Sat 26th | Sun 27th

SEPTEMBER Sat 29th | Sun 30th

EDINBURGH

HOLIDAY HOLIDA AY INN - Edinburgh Edinburgh Zoo

132 Corstorphine Road, Edinbur Edinburgh gh EH12 6UA

JUNE Sat 16th | Sun 17th

DUBLIN

CASTLEKNOCK HOTEL & COUNTR COUNTRY RY Y CLUB

Porterstown Por terstown Road, Castleknock, Dublin 15

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M3 Jct 13, Leigh Road, Eastleigh SO50 9PE

NEWBURY NEWBUR BUR RY

£90

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See product demonstrations in action by the experts

MARCH Sat 24th 24th | Sun 25th

SOUTHAMPTON

£9VA0T

£200

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- Saturdays Saturdays

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FULL FU U DAY

WALSALL WALSALL

VILLAGE HOTEL - W Walsall alsall

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For fur further ther infor information mation please contact DL DLT: LTT: Riverside Cour Court, t, Stoney Batter Batteryy Road, Huddersfield HD1 4TW Phone: 0845 230 4411 - 01484 641010 Email: sales@dltchiropody sales@dltchiropody.co.uk .co.uk

35439 Chirpody 40pp 19/12/2011 17:20 Page 36

DIARY

34 | page

35439 Chirpody 40pp 19/12/2011 17:20 Page 37

CLASSIFIED

Recruitment SOUTHWEST LONDON Reliable Podiatrist with excellent communication skills required full-time in Battersea SW11. Must be HPC registered. Experience in PPS software and current CPR certificate mandatory. Minimum 3 years post-graduate experience in general palliative care and verrucae treatment, Including Cryotherapy, acid treatment, and needling technique. Experience and confidence in biomechanics and orthotics, including digital gait analysis, custom and pre-fabricated orthotics for adults and paediatrics. Confidence in nail surgeries and LA’s including ankle blocks is required. Training in acupuncture an advantage. Salary dependent on experience. In the first instance please send your CV to simon@foothealthbattersea.co.uk. Position starts in February 2012.

Steroid Injections of the Foot & Ankle The Royal College of Surgeons of Edinburgh

3rd & 4th May 2012 £395 Contact: Dr Colin Thomson Consultant Podiatrist Department of Trauma & Orthopaedic Surgery Royal Infirmary of Edinburgh 51 Little France Crescent, Edinburgh EH16 5SU Tel: 07908 458789 Email: cthomson@qmu.ac.uk

Businesses For Sale AyRSHIRE, SCOTLAND Full time podiatry practice for sale within Ayrshire, Scotland, established since 1996. The business has a large and loyal client base. Ground floor premises within busy town centre location with two consultation rooms, one of which is rented to a therapist. Sale includes podiatry equipment, fixtures, fittings, goodwill and lease on premises. Present turnover £35k. Sale due to relocation.

Offers in the region of £20k. For further information please email your contact details to podiatry96@hotmail.co.uk

OUTER LONDON Three bedroom detached house with integral surgery for sale - London 55 Minutes by rail.

Lovely historic market town in one of the best areas of the country.

Lots of benefits including one of the best Grammar schools in the country Established over 30 years. 20,000 population unopposed.

Sale to include all equipment (if required) - ready to walk in and start!

Wonderful opportunity - Further details 01778 426101.

Sale due to retirement.

IOCP_Chiropody

Chiropody Supplies

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

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

All Classified Advertisements must be prepaid and sent to:-

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)

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

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35439 Chirpody 40pp 19/12/2011 17:20 Page 38

CLASSIFIED

AMBER CHIROPODY SUPPLIES Serving the chiropodist/podiatrist with all the essential daily consumable items for a busy practice, including: * Instruments & Equipment * Domiciliary * Padding & Appliances

* Sterilization

* Dressings & Adhesives

* Diagnostics

* Biomechanics

* Retail Products

To view our website/online store please visit:

www.ambersupplies.co.uk PRESS RELEASE

TalarMade 2012 Catalogue set to WOW the Orthopaedic Market TalarMade, one of the UK’s leading suppliers of orthopaedic and footcare products, is launching its new catalogue for January 2012.

This exciting edition offers buyers and clinical users more affordable product options, including lots of brand new products.

The TalarMade catalogue will appeal more than ever to a wide cross section of cost conscious healthcare market buyers, looking to purchase affordable innovative, high quality products. The catalogue itself reflects the evolution within TalarMade; positioning itself as a fresh, vibrant, contemporary company, whose objective is to utilise its heritage and experience to satisfy the needs of the modern market.

The range of orthopaedic supports under the flagship Bodymedics brand, includes improvements made to existing popular products, hi technology design innovations and new value for money trusted clinic solutions.

TalarMade heritage lies strongly in the provision of functional foot orthoses, led by the 3 Point Pivot System Prescription System, which 36 | page

Extra Stretchy Boot for Men

Following the immense success of the Patty boot for women, Cosyfeet has launched a new superstretchy boot for men named the Patrick. With an HH+ fitting, this boot has been designed to fit problem feet that can’t be accommodated by other types of footwear.

Made from elastane treated with a weatherproof coating, the Patrick gives a ‘made-to-measure’ feel for very swollen feet and ankles as well as bunions, problem toes and heavily bandaged or misshapen feet. The boot will reduce the need for shoes to be specially made in many of the most challenging cases.

This lightweight boot has a seam-free toe area to protect vulnerable toes and a protective back to support the heel area. It opens right out to make it easy to put on and take off and its touchfastening leather straps provide a very adjustable fit. Two removable insoles are also provided so that orthotics can be inserted if necessary.

The Patrick is priced at £77.00, or £64.17 if patients qualify for VAT relief due to a chronic medical condition. It is available in sizes 6 to 12 and is made from black elastane with leather trim. Extension straps can also be purchased for exceptionally swollen feet.

For more information on this and other extra-roomy footwear, socks and hosiery call Cosyfeet on 01458 447275 or see www.cosyfeet.com

has been given a new fresh approach for 2012. Conscious of the need to offer the clinician a selection of product options, TalarMade have also been awarded exclusive distribution of the groundbreaking Quadrastep System™, bridging the gap between custom and pre fabricated foot orthoses.

In acknowledgement of the changing market dynamics and the financial restraints practitioners face, TalarMade has also revamped the Footmedics and Foot Heaven ranges of footcare products. Range enhancements not only include high quality new products, but also improved retail friendly packaging and point of sale display options, all at highly competitive prices.

Changing market dynamics has also encouraged TalarMade to invest in a new improved website, making it more convenient for customers to shop at a time to suit their busy schedules. www.TalarMade.com also includes a facility for clinicians to refer patients to shop directly from the site at retail prices. Thereby, avoiding the need to be directly involved in the administration process of providing patients with the products they need.

TalarMade CEO, Bernie Crewdson says, ‘This catalogue is the culmination of over 20 year’s experience in the orthopaedic market. It offers the full portfolio of TalarMade products, in one convenient product guide. We are very proud to provide our customers with an even better choice of high quality and great value products and services.’

35439 Chirpody 40pp 19/12/2011 17:20 Page 39

National Officers Area Council Executive Delegates Branch Secretaries

page | 37

35439 Chirpody 40pp 19/12/2011 17:20 Page 40

VASYLI ONE DAY WORKSHOPS

36>,9 304)

BIOMECHANICS

JOIN ONE OF OUR NEWLY DEVELOPED COURSES FOR A FULL DAY’S BIOMECHANICS WITH DR. IAN MATHIESON. 2012 SEMINAR DATES AND LOCATIONS: INTRODUCTORY COURSES Sat 31st Mar ¶ )YPZ[VS

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Sat 12th May – Leeds

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