Podiatry Review September/October 2010

September/October 2010 Vol. 67 No. 5 ISSN 1756-3291

Hansen’s Disease Diabetes News Garra Rufa Fish

The Institute of Chiropodists and Podiatrists Abductor digiti minimi

Cuboid

Metatarsals

Phalanges

SAVE 20% on Elsevier podiatry books with the ICP Book Club!

Quick and easy learning features

Puts key information in clinical context

Up-to-date information covers the conditions most commonly encountered in day-to-day practice

Fits easily into your white-coat pocket Referenced back to Neale’s Disorders of the Foot so the two work together

Evolve contains full image library, video sequences, case studies and interactive self-assessment tools

Full colour throughout helps you access information quickly and accurately

9780702030291 • May 2010 £57.99 ICP PRICE £46.39

9780702031717 • May 2010 £24.99 ICP PRICE £19.99

The full range of injectable drugs available to the practitioner Essential information on nerve physiology, drug action, equipment, patient selection, injection techniques and many other topics A Step-by-step guide to injection techniques DVD with video clips to supplement the text 9780702031076 • Feb 2010 £39.99 ICP PRICE £31.99

These handy volumes include helpful diagrams, full colour photographs, tables, tips and summary boxes to give you quick access to key information.

Relevant – focuses on key information Convenient – handy sized volumes can easily be carried in coat pocket Practical – a minimum of theory and a maximum of clinical emphasis Specialist – written by podiatrists for podiatrists Clear – full colour design and colour photographs throughout 9780702030420 • May 2010 £29.99 ICP PRICE £23.99

9780702030314 • Jan 2010 £29.99 ICP PRICE £23.99

ORDER TODAY! Please send orders for these, or any other Elsevier titles to: Tel +44 (0) 1704 546 141 / Fax +44 (0) 1704 500 477

Institute of Chiropodists and Podiatrists, 27 Wright Street, Southport, Merseyside, PR9 0TL

*Prices displayed do not included local added tax. Prices, availability and offers on our products may occasionally change without notice.

Please refer to www.elsevierhealth.com for further details

Contacts Editor: Mr. R. H. S. Henry Email: editor@iocp.org.uk Head of Media: Mrs. B. K. Willey Email: bernie@iocp.org.uk Press & Public Relations Officer: Mr. F. Beaumont Telephone: 0191 297 0464 Published by: The Institute of Chiropodists and Podiatrists 27 Wright Street, Southport, Merseyside PR9 0TL Telephone: 01704 546141 or 08700 110305 Fax: 01704 500477 Email: secretary@iocp.org.uk Web: www.iocp.org.uk

Contents 1. Editorial 2. Diabetes News 4. Article - Hansen’s Disease 8. Article - Tasty treat for feet or a fishy fad?

10. Article - Part 2 Evolution of the Human Foot Greg Quinn 12. Article - Nail Surgery A Step Foward 14. Article - Heat wave health advice

Dear Reader

As I sit indoors, on a lovely warm and sunny day to write this editorial I am reminded that on page 14 we have included Heat wave health advice courtesy of St John Ambulance!

What else have we of interest and note in this issue of Podiatry Review?

On pages 4&5 we have an article on Hansens Disease by Michelle Taylor M.Inst.Ch.P., BSc. On page 10&11 we have part 2 of the presentation given at the Institutes Annual A.G.M. “Evolution of the Human Foot” by Greg Quinn FCPodS, Podiatric Surgeon On page 12 we have a rational for Nail Surgery by Gillian Webster MInst ChP which makes interesting reading.

Verrucae Pathology by Judith Barbaro-Brown MSc PGDip BSc PGCE MChS DpodM BA Teaching Fellow Durham University, is our Continuous Professional Development pull out supplement. We thank Judith once again for her contribution.

We give advance notice of seminars of interest.

Midland Area Council Saturday 30th October at the Hilton Hotel, Braunstone Leicestershire discussing Podiatric Rheumatology and Silicon Injection Therapy.

September/October 2010 North West Area Council Seminar on Sunday 21st November discussing Leg Oedema and DVT and Dealing with Dementia.

Sheffield branch Seminar Sunday 17th October discussing Pharmacology and Lymphoedema.

Leicester and Northants Branch Seminar discussing Dermatology at the Lutterworth Cricket Club Lutterworth. I see our old friend Ivan Bristow M Sc FC Pod Med Lecturer in Podiatry Faculty of Medicine, Health and Life Sciences University of Southampton is lecturing on his core subject Dermatology. I might even try and get to listen to that myself, it should be good.

I have left leaving the fun item till last. On pages 8&9, there is an account

by Stephen Gardiner BSc MInst Ch P on Garra Rufa Fish. What is that, I hear you ask.

Apparently it is the latest way to remove callus, dead skin and psoriasis being marketed to the public in the UK. You put your feet in a tank of water with flesh eating fish and they do the business! Whether it will catch on remains to be seen.

Enjoy reading your Podiatry Review.

Roger Henry, Editor Podiatry Review

15. IOCP Business Matters report from the Treasurer 18. Letters to the Editor 21. Branch News 28. Rambling Roads 33. Classified Adverts 34. Diary of Events Annual Subscription: £25.00 Single Copy: £5.00 Including Postage & Packing ISSN 1756-3291

© 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.

European Union urged to take action on diabetes and other chronic conditions

A

coalition of organisations representing people with chronic conditions is campaigning for the introduction of measures to address poor diet, lack of exercise, excessive use of alcohol and smoking in a bid to improve the health of people across Europe.

The International Diabetes Federation (Europe) – of which Diabetes UK is a member – is one of the ten organisations in the Chronic Disease Alliance, which represents healthcare professionals and people with conditions including diabetes, respiratory disease, liver disease, cancer, heart disease and kidney disease. These diseases account for 86 per cent of deaths in Europe, according to the World Health Organisation.

Within the European Union there are more than 30 million people with diabetes.

Recommendations for improving health

Recommendations in the campaign document called ‘A Unified Prevention Approach’ include:

Nutrition: Make efforts to reduce fat, sugar and salt content in food, increase supply and access to affordable fresh fruit and vegetables, ban the marketing of unhealthy food to children.

Physical activity: Ensure children have access to physical education every day at school and improve P.E. facilities, set urban planning priorities for non-motorised transport and parks. Tobacco: Harmonise tobacco taxation across Europe, devote 80 per cent of cigarette packaging to visual health warnings, ban internet sales of tobacco and cigarette vending machines. Alcohol consumption: Ban alcohol advertising on television and radio, introduce uniform minimum EU taxes on alcohol and create educational programmes to raise awareness of excessive alcohol consumption.

Human and financial costs

The report also stresses that chronic diseases place an unsustainable financial burden on health care budgets, as well as having individual human costs which cannot be overstated.

Instant Relief for Sufferers of Cracked Heels

A

s warmer months approach and thoughts turn to preparing our feet for summer shoes, many people dread the recurring problem of this distressing condition.

Visually small breaks in the skin commonly referred to as Heel Cracks, or the clinical term Heel Fissures, commonly occur in a wide range of groups including females that wear open backed shoes, over-weight patients and patients with diabetes” as patients don’t like to be labeled as diabetic or obese. Treatment of this painful, unsightly and often chronic condition has proved to be challenging for health professionals such as; GP’s, chiropodists, podiatrists and pharmacists.

A recent case series produced by four private podiatry practices, under the auspices of the University of Southampton, evaluated the clinical use of medical grade tissue adhesive (Liquiheel™) for the treatment and management of dry heel fissures. It concluded that Liquiheel™ offered “instant and lasting pain relief following application… and functioned as an occlusive dressing with a reported microbial barrier, and were aesthetically pleasing to patients”.

2

The beneficial effects of using tissue adhesives for closure of simple lacerations have been demonstrated in Accident and Emergency departments. The production of Liquiheel™ involves a basic cyanoacrylate being distilled to achieve purity and to remove any toxic by-products, resulting in a low viscosity liquid. On contact with skin Liquiheel™ forms a solid film that bridges wounds and holds the apposed edges together. Since the adhesive film generally sloughs off within 5 to 10 days, as the epidermis regenerates, there is no need to remove the adhesive.

The Leading Podiatrist in the study, Belinda Longhurst, commented:- “Overall the response was positive from patients and practitioners alike with regard to ease of application of the product, aesthetics and patient comfort.

The majority of patients were delighted with the immediate and lasting pain relief and I was impressed with the apparent barrier to infection that Liquiheel™ provided”.

LiquiHeel™ is only available in the UK through Bailey Instruments Ltd www.baileyinstruments.co.uk

RAPID PAIN RELIEF

MICROBIAL BARRIER

WATERPROOF

AMBIENT STORAGE

t3BQJE SFMJFG t3BQJE SFMJFG F GSPN GSSPPN DSBDLFE DSSBBDLFFE IFFMT JOO POF TJNQMF TUFQ TUFFQ TU tt1SFDJTJPO 1SSFFDJTJJPO "QQMJDBUPS "QQMJDBUUPS t'BTU TFU TFFU UJNF t'BTU t*OTUBOU t*OTUUBBOUU QBJO SSFMJFG FFMJFG t.JDSPPCCJBM #BSS JFS t.JDSPCJBM #BSSJFS t&BTZ t&BTZ UP UP VTF t/P t/P TFDPOEBSZ TFDDPOEBSZ ES ESFTTJOH SFFTTTJOH t'BTU t'BTU FGGFDUJWF FGGGGGFDUJW F WF USUSFBUNFOU SFFBUN NFOU *Case series in private e practice in co-operation with Southampton ampton University 2009 SOCAP poster er

Sterile St terile Topical Topical al Tissue Adhesive Adhesiv ve

www.baileyinstruments.co.uk w www .baileyinstruments.co.uk baileyinstruments.co.uk yyinstruments.co.uk s u e ts.co.uk s co.uk helpline +44 (0) 161 860 5849

email | sales@baileyinstruments.co.uk truments.co.uk

Contact us if you ou would like to join an extended tended study and rreceive eceive a discount on your first order or der d @ gemma.bailey@baileyinstruments.co.uk ey@baileyinstruments.co.uk o.uk

Hansen’s Disease H

Michelle Taylor M.Inst.Ch.P., BSc ansen’s disease is more commonly referred to as leprosy and is essentially a problem within developing countries. It is a chronic progressive disease caused by the Mycobacterium Leprae (M. Leprae) bacteria which is closely related to tuberculosis. (Helicon). This chronic infection which affects the nerves and skin is classified by its cell mediated immune response. (CMI) (Spicer, W.J 2008). The incubation period for leprosy is long roughly 5 years according to the World Health Organization as the M. Leprae multiplies very slowly. It is not classed as a highly communicable disease as only 5% of people living in close contact with a person with the leprosy acquire the disease. (Health State University online accessed 7th December 09).

Numerous acid-fast bacilli, Mycobacterium leprae, in nerve (Fite stain, original magnification _40). (Anderson et al 2007)

Hansen in 1874 recognized the Mycobacterium Leprae bacteria as an intra – cellular pathogen of humans. The bacteria are acid fast parallel – sided rods 0.4 um × 1.8um and do not grow in artificial media. (Spicer, W.J 2008). M. Leprae divides by binary fusion, is Gram positive and is strong acid fast after staining with basic fuchsine, which stains the bacteria pink.

(Katoch. V.M 2002). Staining with acid allows the bacteria to be seen under a microscope (see figure 1). This technique is often referred to as acid – fast bacilli (AFB). (Health State University online accessed 7th December 09).

As the bacterium is an obligate intra - cellular parasite it is commonly found in the macrophages. Predominant sites of infection occur within the cooler areas of the body skin, nasal mucosa and the superficial peripheral nerves – in particular the Swann cells. These sites offer optimal growth of the M. Leprae bacteria. (Katoch. V.M 2002). By swapping histiocytes the bacilli have a vehicle in which to travel to and infect other nerves and tissues. These cells are known as Lepra cells, collectively they are known as globi. (Lorimer et al 2006).

As it has not been possible to cultivate M. Leprae in vitro this has lead to difficulties in understanding the biology of the leprosy bacillus. Advances have been made in cultivating Leprosy bacillus within the pads of mice. This has lead to the development of chemotherapeutic agents, analysis of bio – chemical antigenic and the molecular structure of the leprosy bacillus. With these

4

developments molecular diagnostics has enabled early diagnosis and effective regimens for treatment of leprosy. (Katoch, V. M 2002).

While the bacillus is not virulent, and the leprosy patient can host large numbers of the bacteria without any ill effect, it is the undiagnosed who offer the greatest treat of spreading the disease.

There is a debate on how leprosy is transmitted it is of a consensus that there are 3 possible routes respiratory and gastrointestinal tracts and through the skin. While direct skin to skin is considered an unlikely form of transmission as M. Leprae is incapable of entering the papillary zone of the dermis. (Lorimer et al 2006).

Jopling and McDougal in 1988 have not excluded transmission via skin abrasions. It is thought that inhaling dust containing the bacillus could be form of transmission. (Health State University online accessed 7th December 2009).

The most likely form of transmission is through infected droplets being expelled during sneezing, coughing and talking.

The M. Leprae enters the uninfected person via the alveoli in the lungs, where it enters the blood stream and targets the superficial peripheral nerves in particular the Schwann cells. M. Leprae also targets the macrophages, endothelium, chrondrocytes and the melanocytes. (Lorimer et al 2006). These cooler areas of the body offer optimal growth for the bacteria, as it has been clinically observed to multiply at 27 – 30 degrees. (Katoch, V. M 2002). It has also been demonstrated by Sabin and Swift (1984) through thermographic scanning of subjects a relationship and evolution of both neurological damage and sensory loss through cooler body temperatures.

Leprosy is a slow development disease that has a wide range of clinical, histopathological and immunological characteristics.

Clinically it can resemble many other conditions – tinea pedis, contact dermatitis, vitiligo, pityriasis, alba and myxedema. Hansen disease is similar to a chameleon. (Anderson, H et al 2007).

Ridley and Jopling devised a clinical classification system that recognized the gross appearance of the lesions, and gave parameters for histopathological classifications. Immunological manifestations are also taken into account aiding diagnosis.

While histology confirms suspect cases that may be missed in clinical practice, and provides an indication of the progress and remission of treatment. (Lorimer et al 2006).

Classifications of Hansen Disease.

Type

Cutaneous Findings

Nerve Changes

Histology

TT

1 – 3 sharply outlined dry, flaky, hairless, plaques, papules.

Nerve is thickened and/or tender, pain, touch, and temperature sensation destroyed.

BT

3 – 10 lesions with satellites pathognomonic

Nerve thickened and/or tender; sensation impaired or completely lost

Grannulomas of epitheliod cells, giant cells and numerous lymphocytes along neurovascular bundles; rare bacilli.

BB

Reassembles BT and LL

Nerve tender and/or thickened; loss of sensation variable.

BL

BT and LL – like lesions, but more LL – like; lesions tend to be symmetrical, numerous, and punched – out appearing.

Symmetrical, thickened, and/or tender nerves; sensory loss minimal to definite.

LL

Numerous, symmetrical hypo pigmented or erythematous nodules and macules.

Macular: ill defined, confluent, erythematous or hypo pigmented macules, often infiltrated Infiltrative – nodular: classic papules, nodules, diffuse infiltrates, often dull red leonine facies.

Diffuse type; Lucio leprosy, diffuse skin infiltration without nodules; alopecia of eyebrows and eyelashes, acral symmetrical anesthesia

Multiple nerve thickening; if large peripheral nerves involved and decreased sensation involved, nerve paralyses and decreased sensation result with neural changes later than skin changes.

1

1 to a few hypo pigmented macule(s) that may be well or poorly defined.

Nerve thickness and/or sensation may or may not be affected.

Lymphocytes and histocytes around neurovascular bundles and adnexa, some bacilli without well formed grannulomas.

Epitheliod cell grannulomas along neurovascular bundles and infiltrating erector pili and sweat glands, grannulomas not in epidermis, bacilli scant.

Grannulomas with epitheliod cells and lymphocytes, but not giant cells; grenz zone, many bacilli.

Diffuse, poorly to moderately defined grannulomas in the mid lower dermis made up of histiocytes, sheets of bacilli; histiocytes invasion produces “onion skin” nerves, many bacilli

Numerous dermal histocytes with numerous bacilli extending into subcutis: grenz zone without grannulomas or prominent lymphocytes; lepra cells (foamy macrophages) with globi of bacilli

PBSL

1 skin lesion

No bacilli on skin smear

MB

More than 5 lesions

May be skin – smear positive.

PB

2 – 5 skin lesions

(Anderson, H et al 2007)

Ridley and Jopling classification is both widely used and understood. The classifications of leprosy are split into types tuberculoid tuberculoid (TT), borderline tuberculoid (BT), mid borderline (BB), borderline lepromatous (BL), and lepromatous (LL). Each type of leprosy has its own clinical bacterial, immunological, histological and pathologic criteria to aid identification. (Ridley DS, el al 1996). There are 5 main categories, but there are 6 categories if the type of leprosy can not be determined.

Skin lesions and nerve damage are symptoms of leprosy; tuberculoid leprosy (TT) is the milder form of the disease. The immune system of the host surrounds the invading pathogen within the deeper layers of the skin leading to damage of the hair follicles, sweat glands and nerves. This damage causes

No bacilli on skin smear

dryness, discoloration and a lack of sensitivity within the skin.

Enlargement of the nerves in the face, arms and legs is suggestive of TT. While the scarcity of bacteria within this form of bacteria leads to it been referred to as paucibillary leprosy (PB). With 70 - 80% of all cases of leprosy are caused by tuberculoid leprosy. (Health State University online accessed 7th December 2009).

The cutaneous and subcutaneous nerves show the most significant changes within tuberculoid leprosy (TT). Damage to the nerves is an unstoppable part of the response to the effects of the disease, and is not due to the growth of the bacilli. As the infected nerves are invaded and destroyed by the epitheloid granulomas. This may lead to necrosis and development of nerve abscesses. A sensory motor deficit will be superimposed

5

if a trunk nerve is affected, leading to a localized mixture of neurological defects typical of tuberculoid leprosy. Dermal nerves are destroyed through localized anaesthetic patches, these patches are often the only indication of polar tuberculoid leprosy. A feature of tuberculoid lesions is autonomic due to the axon reflex and the absence of sweating. Nerve trunk involvement close to skin lesions is probably secondary to cutaneous nerve involvement. Within the lower limb the common peroneal and posterior tibial nerves are most commonly affected. (Lorimer el al 2006).

Lepromatous leprosy (LL) is due to cell – medicated immunity, the haematogenous spread allows the bacilli to multiply unchecked. Within the Swann cells and perineurium the bacilli continues to both multiply, destroy and spread to other areas. Due to the large widespread of bacilli symmetrical and sensory loss is a common symptom of this type of leprosy. Nerve damage is slower than other forms of leprosy. (Lorimer et al 2006).

Borderline causes of leprosy fall into 3 categories, leading to the potential for catastrophic peripheral nerve damage. A borderline case falling close to the tuberculoid (BT) end of the spectrum, paralysis and sensory loss are always asymmetric.

While the mid point (BB) involvement is asymmetric and indicates intracutaneous nerve damage as the borders of insensitivity do not conform to the dermatomes (lesions). A BL borderline case will be nearer the lepromatous end of the scale have numerous lesions and be symmetrically distributed.

Insensitivity may exceed the boards of the lesions with temperature linked patterns of sensory loss. While the spread of the lesions is not as proliferate as in LL they are not as symmetrical in appearance.

Dehydration of the epidermis caused by a combination of nerve and sensory impairment, loss of sweat glands and axon reflexes, causes a reduction in the keratin levels, flexibility and elasticity of the skin. These compromising factors lead to fissures and possible ulceration of the skin and potentially provide an entry route for infection. Other potential problems of M. Leprae include periostites, osteoporosis, osteomyelities and pathological fractures. (Lorimer et al 2006).

The major break through in drug treatment for leprosy occurred in the 1940’s with Dapsone. By the 1960`s resistance to this drug was noted, leading to the World Health Organization (WHO) recommending the use of a multi – drug therapy for the treatment of leprosy. (World Health Organization online accessed 7th December 2009) As the use of multi – drug therapy has been found to be safe, effective and easily administered as the treatment compromises the viability of the bacillus (Lorimer et al 2006). From 1995 – 2000 the Nippon Foundation of Japan and from 2000 to date the Novartis Foundation for Sustainable Development, via the World Health Organization have been able to provide MDT drugs free of charge.

A three drug regimen is recommended for multi – bacillary leprosy – Lepromatous (LL), borderline lepromatous (BL) and borderline leprosy (BB). The drugs prescribed for this regimen include: • Rifampicin – 600mg taken once monthly – supervised.

• Daspone – 100mg daily – unsupervised.

• Clofazimine – 300mg once monthly – supervised, with 50mg taken daily supervised.

Multi – bacillary leprosy is treated for at least 2 years.

Treatment remains unchanged unless the patient experiences neuritic pain or weakness as this could be a sign of rapid permanent nerve damage; if this occurs prednisolne (40 60mg) needs to be taken daily.

6

If erythema nodosum leprosum – bright red tender nodes – are found on the lower leg or the forearm of the patient aspirin or chloroquine is usually given in mild cases. For serve cases corticosteroids or thalidomide (unlicensed) are recommended in men and post – menopausal women. Treatment for these nodules is given under supervision.

Clofazimine may be prescribed up to three times a day in quantities of 100mg for the first month. This may be extended for longer if the effects of this drug have not had the required affect on the body. (Mehta. D, K) While a two drug regimen is advised for paucibacillary leprosy – borderline tuberculoid (BT), tuberculoid (TT), and indeterminate (PB). Drugs prescribed are; • Rifampicin – 600mg taken once monthly – supervised.

• Dapsone – 100mg daily – unsupervised

Paucibacillary leprosy is treated for six months. If treatment is stopped before completion of the course, it requires completion of the course starting from the point where the treatment was stopped. (Mehta. D, K 2005).

Looking towards the future a combined tuberculosis and leprosy vaccine is being trialled that induces a cellular immunity within the leprosy patient. This research is being conducted by the Leprosy Research Centre, in Tokyo, Japan.

(Pub Med on line accessed 27th December 2009).

Dr. Tom Gillis of the National Hansen’s Disease Programs says that it is safe to say that in the next five years, there will be one to two new vaccines for tuberculosis that might include a leprosy component. As far as a vaccine exclusively for leprosy, we might see one in the next 5-10 years, and then it would take 5-10 years to follow up on it and test it. His estimate is that it could be about 10-20 years before we see an official leprosy vaccine that is universally accepted worldwide. (Stanford Online accessed 27th December 2009).

References.

Anderson, H. Stryjewska, B. Boyanton, B. Schwatz, M. Hansen Disease in the Untied States in the 21st Century. A Review of the Literature. Arch Pathol Lab Med – Vol. 131, June 2007.

Health State University http://health.stateuniversity.com/pages/901/Leprosy.html">Leprosy - Definition, Description, Causes and symptoms, Diagnosis, Treatment, Prognosis, Prevention</a> Accessed 7th December 2009 Helicon (2006). Hutchinson Science Desk Reference. Helicon Publishing Abingdon, Oxfordshire GBR. Jopling, WH, McDougal, AC. (1988) Handbook of Leprosy 4th edition. Heinemann, Oxford.

Katoch. V, M (2002) Advances in the diagnosis and treatment of Leprosy. Cambridge University Press.

Lorimer, D. French, G. O’Donnell, M. Burrow, J. G. Wall, B. (2006) Neale`s Disorder’s of the Foot. 7th Edition Churchill Livingstone Elsevier Mehta. D, K. (September 2005). British National Formulary. 50. BMJ Publishing Group Ltd. Ridley, D, S. Jopling. W, H. Classification of Leprosy according to immunity: a five – group system. International Journal of Leprosy 1996 34 – 255 - 77 Sabin. T, D. Swift. T, C. Leprosy International (1984). – Dyck. P, J. Thomas. P, K, Lambert. E, H. Bunge. R. (eds) Peripheral neuropathy. Vol. 2 WB Saunders, Philadelphia) Spicer. W, J (2008) Clinical Microbiology and Infectious Diseases 2nd Edition Churchill Livingstone Elsevier Pub Med govhttp://www.ncbi.nlm.nih.gov/pubmed/19803378?itool=EntrezSystem2.PEntrez.P ubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos. Acessed 27th December 2009 Stanford http://www.stanford.edu/class/humbio103/ParaSites2006/Leprosy_vaccine/vaccinein ternationally.htm accessed on line 27th December 2009 World Health Organization. http://www.searo.who.int/EN/Section10/Section20/Sectiom 2293.htm Accessed 7th December2009 World Health Organistation http://www.wpro.who.int/sites/leprosy/treatment/treatment_main.htm Acessed 7th December 2009

Tasty treat for feet or a fishy fad?

I

t would appear that the latest way to remove callus, dead skin and psoriasis being marketed to the public in the UK is to put your feet in a tank of water with flesh eating fish!

Having seen the recent local media frenzy and TV news reports, I decided to investigate the new UK trend that has already hit spas in the US, Far East & Asia and has now arrived just up the road from your local private practice Podiatry clinic.

Was this something to consider as a business sideline for my clinic, or was the closest my receptionist would get to fish be phoning old Mrs Jones to let her know she’d left a tin of pilchards in the waiting room that morning? This is my personal account of a visit to one such newly opened “Appy Feet” spa in the Westfield shopping centre, Derby. (see http://www.appyfeet.co.uk for more details)

I knew they were waiting for me… circling impatiently… sat on a wooden bench in the centre of a Westfield Shopping Centre retail unit, a customer lowered her feet into the tank towards the ravenous swarm… they latch on… over a hundred tiny mouths sucking, licking and nibbling at her heels, ankles and in between her toes! The growing crowd on the other side of the glazed shop front point and leer as another customer becomes fish food!

These sucking mouths belong to the Garra Rufa fish, which originate from the warm waters of Kangal, Turkey. For hundreds of years, the local people of this area have used the Garra Rufa for the treatment of numerous varieties of skin diseases, such as psoriasis, eczema, callus removal and acne.

My “research” partner and I paid our £20 each for the 35 minute “fish encounter”. The treatment commenced with a health questionnaire whilst taking foot bath. The foot bath is necessary to remove sock fluff and general toe grime, although having been on the receiving end of far worse in my clinic; we’d of course washed our feet thoroughly and applied clean hosiery before leaving home. The Scholl branded mobile foot spa softened our callus in preparation for the good nibbling that was to come.

After what seemed to be a few minutes, well less than five, we were provided with flip-flops and ushered over to the tanks.

These tanks were arranged in communal groups of six and we sat side-by side with other customers on a wooden slat bench as we lowered our feet towards the hungry mouths.

8

By Stephen Gardiner BSc (Hons)

These Perspex tanks are in the main shop-front and it’s open plan so every member of the general public sees you and your exposed tootsies in these tanks of approximately 150 fish. This takes it to another level when as we experienced, there were curious shoppers with kids in tow, munching on their Gregg’s Cornish pasties - faces pressed up at the window, pointing to see what on earth you were doing! Not the relaxing foot massage experience it suggests.

Now I know I deal with feet on a daily basis, but this doesn’t necessarily mean I enjoy either exposing my own plates-ofmeat to public scrutiny, nor do I overwhelmingly enjoy them being tickled; which in this case is the sensation I felt. My initial reaction as the fish swarmed around my feet was to pull out sharply. The tickling sensation became tolerable and I managed to control myself to stop moving my feet away from the fish. However, relaxing was difficult as the non-paying audience of shoppers on the other side of the shop window observing me like a circus sideshow was somewhat off-putting, plus the comfort of the wooden slat-bench certainly lacked padding for my now very numb posterior.

It was however an interesting and novel experience watching the Garra Rufa swarm over my feet and ankles as they started building up in areas I was unaware I had dead skin.

After my timer rang to notify the shop assistant that our time was up, I was given a soft towel to dry my feet and offered a squirt of moisturising cream. I looked at my tootsies… they were extremely pink and clean, but then again, I had just been soaking them in bubbling water for 35 minutes. Whilst some areas of callus appeared to be visually reduced, the fish had only sucked at the surface of these areas and felt I really needed the services of a Podiatrist with a scalpel to complete the job properly.

My concerns throughout this 35 minute session were about the spread of infection via the tanks and their inhabitants, particularly if people have sores, blisters, or verrucae on their feet prior to treatment. Also, without wishing to be too crude, once the fish have eaten and digested human skin, it has to go somewhere… and how clean can the tanks be when the fish are living in them day in, day out? These concerns could not be answered on my visit, but upon reading literature and viewing video interviews with “Appy Feet” founder Christine Wright, it’s stated that the water is filtered 17 times an hour via a strong UV light to kill any bacteria and to keep the treatment safe and hygienic.

However, the water may be filtered and UV treated, but the fish cannot be sterilised between customers, as we would sterilise instruments. Limited screening was carried out prior to my treatment other than a general health questionnaire that we were left to complete ourselves, and that appeared to be more concerned with whether I had a heart condition than if I had Verrucae.

Media reports quote Dr Sunil Chopra, Dermatologist from The London Dermatology Clinic stating “These fish will certainly help relieve scaly, dry skin. The actual effect may not be much more than a pumice stone – but a key factor of this treatment is that it is meant to be relaxing and reducing stress levels can improve to condition of the skin.” He warns against using the treatment for severe disorders such as psoriasis because it may make the condition worse.

My view is that as Allied Health Care Professionals we should have no concern about losing patients to this experience. These fish and their carers cannot take on the diagnosis and treatment

of trained medical professionals. However, if this therapy were to be combined with a professional Chiropody treatment, in the relaxing surrounds of an exclusive health spa, it would certainly appeal to those preferring a pampering experience.

The business is not a cheap affair. “Appy Feet” franchise starts at £60k to buy the fish and UV filtering system from £20k and it is recommended to change your fish every three to four months… that’s an expensive workforce and I’m unsure what happens to the old fish when they’re “retired”! Should they be disposed of as clinical waste? The non-specific legislation that could potentially be applicable to such enterprises would be a minefield to first interpret and then comply with.

Judging from the crowds around and the queue inside the shop on my visit it certainly looked as though this franchise was a licence to print money - but for how long? Given the amount of callus I removed from the feet of my “research” partner the day after we experienced the 30 minute fishy feeding frenzy, I’m reassured that the private Podiatry practitioner with good scalpel technique has nothing to fear from the fish with a foot fetish!

This is my own personal opinion, and with “Appy Feet” opening locations all over the UK it may be worth visiting and seeing/experiencing it yourself. Current outlets are in Sheffield, Derby and Manchester with many more coming soon.

Is this treatment a tasty treat for your feet or a fishy fad? You decide. I for one prefer my fish in breadcrumb, with a dollop of tartar sauce!

Are your nipp ppers letting you o down?

You ou may not even realise it until you ou try the best!

Wee are told the 2 key factors r in a good nipper are: 1. Sharpness 2. Reliability We say: y: Both of these relate to quality of steel and quality of finish in manufacturin ng.

Don͛t be deceived by some claims that ͚Made in Solingen͛ means both steel and instruments are made in Solingen.

The house of Clauberg rg is a small family business in i Solingen producing hand finished, quality instruments t from Solingen steel. If you value quality instruments you will not be disappointed. If treated e properly and professionally it is an investment that will last you for years. Until you try them you won͛t realise what you are missing.

g General purpose

From sturdy general eral purpose nippers, finest in i growin ng nippers, specialist diabeticc nippers (Onychosoft) to robust can ntilevers helping those with weakeer wrists or hands. A small bu b t exclusive range!

Also availilab ble l fr f om the h Lau L fwunder range: SALq q ʹ gentle l nailil & skin kin softener - speeds up u treatment time; Mykored d ʹ nail & skin antifungal (pipette, spray, crea eam & oil); the Laufwunder ran r ge of creams ʹ moisturising, warming, cooling and the new Callu allus Reduction Cream.

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

9

Greg Quinn’s Presentation at the Institute’s Annual A.G.M.

Part 2 Evolution of the Human Foot Greg Quinn, FCPodS, Podiatric Surgeon

I

‘History does not repeat itself, but it does rhyme.’ Mark Twain n considering the anatomy of modern humans as upright bipedal apes, it is striking how similar yet distinct our anatomy is when compared to other apes. In fact, many other apes can and do walk bipedally; despite their anatomy not being as well adapted to do so. What scientifically valid explanation is there for us to have acquired such key characteristics? Evolution is the grand unifying concept of the biological sciences and so to answer this question we might examine how the process works. To do this we should understand that the most succinct definition of evolution is that it is genetics plus time.

Genetic mutation can produce effects that are neutral, advantageous (to survival and thereby breeding) or disadvantageous (reducing the likelihood of such mutations being passed on). Human Genetic studies have been made possible with advances in biological molecular technology, exemplified by the completion of the ‘decoding’ of the human genome, which contains some 20,000 - 25,000 genes. Since the completion of this work, studies have now begun to assess how the genome actually works. Several surprising facts have emerged: 1. Human DNA varies by only 0.1% indicating that modern humans evolved relatively recently (c.150k yrs ago) from Africa with around 10,000 individuals emerging to replace other existing human species.

2. Our DNA is 98.6% identical to that of chimpanzees, with whom we share our most recent common ancestor.

3. The human accelerated conserved non-coding sequence 1 (HACNS1) gene has been linked to bipedalism1.

4. The vast majority of human DNA does not code for the production of proteins.

5. The evolutionary differences in developmental, morphological and functional detail of modern humans is likely to have been brought about by small changes in regulatory genes2 i.e. Genetic on/off switches that ‘instruct’ protein building genes when and where to assemble body components appropriately.

6. It is therefore apparent that differences between species of apes and their feet (including humans) are better explained in terms of alterations in the timing and duration of the genetic control of common features.

Obviously prior to the introduction of such molecular techniques, researchers were restricted to consider human evolution in terms of comparative anatomy and the human foot

10

has been the subject of considerable study. In 1923, Keith3 argued that from an evolutionary standpoint the hallux was a key contribution to the formation of the essentially human medial longitudinal arch and a year later DJ Morton4 published his thoughts on the acquired features of the longitudinal arch through evolution. These papers along with other subsequent works highlight the gradual acquisition of ‘adaptations’ of the feet during the long history of our hominid ancestors.

Hicks was the first to describe the passive use of metatarsophalangeal extension to produce a rise of the medial longitudinal arch, inversion (supination) of the rearfoot and lateral leg rotation with tightness of the plantar aponeurosis5 and the analogy of a ‘windlass’ mechanism was introduced. This mechanical action was revisited by Bojsen-Moller who compared the anatomical and functional features of human feet with other apes6,7 particularly in relation to the shape of the calcaneocuboid joint. These observed changes render the human midtarsal joint stable prior to heel-lift having undergone an initial reduction in stability during initial contact loading of the rearfoot.

Bojsen-Moller also referred to the evolutionary remodeling of the forefoot that served as a reminder that nature tends to act as a remodeler rather than a creator6 of completely new outstanding features.

The adaptive ‘modifications’ of the human foot also received attention from Kidd8, who re-iterated the significant changes in size and proportion of foot bones. Specifically from a human perspective these include a larger tarsus with smaller digits, the absence of a divergent, opposable first ray and the presence of longitudinal and transverse arches.

The anatomical changes gradually effected within the rearfoot included an increase in calcaneal inclination and formed the proximal end of the medial longitudinal arch. These changes to the orientation of the talus created a torque conversion into the subtalar joint (leg rotation produces foot rotation). Such modifications also produced a stable arch arrangement that provided a degree of stability (to stand upright) that is also variable through the pronation and supination cycle.

At a later stage the gradual loss of opposability of the hallux formed the distal element of the arch; in essence defining the arch structure as a complex of traits that gradually evolved through transitional stages that are observable within the fossils of human ancestors.

The fundamental point of understanding here is that changes in the genetic regulation of growth and development would account for the gradual accumulation of anatomical differences that we now broadly recognize as human.

It is important to remember that hominid ancestors do not represent a straightforward family lineage from Australopithecus afarensis (via Homo habilis and Homo ergaster) to ‘arrive’ at Homo sapiens. The use of taxonomical terms is a way to represent distinct anatomical differences between species. These species have, in fact, been a diverse yet continuous and gradually changing physical expression of genetic mutations that have been subjected to natural selection. The genes that we possess initially conferred an advantage to our ancestors who also possessed them before passing them on to us via many generations. Over thousands of years, genetic change has occurred. Once genetically different lineages appeared, reproductive efforts across these boundaries would have failed.

Other groups then evolved separately to create the other modern ape species of today or became extinct e.g. Homo neanderthalis.

The continuing analyses of fossil structure 9-12 and the paleopathological study of foot deformity13 offer significant insights to the evolving suitability of the human foot to upright propulsive gait despite a predisposition for injury. Such injuries represent the outcomes of failure to successfully provide the biological purpose of the foot (see Part 1).

When biological traits are influenced by many genes (polygenic), two significant issues should be considered.

Firstly, that statistical analysis of those traits will demonstrate differences between populations within a normal distribution curve (also Part 1). Secondly, that the trait in question can and will be affected by the environment.

the foot One Day Courses ONLY £95 + VAT

as a

&

3

POINT PIVOT

As with many companies engaged in the manufacture of foot orthoses, Talar Made Ltd. was founded by clinical practitioners. For over a decade our focus has been to broaden the choice of orthoses available to our prescribers, supported by strong design rationales and helpful education programmes.

Our educational courses are based around straight forward explanations of the science that underpins each product, its design and logically its indications and contraindications.

To book your place call Nina Burns 9am-4pm Mon-Fri on 01246 266083 or email nburns@talarmade.com

We can conclude that human feet share common physical traits that will tend to vary and that no; there is no single gene that only causes a single foot deformity. Genetic evolution of the modern human foot took many thousands of years; by comparison we have changed our environment rather more quickly.

References

Carroll SB: Genetics and the making of Homo sapiens. Nature 422: 849-857, 2003.

Blomquist GE: Brief Communication: Methods of Sequence Heterochrony for Describing Modular Developmental Changes in Human Evolution. Am J Phys Anthropol 138: 231-238, 2009.

Keith A: Hunterian Lectures on Man’s Posture: Its evolution and disorders. British Med J 1: 545-548, 1923.

Morton DJ: Evolution of the longitudinal arch of the human foot. J Bone Joint Surg 6(A): 56-90, 1924.

Hicks JH: The Mechanics of the Foot. J Anat 88: 25-30, 1954.

Bojsen-Moller F, Flagstad KE: Plantar aponeurosis and internal architecture of the ball of the foot. J Anat 121: 599-611, 1976.

Bojsen-Moller F: Calcaneocuboid joint and stability of the longitudinal arch of the foot at high and low gear push off. J Anat 129(1): 165-176, 1979.

Kidd R: Evolution of the Rearfoot. JAPMA 89(1): 2–17, 1999.

Susman RL, de Ruiter DJ: New hominin first metatarsal (SK 1813) from Swartkrans. J Hum Evol 47: 171-181, 2004.

Kidd R, Oxnard C: Little Foot and big thoughts - a re-evaluation of the Stw573 foot from Sterkfontein, South Africa. Homo 55: 189-212, 2005.

McHenry HM, Jones AL: Hallucial convergence in early hominids. J Hum Evol 50: 534-539, 2006.

Zipfel B, DeSilva JM, Kidd RS: Earliest complete hominin fifth metatarsalImplications for the evolution of the lateral column of the foot. Am J Phys Anthropol 140 (3):532-45, 2009.

Mays SA: Paleopathological Study of Hallux Valgus. Am J Phys Anthropol 126: 139149, 2005.

The 3 POINT PIVOT One Day Course + Delivers a new approach to understanding biomechanics and proposes a fresh way of linking structure to functional differences + Enhances confidence in relating biomechanics to orthotic prescription + Provides a simple assessment means of prescribing budget friendly, high quality modifiable prefabricated orthoses

A SEVERE PES CAVUS

B Dates and locations for upcoming 3 Point Pivot Courses are: Bristol - 9th November 2010 Oxford - 25th January 2011 Leeds - 8th February 2011

ONLY

£95

+ VAT

MILD PES PLANUS

C NEUTRAL FOOT

THE QUADRASTEP SYSTEM One Day Course

D

+ Enhances understanding of differences in foot structure, form and function, as well as new biomechanical concepts + Delivers theory with an emphasis on biology rather than physics + Provides the practitioner with an alternative to reliance on high cost custom devices

MODERATE PES PLANUS

E Dates and locations for upcoming Quadrastep System Courses are: Manchester - 20th September 2010 Oxford - 28th September 2010 Leeds - 23rd November 2010 Bristol - 18th January 2011

ONLY

£95

+ VAT

ABDUCTOVARUS FOREFOOT

F

SEVERE PES PLANOVALGUS

11

Nail Surgery A Step Forward

D

uring a recent conference it was brought to my attention that out of 54 Practitioners in attendance, I was the only one with a Local Anaesthetics Certificate. I wasn’t surprised at this, as a high proportion of these people were either grand-parented podiatrists or Foot Health Practitioners but was shocked that I was the only one with exception of the lecturer. That equates to less than 2% of attendees.

Local Anaesthetics and nail surgery has not been available to private sector podiatrists in the past unless you were “State Registered”.

Since the inclusion of private podiatrists on the HPC register via the grand-parenting route the training to administer local anaesthetics and carry out nail surgery is now available to all podiatrists.

The Institute is considering running a Local Anaesthetics and Nail Surgery course and I whole-heartedly support this but this can only happen if practitioners are prepared to undertake and support this training.

The views I give below are purely my own and based on the course I took and in no way presume it to be better than any other course available. All members should seek advise before undertaking a course of training and make an informed decision about the course that they choose.

In January this year I chose to pursue this avenue of training and the nature of this article is to give an overview of local anaesthetics and nail surgery training and other aspects of carrying out nail surgery in private practice. My aim is to encourage those who feel it’s not for them to perhaps give it a second thought before dismissing it completely.

The course I took was at Glasgow Caledonian University (Ref 1), with the practical aspect of the training at The Southern General Hospital, Glasgow. Caledonian University has a very active Podiatry Department with excellent facilities both at the University and at the hospital. I have to say I was met with very warm, friendly, enthusiastic tutors at a somewhat inhospitable time of year (the big freeze with temperatures outside of –12 degrees. The course is run over two weeks with a week in between for continuous revision.

There are a maximum of twelve students at each cohort (there were four of us) so we had virtually one to one tutoring.

Prior to the Academic week we received our self-directed learning study material together with a list of further reading recommendations, which I would thoroughly recommend sourcing.

Some online auction sites are useful for this as some of the textbooks were a few years old. (Ref 2) The first week consisted of some long days of lectures and additional practical sessions in the early evening.

The course lectures reviewed Anatomy, the physiology of nerves and the vascular system, Vascular and Neurological Assessment., The History of Anaesthetics, Pharmacology, Basic First Aid, LA techniques, LA drugs and associated complications, Nail surgery techniques and associated complications, Health and Safety and medical legal issues in relation to nail surgery.

12

by Gillian Webster M.Inst.ChP

The Friday was arranged that we meet at the hospital’s Podiatry department and this was when the first procedure would be carried out.

My first patient was a fifteen-year-old veteran of nail surgery and was, I have to say somewhat less nervous than me as I administered his Local Anaesthetic. Throughout his partial nail avulsion procedure he proceeded to play electronic bagpipes to me much to everyone’s amusement. This relaxed me and the procedure in my opinion was a textbook case (unlike the patients bagpipe playing) and this lifted my confidence. The young man then proceeded to ask to shake my hand to thank me for the procedure, I came back from Glasgow that weekend with great enthusiasm and confidence. I firmly believe carrying out the first procedure at the end of the first week is excellent as it feeds your interest and wills you to study and pass the exams.

After a week back at work and a head buried in textbooks it was back to Glasgow for the second part of the training. The first day was spent taking the exams. The exams consist of a Multiple Choice Question paper, and a Viva Voce (oral) exam. Both were fairly straightforward and although I felt nervous about the oral exam it was a fairly relaxed “interview” style exam with the questions being asked by a senior lecturer and Head of the Podiatry Department.

The practical aspect was carried out from the following day for four days with procedures throughout the days. By the Friday we had carried out lots of LA injections and a variety of partial and full nail avulsions, the majority using Phenol. On the final day we worked in the morning in the clinic reviewing procedures carried out in the week, redressing the patients toes and giving advise on how to look after their “wound” and then back to surgery in the afternoon.

We were continually assessed throughout the week by two very patient and friendly tutors and were shown various ways of working, using both autoclavable and disposable instruments. This then gave us a choice of working options within our own practices.

I would say that once you have carried out one procedure under LA you will wonder how you ever managed without it. To be able to remove part of a nail without bleeding throughout the procedure and the patient wincing in discomfort takes the pressure off both the patient and practitioner. To be able to see what you are doing in an area devoid of blood is really helpful. Of course, I am not implying that any of us carry out a partial nail avulsion without LA at present but when a large spike of nail is removed sometimes it can be difficult to see if you have taken all of it if the area is bleeding.

Having come away from the course qualified to have my HPC registration annotated with the LA certification the next hurdle was to sort out First Aid training. The one thing we were taught was that an absolute contra-indication to treatment was “lack of resuscitation equipment.”

We were advised that should anyone have an allergic reaction to the LA drug then we should be able to administer adrenalin to counteract this. To be able to do this safely is necessary to take a First Aid course in Anaphylaxis. You should also be able to administer Oxygen. This is a separate course run with

Defibrillation. The first is certificated for 3 years, the second for 1 year and I would recommend that anyone learning nail surgery follow this line of training in First Aid as there is much to learn about administering Oxygen and Adrenalin.

Purchasing Adrenalin initially seemed confusing, as it is a POM drug and I didnâ&#x20AC;&#x2122;t have a POM certificate but having contacted MHRA (Ref 3) and explained the requirement I was advised that as I had the LA annotation I could purchase it from a pharmacy or podiatry supplier.

Adrenalin is available in either an â&#x20AC;&#x153;Epipenâ&#x20AC;?, â&#x20AC;&#x153;Anapenâ&#x20AC;? both of which are very expensive ÂŁ35-ÂŁ50 plus VAT each with a maximum shelf life of 2 years or in ampoule form of 1mg/mL 1 in 1000 in a quantity of 0.5ml.(This dose refers to adults â&#x20AC;&#x201C; refer to BNF for child dosage)(Ref 4) The latter gives you the option of a second dose should the patient require it whereas the others only administer one dose. This is where the Anaphylaxis training is necessary. The ampoule form is available from your pharmacist and cost me less than ÂŁ16 including VAT and has a shelf life of approximately twelve months.

Build bridges with your pharmacist. My pharmacist asked that I supply a letter with my HPC number on it and contact details, exactly what I required including strength and dosage and what it was for and suggested I keep a copy on the computer to re-date and present when I next required it.

Oxygen is also essential and during the First Aid Training we were given the contact details of BOC (Ref 5) who supply medical oxygen. This is available as an easy to use cylinder in a kit bag with mask and full instructions on use were given during the training. It is expensive at ÂŁ225 including VAT per year to hire the cylinder and kit.

There are many practitioners who I have spoken to who do not carry Adrenalin or Oxygen and that is their choice but referring back to what I said earlier about a lack of resuscitation equipment is a total contra-indication to treatment, I firmly believe if you have been taught that you must have it and your training notes state this then you may invalidate your insurance if you donâ&#x20AC;&#x2122;t have it.

We were also taught that we should not work alone, this is not only sensible from a safety point of view but when we were carrying out procedures in the hospital we were taught under theatre aseptic techniques and so it is helpful if you have set up a sterile field to have someone available to fetch anything you may need and to be there to reassure and look after the patient.

I am very lucky. I arrange my nail surgery for a Friday, a day when a colleague of mine who is a trained dental nurse has a day off and is happy to come in to assist me.

I would also urge anyone thinking of taking on nail surgery to write procedures clearly and concisely so that there is guidance for anyone coming in to assist them.

Nail surgery is not rocket science. It is a simple rewarding task that is part of what we do. HPC registered members of the Institute could, with a bit of revision and enthusiasm, go out and learn this much-valued skill as part of their professional repertoire and move us upwards and forward to meet a level playing field with members of other associations.

It is rewarding part of our job and your patients will appreciate what you can offer them.

References:

1. Glasgow Caledonian University, Department of Podiatric Medicine and Surgery, School of Health and Social Care, Cowcaddens Road, Glasgow G4 0BA www.gcu.ac.uk T: +44 (0)141 331 3000 2. www.AbeBooks.co.uk

3. www.mhra.gov.uk/Howweregulate/Medicines/Availabilityprescribing sellingandsupplyingofmedicines/ExemptionsfromMedicinesActrestrictions/ Chiropodists/index.htm 4. British National formulary 51 March 2006 Page 166 Adrenaline/Epinephrine.

5. www.boclifeline.co.uk/en/index.shtml

ZRXOG OLNH WR LQWURGXFH Daisy

'DLV\ ZLOO ILW D ZLGH UDQJH RI VZHOOLQJ HYHQ H[FHSWLRQDOO\ VZROOHQ IHHW

3DGGHG FROODU

3DGGHG FROODU IRU /DFH IDVWHQLQJ RIIHUV H[WUD FRPIRUW DPSOH DGMXVWPHQW

Heidi

+HLGL LV GHHS HQRXJK WR VXSSRUW VKDSHG LQVROHV RU RUWKRWLFV DQG JUHDW IRU VZROOHQ IHHW ZLWK EXQLRQV RU SUREOHP WRHV

Â&#x2026;

Â&#x2026;

:LWKRXW 9$7

:LWKRXW 9$7

'LVFUHHW WRXFK IDVWHQLQJ 6HDP IUHH WRH DUHD

683(5 /,*+7 62/(6

)/(;,%/( 32/<85(7+$1( 62/(6

1R VHDPV LQ WKH VLGH SDQHOV

1R VHDPV LQ WKH WRH DUHD

2UGHU )5(( $XWXPQ &DWDORJXHV

9LVLW ZZZ FRV\IHHW FRP SURIHVVLRQDO _ (PDLO SURI#FRV\IHHW FR XN _ &DOO

SHUIHFW IRU VZROOHQ IHHW 13

Heat wave health advice eading first aid charity St John Ambulance has issued first aid advice to help people cope in the heat, as the Met Office announces its first health alert of the summer.

L

As temperatures rise, the warning is to be prepared, as many heat-related illnesses can be easy to prevent or treat if you notice the symptoms soon enough.

Be cautious

John Newman, Head of Emergency Operations at St John Ambulance, commented: Extreme heat can be dangerous, particularly for the very young and old, but by being prepared you can spot early warning signs of illness and care for someone who needs your help.

Heat exhaustion and heatstroke are the most serious problems that can develop when the sun is out. It’s essential that people look for signs such as headaches and dizziness, and remove themselves from the heat as soon as possible.

‘When the temperature is this hot, St John Ambulance first aiders typically treat people for cramp, fainting, sunburn and dehydration. It's better to prevent these conditions and save yourself unnecessary pain and discomfort by avoiding prolonged periods of sun, drinking plenty of water and limiting alcohol intake.’

Summer first aid advice

Prolonged exposure to the sun or lack of fluids can cause your body to dangerously overheat. If someone is suffering from heatstroke they may have symptoms such as a rapid pulse, headache and dizziness. Their skin will be hot to the touch, red and flushed. As the condition worsens they will become disorientated and confused. It's important to lower their body temperature as soon as possible.

To treat someone suffering from heatstroke, with their permission, remove as much of their clothing as possible and dial 999 for an ambulance. Move them to a cool place and wrap them in a cold, wet sheet or a suitable alternative until their temperature falls. If a sheet isn’t available sponge them with cold water. Once their temperature returns to normal replace the sheet with a dry one and make a note of their pulse and breathing until help arrives.

Useful tips

Heat exhaustion is caused by the loss of salt and water from excessive sweating. Common symptoms include headache, dizziness, cramps, breathing that is fast but weak, and profuse sweating. Take the person into a cool, shady area and make them as comfortable as possible. Get them to lie down with legs raised and give them plenty of water. If you have them available, use isotonic drinks or a sachet of oral rehydration powder in water instead.

Dehydration happens when the fluid lost from the body – usually through sweat – isn’t replaced. Symptoms are a dry mouth and eyes, headaches, dark urine, dizziness and confusion. Avoid it by drinking water regularly, not just

14

when you feel thirsty. The young and old are at particular risk, so it’s crucial to rehydrate them promptly – and if you’re playing sports or other demanding activities, your fluid needs will be much higher. To treat dehydration, drink plenty of fluids; water is normally suitable but you may prefer to add oral rehydration powder to help replace the salts lost from the body.

Fainting can be triggered by heat. If you’re prone to fainting, ensure you eat regularly and don’t stand up for extended periods during the heatwave. If someone faints, advise them to lie with their head down, then raise their legs on to your shoulders to improve blood flow to the brain.

Make sure they have fresh air, and keep bystanders away if you can. Watch their face for signs of recovery, and as they begin to recover, help them to sit up gradually.

Sunburn is one of the most common injuries presented to St John Ambulance volunteers. It’s best to protect yourself by wearing sunscreen, protective clothing and staying in the shade, but if it’s happened already there are some easy ways to ease the pain. As soon as you notice, cover yourself up and move out of the sun. Take frequent sips of cold water and cool the burnt skin with a cold damp cloth, or you may find it more practical to soak the area in a basin or bath of cool water for around ten minutes. Calamine or aftersun lotion can make you feel more comfortable. If your skin is blistered, you should seek medical advice – otherwise, carry on enjoying yourself out of the sun.

You’re more likely to get cramp in the heat as it’s often caused by sweating, dehydration or exercise. The sharp onset of pain makes it alarming, but by carefully stretching and gently massaging the affected muscles it can quickly be brought under control. If it’s in the foot, stand with your weight in the front of the foot to stretch the muscles. If it’s in the calf, straighten your knee and flex the foot upwards. If it’s in the front of the thigh, raise the leg and bend the knee, and if it’s in the back of the thigh you should straighten the knee. Massage the affected muscles afterwards.

If you get a blister from shoes rubbing, don’t burst it. If it’s broken or likely to be damaged, cover with a dry, nonadhesive dressing that extends well beyond the edges of the blister. Do not cover a blister with any creams or lotions.

Further Information: St John Ambulance, 27 St John’s Lane, London EC1M 4BU. Tel: 08700 10 49 50 Fax: 08700 10 40 65 www.sja.org.uk

IOCP Business Matters

Report from Treasurer

Dear Colleagues Since my election to Hon Treasurer, I have been kept very busy aligning myself with all aspects of the business and financial matters in order to reduce costs and ensure membership fees are utilized efficiently for the forthcoming year.

This has not been an easy task, but with the help and the support from my fellow colleagues on the Executive Committee and the team at Head Office, work is progressing well.

I am pleased to report that the following initial savings have been implemented: • We have gained a reduction on the business rates at Southport with a saving of over £1,000 per year • Negotiated reduced rental fees on the Credit Card machines both at Sheffield and Southport • Made considerable savings by reducing the transaction fee/percentage charge on credit card transactions.

This may not seem a lot, but in working through all of the accounts and identifying efficiency savings in conjunction with contractual agreements, it has not been an easy task. Many identified efficiency savings cannot yet be realized due to contractual agreements in place with vendors, service providers and utility companies.

Ongoing projects we are still working on are as follows: • Producing a business plan for The Institute • Review the costs of printing for the Podiatry Review • Re-development of Sheffield • Introducing additional revenue enhancing services at Sheffield clinic • Streamlining systems at both Sheffield and Southport • Promoting the website and The Institute to potential new membership.

If any member has any of their own ideas in promoting The Institute, then please feed these through to your area delegate and these ideas will be included in our ongoing review.

Congratulations

Loreto and Michelle have confirmed places at Queen Margaret University in Edinburgh to do a Masters in Podiatry commencing September 2010.

The Institute wishes to congratulate Loreto Sine, Michelle Taylor and Denise Willis who recently obtained their BSc at Durham University.

15

Diaped Introduces New Doppler Range

Algeos, the UK’s leading supplier of diabetic footcare products are introducing an exciting new range to augment their existing product range.

Koven Hadeco vascular dopplers have now launched in the UK and Ireland under the Diaped brand. Koven Hadeco dopplers are ideal for monitoring, diagnosis, and wound care and are widely used for clinical applications such as Ankle Brachial Index studies and Peripheral Vascular Procedures.

The collection features three dopplers to suit a wide range of applications: The Bidop3 Visual Pocket Doppler, Smartdop 45 Vascular Ultrasound Doppler and the Smartdop 30EX Vascular Ultrasound Doppler.

The BIDOP® 3 is a unique, handheld pocket Doppler that offers diagnostic capabilities previously seen only in large systems. The BIDOP® 3 has a large viewing panel with real-time Doppler waveform display. The built-in microprocessor calculates ratios automatically without the need for manual adjustments. Store up to 30 waveforms for later reference or download to optional Smart-V-Link® vascular software for documentation and reimbursement. An optional PPG (Photoplethysmography) probe for toe pressures is also available.

The Smartdop® 45 by Koven Technology is a lightweight, hand-held bidirectional Doppler for assessment of the vascular condition. It has a large visual LCD screen for viewing realtime waveforms and an integrated printer for documentation.

Optional PPG and pulse volume is available for toe pressures and PVR studies.

The built-in microprocessor calculates ratios automatically without the need for manual adjustments. Save up to 30 waveforms for later reference, print-out, or download to the optional Smart-V-Link® Software. Smart-V-Link® is a

complete vascular software system for performing ABI’s, TBI’s, Segmental Pressures, Pulse Volume Recordings (PVR) and Venous studies.

The Smartdop® 30EX is Koven Technology’s newest bidirectional portable Doppler for documentation and assessment of the vascular condition.

The Smartdop® 30EX is lightweight and portable with an integrated printer, large visual LCD display, and automatic cuff inflator to facilitate quick, simple, accurate ABI, TBI and PVR studies. Optional PPG and pulse volume modules are available for toe pressures and MVO studies. The built-in microprocessor calculates ratios automatically without the need for manual adjustments. Save up to 30 waveforms for later reference, print-out, or download to the optional SmartV-Link® Software. Smart-V-Link® is a complete vascular software system for performing ABI’s, TBI’s, Segmental Pressures, Pulse Volume arterial (PVR) and Venous studies.

Michelle Weddell, Business Development Executive and diabetes specialist at Algeos noted: “The range of Koven dopplers are cost effective compared to competitors due to the studies they are able to carry out. All units can do pulse volumes and arterial and venous studies. You can see the pulse waveforms as well as being able to hear the audible signal. These units can be easily attached to the computer to give printable reports for referring to vascular consultants.”

You can view our Diaped range by visiting www.algeos.com or contact Algeos for your free Diaped brochure.

David Crew at St. Jamesʼs Palace

On Tuesday 1st June 2010 David Crew, Vice Chairman of the Executive Committee attended a reception at St. James’s Palace in the Presence of H.M. The Queen, HRH The Duke of Edinburgh and HRH Princess Alexandra, to mark the occasion of the 100th Anniversary of the Royal Overseas League.

This was followed by a formal ball to mark the occasion.

16

Bidop Visual Pocket Doppler

46 Arthur Arthur’s ’s C Club lub Po Points int ntss

Bi-directional doppler with real-time visual waveform display for peripheral vascular testing.

Cryoalfa

23 Arthur Arthur’s ’s C Club lub Po Points int ntss

Cost effective treatment for a variety of benign skin . lesions, warts and other minor skin conditions.

Callusan

Cost effective device designed to meet customer demand for a simple and powerful podiatry drill.

The airy, light creme mousse does not clog up your pores.

Quickly absorbed by the skin, without leaving any residue residue.

£3.80

125ml 125 ml

Sprint Sp rint ZZERO ERO

£229.50

Snogg Soft 1 is a cohesive, low-allergy, conforming . bandage, perfect for podiatry use.

£3.55

each

Snogg Soft 1

£465.00

High quality leather covered 3-layer adjustable heel lift.

Each layer can be removed for the right lift height.

£6.95

each

Adjust-a-Lift

Letters to Editor

Dear Colleagues This is to thank you for awarding me the Long Service Award. This was presented to me at a branch meeting by our branch secretary which was held in my home together with a bottle of sherry which Dorothy and I shall enjoy. Dorothy also sends her thanks for a delightful bouquet of flowers.

All this came as a wonderful surprise to both of us. I can only repeat what I said to the then Executive which I was awarded the Honorary Fellowship in 1987 “Being given an award for serving the Institute is akin to being given a prize for drinking malt whisky”.

With best wishes to you all Fred Beaumont, Past President, North East Branch Dear Editor, On reading through the motions made at our A.G.M. of this year, my memory was jolted by motion 22 made by the Nottingham Branch which reads “This annual general meeting resolves that the Institute enhances the democratic process and demonstrates transparency from all executive and national officers by listing expenses including travel, loss of earnings and other expenses which may be itemised and made available to the membership”.

I recalled that in my Presidential Address made at the A.G.M. of 2001 at the Moat House Hotel, Cambridge, I made the following statement “This Institute was founded for the public good and for the benefit of the members, run by the members.

A non profit making organisation. No-one has, or does, or

18

ever will make a lot of money out of running this Institute.

No-one travels first class, no-one stays in 5 or 4 star hotels (except at the A.G.M.)”.

Our allowances were as follows - whether travelling by car or train we received the cost of 2nd class rail fare to and from the meeting. At best we stayed in a 2 star hotel. Basic breakfast with morning and afternoon coffee breaks taken in the committee room and lunch of sandwiches, biscuits, tea and coffee also taken in the committee room. Claim was allowed for loss of earning which, if taken, the Institute had to report to HM Inspector of Taxes. In my time this was eventually cancelled. Normally the Executive Meetings started at 9.00 am on the Saturday morning but many members had to travel down the day before due to the distance involved. Often national officers were required to attend a meeting on the Friday or stay behind after the close of the executive on the Sunday to deal with matters concerning their office. Postage and telephone charges had to be accounted for. All charges were scrutinised by our Treasurer, Accountant and Auditors. Now, since I retired from the Executive costs have rocketed; travel, hotel food etc.

Now, the work of the members of the executive does not end with the ending of the meetings. Reports have to be written by area representatives and the officers have to deal with any ongoing problems which may arise between meetings.

Meetings are run strictly on business lines and are frequently very “intense” I am sure that the standard of service given to our members by those who serve on the executive is as high as it was in my time and the membership enjoys the benefits of this service. What I cannot understand is why this query regarding the cost of the executive meeting could not have been asked of our Treasurer following his report at the A.G.M.?

Fred Beaumont, Past President

Continued ProfessionalDevelopment

The Institute of Chiropodists and Podiatrists

Continuing Professional Development This article is one of a series of educational documents that can be inserted into your portfolio and be a contribution towards your personal CPD learning.

Verrucae Pathology Judith Barbaro-Brown MSc BSc(hons) PGCE, DPodM,MChS

Introduction

Viruses differ from all other infectious organisms in their structure and biology, particularly in their reproduction. Although viruses carry conventional genetic information in their DNA or RNA, they lack the synthetic machinery necessary for this information to be processed into new virus material. Viruses are metabolically inert and can replicate only after infecting a host cell and parasitizing the host’s ability to transcribe and/or translate genetic information. Viruses infect every form of life. They cause some of the most common and many of the most serious diseases of humans. Some insert their genetic material into the human genome and can cause cancer. Others have the ability to remain latent in different cell types and then reactivate at any time but especially if the body is stressed. Viruses are difficult targets for antiviral agents as it is difficult to target only those cells infected by the virus. However, many can be controlled by vaccines.

Viruses range from very small (poliovirus, at 30 nm) to quite large (vaccinia virus, at 400 nm, is as big as small bacteria). Their organization varies considerably between the different groups, but there are some general characteristics common to all:

The genetic material, in the form of single-stranded (ss) or doublestranded (ds), linear or circular RNA or DNA, is contained within a coat or capsid, made up of a number of individual protein molecules (capsomeres).

The complete unit of nucleic acid and capsid is called the ‘nucleocapsid’, and often has a distinctive symmetry depending upon the ways in which the individual capsomeres are assembled. Symmetry can be icosahedral, helical or complex. ● In many cases, the entire ‘virus particle’ or ‘virion’ consists only of a nucleocapsid. In others, the virion consists of the nucleocapsid surrounded by an outer envelope or membrane. This is generally a lipid bilayer of host cell origin, into which virus proteins and glycoproteins are inserted.

The outer surface of the virus particle is the part that first makes contact with the membrane of the host cell. The structure and properties of the outer surface of the virus particle are therefore of vital importance in understanding the process of infection. In general, naked (envelope-free) viruses are resistant and survive well in the outside world; they may also be bile-resistant, allowing infection through the gastrointestinal tract. Enveloped viruses are more susceptible to environmental factors such as drying, gastric acidity and bile. These differences in susceptibility influence the ways in which these viruses can be transmitted.

Infection of Host Cells

Virus particles enter the body of the host in many ways. The most common forms of virus transmission are: ● ● ●

via inhaled droplets (e.g. rhinovirus, influenza) in food or water (e.g. hepatitis A, noroviruses)

by direct transfer from other infected hosts (e.g. HIV, hepatitis B) from bites of vector arthropods (e.g. yellow fever, West Nile virus).

Viruses show host specificity and usually infect only one, or a restricted range, of host species. The initial basis of specificity is the ability of the virus particle to attach to the host cell.

The process of attachment to, or adsorption by, a host cell depends on general intermolecular forces, then on more specific interactions between the molecules of the nucleocapsid (in naked viruses) or the virus membrane (in enveloped viruses) and the molecules of the host cell membrane. In many cases, there is a specific interaction with a particular host molecule, which therefore acts as a receptor.

Attachment to the receptor is followed by entry into the host cell.

After fusion of viral and host membranes, or uptake into a phagosome, the virus particle is carried into the cytoplasm across the plasma membrane. At this stage, the envelope and/or the capsid are shed and the viral nucleic acid released. The virus is now no longer infective: this ‘eclipse phase’ persists until new complete virus particles reform after replication. The way in which replication occurs is determined by the nature of the nucleic acid concerned.

Replication

Viruses contain either DNA or RNA, never both. The nucleic acids are present as single or double strands in a linear (DNA or RNA) or circular (DNA) form.

The viral genome may be carried on a single molecule of nucleic acid or on several molecules. With these options, it is not surprising that the process of replication in the host cell is also diverse. In viruses containing DNA, mRNA can be formed using the host’s own RNA polymerase to transcribe directly from the viral DNA. The RNA of viruses cannot be transcribed in this way, as host polymerases do not work from RNA. If transcription is necessary, the virus must provide its own polymerases. These may be carried in the nucleocapsid or may be synthesised after infection.

September/October10CPD

Continued ProfessionalDevelopment Once viral mRNA has been formed, it is translated using host ribosomes to synthesise viral proteins. Viral mRNA can displace host mRNA from ribosomes so that viral products are synthesised preferentially. In the early phase, the proteins produced (enzymes, regulatory molecules) are those that will allow subsequent replication of viral nucleic acids; in the later phase, the proteins necessary for capsid formation are produced.

In viruses where the genome is a single nucleic acid molecule, translation produces a large multifunctional protein, a polyprotein, which is then split enzymatically to produce a number of distinct proteins. In viruses where the genome is distributed over a number of molecules, several mRNAs are produced, each being translated into separate proteins. After translation, the proteins may be glycosylated, again using host enzymes.

Viral DNA may become complexed with host histones to produce stable structures. With herpes viruses, mRNA translated in the cytoplasm produces a DNA polymerase that is necessary for the synthesis of new viral DNA; adenoviruses use both viral and host enzymes for this purpose. With retroviruses (e.g. HIV), synthesis of new viral RNA occurs in the nucleus, host RNA polymerase transcribing from the viral DNA that has become integrated into the host genome.

The final stage of replication is assembly and release of new virus particles. Assembly of virus particles involves the association of replicated nucleic acid with newly synthesised capsomeres to form a new nucleocapsid. This may take place in the cytoplasm or in the nucleus of the host cell.

Enveloped viruses go through a further stage before release.

Envelope proteins and glycoproteins, translated from viral mRNA, are inserted into areas of the host cell membrane (usually the plasma membrane).

The progeny nucleocapsids associate specifically with the membrane in these areas, via the glycoproteins, and bud through it. The new virus acquires the host cell membrane plus viral molecules as an outer envelope, and viral enzymes may assist in this process. Host enzymes (e.g. cellular proteases) may cleave the initial large envelope proteins, a process that is necessary if the progeny viruses are to be fully infectious. Release of enveloped viruses can occur without causing cell death so that infected cells continue to shed virus particles for long periods.

Insertion of viral molecules into the host cell membrane results in the host cell becoming antigenically different. Expression of viral antigens in this way is a major factor in the development of antiviral immune responses.

Human Papilloma Virus

There are over 120 different types of papillomavirus which can infect humans. Papillomaviruses are 55nm diameter, icosahedral, doublestranded DNA viruses and cause skin papillomas (warts). The different types that can infect humans show over 50% cross-hybridization of DNA, although not all types are common. Human papillomaviruses (HPV) are species-specific and distinct from animal papillomaviruses.

They are highly adapted to human skin and mucosa and are ancient associates of our species; therefore, for most of the time they cause little or no disease. They show some adaptation to definite sites on the body: ●

● ●

At least 40 types, including HPV 6, 11, 16 and 18, can infect the anogenital tract and other mucosal areas and are sexually transmitted HPV 1 and 4 tend to cause plantar warts

HPV 2, 3 and 10 cause warts on the knees and fingers.

September/October10CPD

Papillomaviruses are generally transmitted by direct contact, but they are stable and can also be spread indirectly. For instance, plantar warts can be acquired from contaminated floors or from the non-slip surfaces at the edges of swimming pools, and in a given individual warts can be spread from one site to another by shaving.

After entering the body via surface abrasions, the virus infects cells in the basal layers of the skin or mucosa. There is no spread to deeper tissues.

Virus replication is slow and is critically dependent upon the differentiation of host cells. Viral DNA is present in basal cells, but viral antigen and infectious virus are produced only when the cells begin to become squamified and keratinised as they approach the surface. The infected cells are stimulated to divide and finally, 1-6 months after initial infection, the mass of infected cells protrudes from the body surface to form a visible papilloma or wart. There is marked proliferation of prickle cells, and vacuolated cells are present in the more superficial layers.

Immune responses eventually bring virus replication under control and, several months after infection, the wart regresses, although this can take up to two years. It seems likely that viral DNA remains in a latent state in the basal cell layer, infecting an occasional stem cell, and is therefore retained within the layer as epidermal cells differentiate and are shed from the surface. Hence, when patients are subsequently immunocompromised (e.g. post-transplant) crops of warts may result from reactivation of latent virus in the skin.

HPVs establish their productive life cycle exclusively in stratified epithelium of skin or mucosa. These tissues are complex, composed of several different cell types, majority of which comprise layered sheets of keratinocytes in various stages of differentiation. The remaining cell types include melanocytes, Langerhans cells and Merkel cells.

There are two types of dividing keratinocytes in the epidermis: ● slowly cycling undifferentiated stem cells cells capable of transient proliferation in basal cell compartment

These undifferentiated proliferating keratinocytes are the initial target for productive HPV infections. Some of the infected cells loose the contact with the basal membrane and move up into the suprabasal compartment of proliferating cells, where they establish latently infected proliferating cell population. Subsequent steps in the viral life cycle are strictly dependent on the differentiation of the host epithelium. During the normal skin development, uninfected keratinocytes exit the cell cycle and commit to the terminal differentiation ultimately leading to apoptosis. HPVs have evolved mechanisms to adapt to the normal cellular growth control pathways and adjust their DNA replication cycle and maintenance cycle to contend with all different cell states. The successful infection of a keratinocyte triggers the initial amplification of papillomaviral (PV) DNA copying. This is followed by the stable maintenance phase of the HPV genome per cell. Finally, vegetative amplification of the viral DNA is performed. The precise mechanisms responsible for the switch from one replication mode to another is unknown, however, it seems to be closely bound up with the differentiation state of the cells.

The second amplification round in a subset of spinous cells results in the synthesis of viral capsid proteins and assembly of virus particles that are ultimately shed from a small number of superficial cells during desquamation. The HPV replication cycle takes at least 3 weeks, as this is the time required for the keratinocyte to undergo complete differentiation cycle.

E6/E7 proteins

The viral oncogenes (oncogenes are mutated genes which make cells proliferate), E6 and E7, are thought to modify the cell cycle so as to keep the differentiating host keratinocyte in a state that allows amplification of viral genome replication and consequent late gene expression. E6, in association with host E6 AP (associated protein), acts to modify p53 leading to its proteosomal degradation. Normally, p53 is a protein that functions to block the cell cycle if the DNA is damaged. If the damage is severe this protein can cause apoptosis. p53 levels are increased in damaged cells. This allows time to repair DNA by blocking the cell cycle. A p53 mutation is the most frequent mutation leading to cancer.

Continued ProfessionalDevelopment E7 (in oncogenic HPVs) acts as the primary transforming protein. E7 competes for retinoblastoma protein (pRb) binding, freeing the transcription factor E2F to transactivate its targets, thus pushing the cell cycle forwards.

All HPV can induce transient proliferation, but only HPV 16 and 18 can immortalise cell, i.e. stop the normal limitation of cell division, allowing infinite cell divisions. In the upper layers of the host epithelium, the late genes L1 and L2 are transcribed/translated and serve as structural proteins which encapsidate the amplified viral genomes. Encapsidation is the process of incorporating a nucleic acid sequence (e.g., a vector, or a viral genome) into a viral particle. Once the genome is encapsidated, the capsid appears to undergo redoxdependent assembly/maturation which is tied to a natural redox gradient that spans both suprabasal and cornified epithelial tissue layers. Redox refers to a reduction-oxidation process. This stabilises virions, and increases their specific infectivity. Virions can then be sloughed off in the dead squames of the host epithelium and the viral lifecycle continues.

Daughter cells of epithelial stem cells divide along the basement membrane and then mature vertically through the epithelium without further division (right side of diagram). After introduction of HPV into stem cells in the basal layer of the epithelium, expression of viral nonstructural proteins occurs (left side of diagram). Under the regulation of these proteins, the dividing-cell population expands vertically and epithelial cell differentiation is delayed and is less complete. Viral proteins are expressed sequentially with differentiation as shown, and mature virions are produced only in the most superficial layers of the epithelium. Intraepithelial antigen-presenting cells (APCs) are depleted in the HPV-infected epithelium.

Latency period

Once an HPV viron invades a cell, an active infection occurs, and the virus can be transmitted. Several months to years may elapse before squamous intraepithelial lesions (SIL) develop and can be clinically detected. The time from active infection to clinically detectable disease makes it difficult for someone who has become infected to establish the source of infection.

Clinical presentation

There are multiple presentations of HPV infection, but typically they present as warts. Cutaneously, there are a variety of shapes and types.

Warts can be: ● filiform with finger-like projections ● flat topped ● flat because they grow inwards due to external pressure (e.g. plantar warts) ● a cauliflower-like protuberance (e.g. genital warts) ● a flat area of dysplasia, such as on the cervix.

Common warts (verruca vulgaris)

Common warts are well-demarcated, rough, hard nodules or plaques with an irregular surface. Common sites for cutaneous warts include the dorsum of the hand, between the fingers, periungually, on the palmer and plantar surfaces, and rarely, on mucous membranes.

Common warts are usually asymptomatic unless located on a pressure point, and rarely undergo malignant degeneration. Common verruca represent the most frequent clinical lesions produced by the human papillomavirus. The morphology can vary considerably from relatively smooth, sessile lesions (lying close to the skin surface), to large pedunculated lesions. These are particularly

common in childhood where immature immunologic resistance and frequent skin-to-skin contact with other children increases the likelihood of transmission. Another group who exhibit a high infection rate are meat, poultry and fish handlers. So called “butchers warts” are usually caused by HPV 2 or 7, although the reason why this occurs more commonly in this group of workers is unknown. Individuals with atopic dermatitis appear to have a mild T-cell defect as suggested by a higher prevalence of infection with common warts, and exhibit more numerous lesions. The presence of atopy (allergic predisposition) should be suspected when older children or adults present with more than a dozen common verruca and no other cause of immunosuppression.

Plantar warts (myrmecial)

Plantar (or myrmecial) warts affect mostly adolescents and young adults. They present as thick painful endophytic plaques located on the plantar or palmar surfaces. The lesion is often covered by a thick callous, reduction of which reveals punctate bleeding. One of the distinguishing features is that plantar warts lack dermatoglyphics (the ridges, whorls, and loops that are characteristic of a palm, digit, or sole print of an individual), with the skin striae appearing to form around rather than through the lesion.

These lesions are remarkable for their thickness due to their presence in the acral skin of the hands and feet. The greater depth of infected tissue makes these warts more difficult to treat successfully compared with warts in non-acral skin.

HPV 1 is the most common cause of palmar and plantar warts, although HPV 2 and other viruses cause them. HPV 60, a much less common cause of plantar warts, and is associated with palmoplantar warts that have cystic components. HPV 63, also an uncommon cause of plantar warts, and can cause a punctuate, mosaic-type plantar wart

Flat warts (mosaic warts)

Warts of this type are less exophytic (out-growing) than common warts, frequently presenting as several or dozens of subtle papules 2-4 mm in diameter elevated above the surface by less than a millimeter or so. They can be quite subtle, and may be missed by a casual observer. Pigmentary disturbances may be the most disturbing part of a flat wart infection to the patient. These lesions are frequently a problem on the face and glabrous (hairless) skin of nonimmunocompromised individuals. Flat warts in this setting are commonly caused by HPV 3, 10 and occasionally by HPV 2. A number of other HPV types cause flat warts in glabrous skin, but most of these are seen exclusively in immunocompromised individuals and in epidermodysplasia verruciformis. Treatment can be difficult even in an immunocompetent individual.

Epidermodysplasia Verruciformis

Epidermodysplasia Verruciformis (EDV) is an autosomal recessive disorder of cutaneous immunity which makes affected individuals susceptible to a subset of warts not seen in other individuals. The advent of transplant technology and HIV / AIDS has changed this, and now cases of clinical infection with these viruses are seen in immunocompromised individuals. HPV types characteristic of the disorder include HPV 3, 5, 8, 9, 10, 12, 14, 17, 20, 21, 23, 25, 28, 38, 47, 49.

September/October10CPD

Continued ProfessionalDevelopment Relative effectiveness of treatments

Warts in EDV are typically flat, numerous and subtle, but may be erythematous. When the disease begins to manifest in childhood, the warts sometimes give the clinical appearance of tinea versicolor. They can involve almost any area on the body, but tend to be more prominent on the extremities, especially the arms.

A 2006 study assessed the effects of different local treatments for cutaneous, non-genital warts in healthy people. The study reviewed 60 randomized clinical trials dating up to March 2005. The main findings were: ● overall there is a lack of evidence (many trials were excluded because of poor methodology and reporting). ● the average cure rate using a placebo was 27% after an average period of 15 weeks ● the best treatments are those containing salicylic acid. They are clearly better than placebo ● there is little clinical trial data for the absolute efficacy of cryotherapy ● two trials comparing salicylic acid and cryotherapy showed no significant difference in efficacy ● one trial comparing cryotherapy and duct tape occlusion therapy showed no significant difference in efficacy ● evidence for the efficacy of the remaining treatments was limited.

Learning Objectives 1.

2.

3.

describe the method by which viruses enter a cell, replicate, and release further viral particles understand the structure if the papilloma virus appreciate the role of the human papilloma virus in the development of cutaneous pathology.

Key Learning Points: 1.

2.

3.

4.

5.

6.

The combination of HPV infection, relative immunosuppression and sunlight are a potent carcinogenic combination; if these individuals are not recognized and treated appropriately, they are at substantial risk of developing skin cancers, such as squamous cell carcinoma (Bowen’s disease).

7.

8.

9.

10.

11.

12.

13.

14.

15.

September/October10CPD

Viruses have RNA or DNA but are absolutely dependent upon the host to process their genetic information into new virus particles.

The outer surface of a virus (capsid or envelope) is essential for host cell contact and entry, and determines the capacity to survive in the outside world.

Viruses are most often transmitted in droplets, in food and water or by intimate contact.

Replication of viral RNA or DNA is a complex process, making use of host and/or viral enzymes.

RNA of retroviruses becomes integrated into the host genome.

New virus particles are released by cell lysis or by budding through the host cell membrane.

Some viruses, such as herpes viruses, may become latent and require a trigger to resume replication; others replicate at a slow rate, persisting as a source of infection in symptomless carriers.

A number of viruses transform the host cell by interfering with normal cellular regulation, resulting in the development of a cancer cell. This may be the result of the activity of viral or cellular oncogenes.

HPV are species-specific, and are highly adapted to human skin and mucosa.

They are generally transmitted via direct contact, but may also transmit indirectly.

The virus will not affect tissues deeper than the basal layer of the epidermis.

Differentiation and proliferation of the host epithelium is affected by the virus.

HPV produces transient proliferation in keratinocytes.

Lesions may have many presentations, and can appear on any epidermal surface.

Patients who are immunosuppressed are at risk of developing multiple, resistant lesions, which are difficult to treat.

A proven foot therapy now designed and delivered in a professional way with the PODIATRIST DESIGNED PediRoller Stretching and strengthening programmes play an important role in the treatment of heel and arch pain caused by plantar fasciitis.

In a study* 83% of patients involved in stretching programmes for heel pain were successfully treated.

LATEX FREE CAN BE FROZEN RIDGED DESIGN AIDS CIRCULATION EXERCISE LEAFLET INCLUDED

available at â&#x20AC;

and independent pharmacies

PediRoller

Helps relieve heel & arch pain www.pediroller.co.uk

â&#x20AC; Available

from selected Boots stores subject to availability. *Reference: Wolgin M, Cook C, Graham C, Mauldin D. Conservative treatment of plantar heel pain: long-term follow-up. Foot Ankle Int. 1994;15:97-102

Cuxson Gerrard & Co. Ltd, 125 Broadwell Road, Oldbury, West Midlands B69 4BF, England. Tel: 0121 544 7117 Carnation is a registered trade mark. Carnation PediRoller registered design pending.

She saved Money Her Podiatry Business & H er S anity! ͞ZdZ Őŝǀ ͞Zd Z ŐŝǀĞƐ LJŽƵ Ă ĨƵůů Ƶůů ƚŝŵĞ ƌĞĐ ƚŝŵĞ ƌĞĐĞƉƚŝŽŶŝƐƚ Ăƚ Ă ĨƌĂĐƚŝŽŶ ŽĨ ƚŚĞ ĐŽƐƚ͟ When Podiatrist Jennie Spencer moved to her own newly built clinic she immediately missed the convenience of having a full time receptionist answering the telephone, making diary bookings, dealing with enquiries and cancellation or just moving appointments and giving out clinic information.

The anxiety generated in missing calls and having to interrogate an answer machine (which few of her patients liked), was unbearable. :ĞŶŶŝĞ ƚŚŽƵŐŚƚ ͞Why not share with other professionals a remote receptionist connected via the internet.͟ It would be cost effective, efficient and give a professional image to all those phoning in.

And it would provide cover through all the working hours which the business could never afford by itself.

She could not find a company to provide the professional, friendly and individually tailored service she wanted so rather than be defeated, she started the company - Real Time Rece ecept ption ʹ herself!

Five years on the systems and methods of the service are well tried and tested, becoming a popular choice for individuals, start-up clinics and multi-practitioner ones.

9 9 9

Growing business? No need to engage extra admin staff- Simple!

Moving premises, taking on extra associates? - Simple! ^ŶŽǁĞĚ ŝŶ ĂŶĚ ĐĂŶ͛ƚ ŐĞƚ ƚŽ ƚŚĞ ĐůŝŶŝĐ͍ ʹ Simple!

Real Time Rece ecept ption provides simple solutions to all these problems. /ƚ͛Ɛ ĨůĞdžŝďůĞ ĂƐ ǁĞůů͘​͘​͘

o o o o o

o o o

We can tailor our service to your needs.

We can take multiple calls for you, and your colleagues We can give your clients all the information they need.

Your calls answered and appointments made from 8.30 to 5.30 Your calls answered with your business name.

Calls answered when LJŽƵ͛ƌĞ ŝŶ ĐůŝŶŝĐ͕ ŽŶ ŚŽůŝĚĂLJ͕ sick or training.

No employment issues.

You choose when you want to divert calls or answer yourself, you can let us pick up the calls when your receptionist is busy.

You are then fr free to pursue your real business 20

0845 873 3251

www.realtimereception.com

Sheffield Branch Seminar

$4&00+&9-#:")(;#<&%')1*&,1#$%")1;#=9/># ?&&9&@#.',(#A"'-B#$4&00+&9-#$C#7D2

Sunday 17th October 2010 !"#$%&'(&)#$&*+,')#',-#./00&1#2/,34#5#678 !"#$%&'# ()*+),-,((,*)),,,,,,,,,,,,,,,,,,,,,,,,,,,.#/!0$1%$!2345266## ((*)),-,(7*,(8, ,9#:$;1#,

<=%1"%:2'2/> ?%1$!3,@%1A#>,?*B30$*5=*<*C,DE:,<2F,?#F, G.E?C,<H,5#1$

(7*(8,-,(+*(8, D;66#$,9;3:=,,,ID%1,JA%!'%&'#K (+*(8,-,(+*+),,,,,,,,,,,,,,,,,,,,,,,,,,,,,@##'#>,E;1/!:%',9$F (+*+),-,(L*+),,,,,9#:$;1#,

9>"M=2#F#"%, ?%1/%1#$,@%11!023C,EM#:!%'!0$,N;10#

These two exciting speakers will be sure to give us a very interesting and informative update on their chosen topics.

Present throughout the day

Heeley Surgical Ltd. â&#x20AC;&#x2DC;How to Revolutionise your thinking about working with single-use equipmentâ&#x20AC;&#x2122;

To Book a place Contact Debbie Straw (Secretary) Tel: 01623 452 711 Email: debbie.straw1@ntlworld.com

Please Book by 17th September 2010

THE INSTITUTE OF CHIROPODISTS AND PODIATRISTS

Leicester and Northants Branch

Autumn Seminar 2010 Sunday 28th November 10:00 - 4:00p.m. at

Lutterworth Cricket Club, Coventry Road, Lutterworth

Dermatology Guest speaker

Ivan Bristow Msc, FCPodMed

Lecturer in Podiatry Faculty of Medicine, Health and Life sciences University of Southampton

Autoclave Service available by prior arrangement Trade support from Canonbury

Cost of day is ÂŁ80.00 Including lunch, refreshments and free parking Closing date for registration is 1st October 2010

Name .............................................................................................

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

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

Tel .............................................................................

Dietary requirements ........................................................

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

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

Please make cheques payable to L&N Branch and send with booking form to: Mr. D. Ayres (Treasurer) Little Acre, Stemborough Lane, Leire, Leicestershire LE17 5EX Any other information please contact Sue Forster on email sue.IOCP@ntlworld.com

22

The University of Central Lancashire, Preston

23

NEW DATE The Institute of Chiropodists & Podiatrists MIDLAND AREA COUNCIL 3rd ANNUAL SEMINAR Saturday 30th October 2010

Hilton Hotel, Braunstone, Leicestershire LE19 1WQ Off Junction 21, M1 Free Parking

PROGRAMME 9:00 Registration, tea, coffee & Danish Pastries

9:30 Podiatric Rheumatology Judith Barbaro-Brown MSc PGDip BSc PGCE MChS DPodM BA Teaching Fellow Durham University 11:00 Refreshments & Biscuits 11:20 Part 2 Podiatric Rheumatology 12:30 3 Course hot & cold buffet & Trade 2:00 Silicon njection Therapy Dr Frank L Bowling. Research Fellow/Podiatrist University of Manchester and Manchester Royal Infirmary.

3:00 Interval, Tea, Coffee & warm cookies 3:20 Practical Demonstration 4:30 CPD Certificates and close of seminar COST: ÂŁ75

The seminar is open to Chiropodists and Practitioners from all organisations and all will be made very welcome. Further information contact Pam 01386 47695

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

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

24

New Date for the Midland Area Council 3rd Annual Seminar

T

Saturday, 30th October, 2010

he Midland Area Council wish to offer apologies for the change of date of the seminar from that which had previously been published. Several occurrences beyond its control resulted in having to reschedule a date several weeks later. It is hoped that members will not be unduly inconvenienced and as a goodwill gesture the MAC is holding the Delegate fee at £75 for all future bookings.

Once again, we have chosen one core subject for the day, as with dermatology and diabetes in previous years, because there is provision of a more concentrated approach to the subject and allied conditions; provides ample time for your questions as well as structuring the day so all may feel that, at conclusion, they have advanced their continuous professional development on the subject in an encompassing way but well-paced to absorb information. Inter-active and hands-on sessions ensures that there is not the need for all-day note-taking and the subject matter chosen is listed in 2b.2 of the HPC Standards of Proficiency.

We are delighted to welcome back again Judith Barbaro-Brown as key presenter, Teaching Fellow at the University of Durham, and who is very supportive of the Institute and its membership. Judith always receives accolades for her knowledge and lightness of touch in presentations; is always approachable and ensures an enjoyable approach to learning. Her presentation will include new drug therapies: do you know what they do?

Are you aware of associated problems you might see if patients are taking these drugs? How does RA pathology contribute to lower limb neuropathy? All these questions will be answered and a free CD Rom provided of the presentation.

After lunch Dr Frank Bowling will present and demonstrate Innopad Silicone Injection Therapy with representation from the company Osteotec. Dr Bowling is currently a Research Fellow/Podiatrist in the University of Manchester and Manchester Royal Infirmary and has authored and co-authored over twenty publications in various medical journals.

Innopad silicone is indicated for direct sub-dermal injection into the plantar surface of the foot for soft tissue augmentation where the plantar fatty pad is compromised over pressure points which are painful to walk upon or at risk of ulceration. There will be opportunity for practitioners to practice on chicken breasts! To administer to patients does require a current LA certificate but this should not be a bar to learning more at first hand as Podiatric Surgeons and PCT’s are increasingly carrying out the therapy and it may be that we see patients that have had the treatment and therefore we need to keep upto-date.

We are also pleased and delighted that, once again, Heather Bailey our President and Bill Liggins, Chair of the Board of Education have accepted our invitation to attend. Both work extremely hard for the furtherance of the Institute and its membership, have many calls on their time and so it is much appreciated that they give their support to seminar events and to meet with the membership.

The Hilton Hotel, Braunstone, Leicester, LE19 1WQ just off Jct 21 of the M1 has been chosen again as our venue because the accommodation is very comfortable and spacious; the buffet lunch is very good; inclusion of Danish pastries with refreshments at Registration, [welcome for those having made an early start], and there is provision of warm cookies with the afternoon’s coffees and tea. Along with free parking we feel it meets our requirements when offering practitioners a professional and enjoyable learning event.

All welcome at the Midland Area Council Seminar and apologies again for any confusion or disappointment by the change of date. We hope that it will be a most enjoyable learning day!

Valerie Dunsworth, Midland Area Council

25

Heeley Surgical Ltd Manufacturer of Surgical Instruments Quality without compromise

Why Choose Heeley Surgical Ltd.....

Outstanding Quality Manufacturing Expertise ISO 13485 & CE Mark Full Traceability

Reusable Single Use - Sterile & Non Sterile Custom Sets/Packs Replacement Guarantee

We are a company that offer a wide range of the highest quality podiatry surgical instruments available in todayâ&#x20AC;&#x2122;s market place, in both single use and reusable form, at very competitive prices.

Our single use instruments imitate their reusable equivalents. All carry the wording single use and the recognised worldwide single use logo 2 . They can be supplied sterile or non-sterile, if supplied sterile they come double peel pouched with full traceability and a tear off barcode to attach to patients notes.

We are also able to assemble any size of sterile sets to suit your requirements.

All products manufactured and supplied by Heeley Surgical Ltd comply with the requirements of recognised standards; these include British, European and International quality management systems ISO 13485. All our instruments carry the CE Mark.

Our instruments are made from the highest quality materials and carry a replacement guarantee.

Managing Director, Mr Alan Heeley, has 48 years experience in surgical instrument manufacturing and design.

Having been an instrument maker himself he brings an in depth knowledge and expertise to the company.

If Heeley Surgical Ltd can be of any help or service to you, or you would like to discuss any requirements you may have we would welcome the opportunity to provide you with any information or help you may require.

Market sectors supplied by Heeley Surgical

Private hospitals and clinics Trade Companies

Primary Care Trusts

04 Park Square, Thorncliffe Park, Sheffield S35 2PH Tel: 0114 220 2272 Fax: 0114 220 2271 Email: sales@heeleysurgical.com Web: www.heeleysurgical.com

26

Fed up with rough callus, dry and cracked skin?

Is it taking too much treatment time?

Dry, flaky skin and rough thick callus are on the increase. >ĂƵĨǁƵŶĚĞƌƐ͛ ŶĞǁ ĂůůƵƐ ZĞĚƵĐƚŝŽŶ ƌĞĂŵ helps to restore the skins natural state, reduce callus - softening skin and speeding up your treatment.

A 3 week dermatological usage test with sonographic callus thickness evaluation showed conclusive results C allus reduction 0 -5 -10 -15

shiftn i %

-20

D iffere nz u inc%tion Red

-25

%

-30 -35 -40 -45 -50 1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

testperson

CALLUS REDUCTION CREAM x Reduces callus by up to 50% (avg 30%); x Cares for the skin with Willow Bark extract; x Works quickly and reliably; y x Contains salicylic acid and allantoin; x For soft smooth skin.

HYDROBALM x Increases skin moisture by more than 24%; x With 10% urea; x Clear improvement in the skin structure; x With regular use dry skin areas are rehydrated and regenerated; x Good skin compatibility.

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

Sky Pro Cycling Appoint Systagenix as Official Wound Care Partner Systagenix Wound Management is delighted to announce an exclusive partnership with British based Sky Pro Cycling, the worlds newest and most talked about professional cycling team.

Systagenix will be Team Sky’s official wound care partner for the next three years and will support them in their ambition to become the greatest sports team in the world.

Offering the latest wound care technology and professional advice, with cutting edge products, including TIELLE®, SILVERCEL® Non Adherent and PROMOGRAN® Systagenix will help improve Team Sky’s rider’s injury recovery time to ensure they are in the best possible condition for every ride.

“We are delighted to be partnering with Team Sky whose values and mission are synergistic with our own,” comments Steve Atkinson CEO for Systagenix Wound Management. “The team’s professionalism and performance based culture are inspirational and again aligned to our own as we both strive to deliver optimum performances in our respective environments.”

“We are committed to providing the team with innovative products and in-depth technical support to maximise riders recovery times. Our experience and understanding of wound

healing will give Team Sky the confidence that they are receiving the most advanced wound care treatments available.”

Team Sky’s Doctor, David Hulse, comments, “The riders and carers are all very impressed with the support from Systagenix. In particular, the TIELLE® and BIOCLUSIVE® products are proving to be excellent - they are adhesive whilst also having the necessary flexibility around moving joints. We've had some really impressive healing times using TIELLE® for road rash.”

In March, Team Sky was awarded a place in this year's Tour de France by race organisers ASO. The team will line up alongside 22 other professional cycling teams at the prologue in Rotterdam on Saturday 3 July.

David Bailsford, Principal of Team Sky remarks, “We are delighted to be working with Systagenix Wound Management. Competitive cycling is a highly pressured sport and brings with it many challenges and injury risks and we are fortunate to have found the perfect partner in case injury occurs. With our profile, attitude and success, we want to motivate millions of people around the world to get on their bikes and ride for fun, for fitness and the environment.”

27

Continuing Professional Development 2010 !"#$"%$"&'()!*+,,$!"-.'/+0+.!12+"#'3454'

(6/789:7 '/;:<896=6>?

F!)2-.'G';A%B-#$!"-.

!"#$%!&'(")' *+"*,-*$'./0/

9@+'-$2'$,'#!'%1A-#+'1)-B#$#$!"+),'$"'#@+')+B!&"$#$!"C #)+-#2+"#'-"A'2-"-&+2+"#'!*'B!22!"',D$"'-"A'"-$.

B!"A$#$!",'-"A'2-.$&"-"#',D$"'.+,$!",E'7"B.%A+,'-'1)-B#$B-. ,+,,$!"E

9H96:IJ' K$..'=$&&$",'L'<-)#$" M-)0+N

1*2#*3 76 ('9)-$"$"&' +"#)+C'I@+**$+.A

Q8I H=8:'L'R;H:6=6>7 8='8II;II<;R9

F!)2-.'G';A%B-#$!"-.

!"#$%!&A'0B")'9C"D-*$'./0/

1: ;<=:7': 5 458> Q-,B%.-)'-,,+,,2+"#'$,'-')+S%$)+A'1-)#'!*'#@+'#)+-#2+"# )+&$2+"'*!)'-"N'1-#$+"#E'M!T+0+)C'T$#@'#@+')-1$A.N'$"B)+-,$"&' "%2U+)'!*'1-#$+"#,',%**+)$"&'*)!2'A$-U+#+,'2+..$#%,'-"A'-"' -&+$"&'1!1%.-#$!"C'-',N,#+2-#$B'-11)!-B@'#!'#@+',%UV+B#'$,' +,,+"#$-.E'9@+'B!%),+'T$..'$"B.%A+'.+B#%)+'2-#+)$-.'-"A'W@-"A,X' !"W'%,$"&'A!11.+)'-"A'8"D.+GU)-B@$-.'$"A+Y+,E'7#'$,'A+,$&"+A'#!'

U+'$22+A$-#+.N'-11.$B-U.+'#!'N!%)'1)-B#$B+'-"A'#!'.$"D'T$#@' #@+'R+%)!.!&$B-.'-,,+,,2+"#'B!%),+E

454657 ' O' 'P544 898'454657 ' O' 'P534

454657 ' O'

9H96:IJ K$..'=$&&$",'L'Z!@"' (-##+),!"

P544

1*2#*3 76 ('9)-$"$"&' +"#)+C'I@+**$+.A 898'454657 ' O'

'P534

85<79=9?@;:=': 5 458> 9@$,'B!%),+'!*',#%AN'@-,'U++"'A+,$&"+A'#!'@+.1'N!%'%1A-#+ N!%)'D"!T.+A&+'!*'"+%)!.!&$B-.'-,,+,,2+"#'!*'#@+'.!T+)'.$2U' *!)'*!!#'"+%)!1-#@N'%,$"&'-'"+%)!#@+,$!2+#+)C'"+%)!1-AC' "+%)!1+"'-..'*!)'"+)0+')+,1!",+C'#+,#$"&')+*.+Y+,'+#B' B!22+"B$"&'T$#@'#@+!)N'*!..!T+A'UN'@-"A,X!"'#%$#$!"

F!)2-.'G';A%B-#$!"-.

;9 45>@;'8:@='75;98 >7<;>@98'E97F G9H = R'[$.A+X(+A$S%+'"-$.')+B!",#)%B#$!"C'-'%"$S%+'.$&@#'B%)$"&' 2-#+)$-.'*!)2%.-#+A'+YB.%,$0+.N'*!)'#@+')+,#!)-#$!"C'B!))+B#$!"'

-"A'"!)2-.$,-#$!"'!*'#@+'#!+"-$.,E' !"#$%!&'("&)$!*($+()%(*!&($&,$-!.($&,("!'/)$&-!&$/,,0$ ",*1!/2 @2'D$%*$'"D'!""*2%'")*'CD#$I*'&D#'JKLL'2**%'"D'+#$C)!I*'")*' =;8'H*%KM#*' "!$"*$'NK"A'J*')!O*'!$$!2P*%'!'0QR'%KICD#2"

7"B.%A+,' )N!#@+)-1N'-"A'B-%#+)N'UN'MN*)+B-#$!"'T@$B@' +"B-1,%.-#+,'#@+'#T!'1)!B+,,+,'!*'A+,,$B-#$!"'-"A' *%.&%)-#$!"E 9@$,'B!%),+'$,'A+,$&"+A'*!)'1)-B#$#$!"+),'T@!'T$,@'#!'%1A-#+' -"A'+Y1-"A'#@+$)'D"!T.+A&+'!*'#)+-#2+"#,'*!)'#@+,+' #)!%U.+,!2+'.+,$!",E'9@$,'B!%),+'$"B.%A+,'-'^M-"A,'6"_' 1)-B#$B-.',+,,$!"'-"A'T$..'-A0$,+'!"'@!T'#!'2-D+'#@+' #+B@"$S%+,'-**!)A-U.+'#@-#'#@+N'B-"'U+'$22+A$-#+.N'%,+A'$"' 1)$0-#+'1)-B#$B+,

FULL 2-Y$2%2'\',#%A+"#,

7"B.%A+,'#@+!)N'$"'#@+'2!)"$"&'1+)$!A'*!..!T+A'UN'-'W*%..'X!"W ,+,,$!"'$"'#@+'-*#+)"!!"'!*'1)-B#$B-.'#)+-#2+"#,'-"A' B!"#)-$"A$B-#$!",E'7"B.%A+A'T$..'U+'J'#$,,%+')+1-$)C'1-$"')+.$+*C T!%"A'2-"-&+2+"#C'1-$"'2-"-&+2+"#'L')+@-U$.$#-#$!"C',D$"' B!"A$#$!",C'0$)-.'$"*+B#$!"'L'U$!2!A%.-#$!"E'8.,!'$"B.%A+A'T$..

U+'#@+'!11!)#%"$#N'#!'%,+'.-,+)'+S%$12+"#',%11.$+A'UN'62+&-' =-,+)'IN,#+2,'X'F$"-"B$-.'1.-",'-0-$.-U.+'#!'1%)B@-,+'.-,+)' +S%$12+"#E

1*2#*3

898'454657 '

76 ('9)-$"$"&' +"#)+C'I@+**$+.A

O'P554

!"#$%!&A'B")'8DO*,-*$'./0/

454657 O'P53`

9H96:I K$..'=$&&$",'L

1*2#*3

898'454657 '

76 ('9)-$"$"&' +"#)+C'I@+**$+.A

O'P5a`

<-)#$"'M-)0+N 2-Y$2%2'53' ,#%A+"#,

F!)2-.'G';A%B-#$!"-.

=: 57'>G57:HU

454657 O'P]4

F!)2-.'G';A%B-#$!"-.

1577<;:5'>75:>458>

#2%!&A'0T")'9C"D-*$'./0/,'

!"#$%!&A'0Q")'V!2#!$&'./00

454657 ' O'

9H96: Z!@"'(-##+),!"

P544

1*2#*3 76 ('9)-$"$"&' +"#)+C'I@+**$+.A 898'454657 O'

'P534

RKJ'()-B#$#$!"+),')+S%$)$"&'-'`'A-N'ID$..'L'9+B@"$S%+'H1A-#+' !%),+'!)'b4'A-N':+#%)"+),'#!'()-B#$B+' !%),+C',@!%.A'B!"#-B#'M+-A'6**$B+'*!)'B!,#,E >9'699F'U9<7'H=:;5A'H=5: 5';94H=5>5'>G5'699F@8?'W974':8X' 58X'>9?5>G57'E@>G'U9<7'754@>>:8;5'>9'G5:X'9WW@;5A' 8==' =6I7R>'/89;I'8:;'6R;'<6R9M'(:76:'96'9M;';Q;R9'/89;

@8'>G5'5158>'9W'@8 <WW@;@58>'8<4657 A'>G5'4:8:?5458>'75 5715'>G5'7@?G>'>9';:8;5=' @8'>G@ '<8=@F5=U'5158>A'W55 'E@=='65'75W<8X5X'@8'W<== ;!2C*LL!"KD2I'#+'"D'0('%!&I'+$KD$'"D'")*'*O*2"A'$*Y#2%'DY'Y**A'L*II'Z.Q[//'!%,K2KI"$!"KD2'C)!$P*[ ;!2C*LL!"KD2I'JK")K2'T'%!&I'DY'")*'*O*2"A'89'75W<8X\A')DJ*O*$'!2'!L"*$2!"KO*',*,-*$]2D2',*,-*$'JKLL'-*'!CC*+"*%[ c:+*%"A,'2-N'U+'B!",$A+)+A'$"'+Y#+"%-#$"&'B$)B%2,#-"B+,

28

Continuing Professional Development B OOKI NG FORM

Please send your booking, together with a cheque or completed Credit/Debit Card Form to:The Institute of Chiropodists and Podiatrists, 27 Wright Street, Southport, Merseyside PR8 0TL Telephone: 01704 546141 Fax: 01704 500477 Email: secretary@iocp.org.uk Website: www.iocp.org.uk PLEASE COMPLETE IN CAPITAL LETTERS Name: .....................................................................................................................................................................................

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

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

Seminar/Workshop

Branch/Organisation:

Date

Postcode: .............................

............................................................

Venue

Cost

Podiatric Dermatology

Saturday, 4th September 2010

Sheffield

Vascular & Neurological Assessment

Saturday, 16th October 2010

Sheffield

Cosmetic Nail Reconstruction Workshop

Sunday, 17th October 2010

Sheffield

Verrucae Treatments

Saturday, 6th November 2010

Sheffield

Laser Therapy

Saturday, 15th January 2011

Sheffield

TOTAL

£

PAYMENT BY CREDIT CARD Please debit my VISA / MASTER CARD (Delete as applicable) with £............................................ as payment for the above.

Card Number: Expiry Date of Card:

........./.........

Security Number:

...................

Issue Number: (Switch/Maestro) ...........................

Cardholder’s Name:

.................................................................................................

Cardholder’s Signature:

...............................................................................................................................................................................

Cardholder’s Address:

...............................................................................................................................................................................

Initials: .................................................

.............................................................................................................................................................................................................................. .............................................................................................................................................................................................................................

29

Achilles has a habit of wandering through a multitude of journals, but any additional material is always welcome and should be sent to the Institute H.Q. Via post or email bernie iocp.org.uk. Achilles is, and will remain, anonymous! apes (humans, chimpanzees, gorillas and orang-utans), in which the feet perform different functions.” It might be pointed out that homo sapiens are not truly quadrupedal. Be that as it may, and it may be a misquotation, Rolian also worked with Hallgrimson and Leiberman D., the latter of Harvard University, who used computer modelling which suggested that natural selection acted primarily on the big toe to enlarge it, reduce the size of the lesser toes and allow stabilisation for walking. It is claimed that the thumb also grew to allow opposability between it and the fingers allowing for greater dexterity. This all seems to fly in the face of the work carried out many years ago by Wood Jones who noted a considerable difference in the foot of man and those of the great apes. He also noted the opposable great toe in the great apes. It is clear that a good deal more research is required before making definitive claims.

RA

The Journal of the Royal Society of Medicine 103-06 June 2010 features an article by Hubbeling D. on ‘Criminal Prosecution for Medical Manslaughter’. Although highly unlikely in the world of Podiatry, deaths, usually associated with infection, have occurred following podiatry treatment. The author points out that the legal threshold for medical manslaughter under English criminal law is ‘gross negligence’, the interpretation of which is contentious. There must be a breach in the duty of care which is so serious that it has fallen far below the standard of a reasonable practitioner (Bolam Test) and the Crown Prosecution Service has two expert witnesses who are willing to state in court that gross negligence existed.

The article notes that not all errors are the same and can fall under the headings of mistakes, (ie errors in planning), slips, (failures in execution), technical errors and violations (deliberate deviations from safe practices). It is far more likely that incidents of gross negligence will come under the latter heading. Such incidences might include causing death whilst under the influence of alcohol or drugs.

MBLIN RO

G

A reply by Steinfelt T. to a letter by Snell A. is published in the British Journal of Anaesthesia 105-01 July 2010 commenting on an original article by Steinfeldt. The matter in question is the use of large diameter needles, guided by ultrasound to avoid intraneural injections when using local anaesthetic nerve block techniques. The author noted the difficulties in appreciating 2 dimensional images in attempting control of 3 dimensional space. He and his fellow authors recommended instead the use of the smallest diameter needle feasible. (Podiatrists have long used 25 or 27 gauges needles in dental syringes to achieve nerve blocks in the foot and leg). As a note of caution, Steinfeldt proposed further study.

The British Medical Journal of 24th July 2010, notes in an editorial that there is little evidence to support NHS reorganisation. However, the White Paper ‘Equity and Excellence: Liberating the NHS’ of July 2010 ISBN: 9780101788120 (Crown copyright) indicates that this is precisely what the coalition government intends. Amongst the reforms which are laid out in the paper (which is available on line and will reward the reader), “The Headquarters of the NHS will not be in the Department of Health or the new NHS Commissioning Board but instead, power will be given to the front-line clinicians and patients. The headquarters will be in the consulting room and clinic. The government will liberate the NHS from excessive bureaucratic and political control, and make it easier for professionals to do the right things for and with patients, to innovate and improve outcomes. (We) will create an environment where staff and organisations enjoy greater freedom and clearer incentives to flourish, but also know the consequences of failing the patients they serve and the taxpayers who fund them.” Also noted is the fact that “Patients will have the choice of any provider, choice of consultant led team, choice of GP practice and choice of treatment”. There are a number of complex changes – not least that it is intended that management costs should be cut by 45%, but, after suitable consultation, it is intended that the changes should be in place by 2015.

A DS

Is re-validation for Podiatrists on the horizon? Where Medicine leads in legislative matters, there is a tendency for Podiatry to follow. The British Journal of General Practice 60-576 July 2010, notes that the General Medical Council is consulting on the subject of revalidation for the Medical Profession. A suggestion is that in instances of Doctors employed in education , or management, or industry but not carrying out clinical work, they may only be revalidated for those elements of their employment and not for clinical practice.

Achilles Hele.

With the production of new materials, the use of dermal fillers in the plantar surfaces of the metatarsophalangeal joints of the feet is no longer a contentious issue. It might be argued that in suitable cases of lack of fibro-fatty padding all Podiatrists should be offering the technique of part of their practice. However, Cosmetic News July 2010 reports that the Transform Cosmetic Surgery Group have seen a percentage increase of younger females seeking this treatment of 49% between 2009 and 2010. The increase is largely due to ‘high heel pain’ occurring when wearing shoes of up to 6” heel height. The spokesman stated that even though high heeled shoes cause pain, more and more females are following ‘fashion icons’ such as Cheryl Cole. They believe that the shoes make them feel taller, thinner, sexier and boost their confidence. Because of these factors, they are unlikely to give the shoes up. Whether it is appropriate to treat such people is, of course, a matter for debate.

Jones D. suggests in New Scientist 26th June 2010 that ‘Evolutionary pressures on the feet might have prepared our hands for tool use and manual tasks’. He quotes Rolian C. at the University of Calgary comparing “quadrupedal primate species such as macaques – in which he claims that the hands and feet perform similar roles – with the great

30

Cos yfee t Pod ia tr y A war d for Podiatry Student

A

bdulkadir Abdul, who will commence his final year studies at Southampton University this autumn, has been awarded the Cosyfeet Podiatry Award 2010.

The £1000 grant will fund Abdul’s travel and living expenses during his voluntary work this summer with Central London Community Healthcare, based in Westminster. Here he will work as a volunteer student podiatrist, treating vulnerable and homeless patients as part of a multidisciplinary healthcare team.

Abdul will be working under the guidance of Alison Gardiner, a Specialist Podiatrist with Central London Community Healthcare.

“We provide high quality equitable care to patients, carers and service users throughout Hammersmith and Fulham, Kensington and Chelsea, and Westminster, Abdul will be working with our Homeless Health Services team in Westminster and I am looking forward to having him work with us this August,“ said Alison.

“I think receiving this award is a credit to Abdul and reflects the increased awareness and importance of tackling health inequalities in the UK.”

Homelessness in the UK continues to be a major issue with 4692 rough sleepers counted in the capital last year ('Street to Home Annual Report - 2008/2009' Broadway).

Abdul expects to be working with patients suffering from a wide range of conditions including Diabetes, TB, HIV, trench foot and malnutrition. In addition he expects many of his patients to have mental health and social issues, such as drug and alcohol dependency, which will necessitate specialist care and attention from the multidisciplinary healthcare team of which he will be part.

“I hope this experience will make me a more rounded and broader thinking practitioner,” said Abdul. “I also hope to raise awareness about homelessness. This highly vulnerable and difficult to reach group of people is on our own doorstep but is all too often forgotten.”

For more information about the Cosyfeet Podiatry Award email prof@cosyfeet.co.uk.

31

ANSWERS to Self Assessment Questions Centre CPD July/August 2010 1. What type of reaction caused the necrotising vascultis pictured?

A. An antigenic reaction to hair dye caused the necrotising (or necrotizing) vasculitis. The aggressive autoimmune reaction causes the walls of the blood vessels to scar and thicken, or die (become necrotic). The blood vessel may close, interrupting blood flow to the tissues it supplies. The lack of blood flow will then cause the tissues to die.

Necrotising vasculitis may affect any blood vessel in the body. Therefore, it can cause problems with the skin or any of the body's organs.

2. Which part of the skin does SCC originate in?

A. From Keratinocytes. Squamous Cell Carcinoma is a malignant tumour most commonly found on sun-exposed areas of the body.

It mainly occurs in people over 55 years of age and is 3 times more common in males than females Signs of squamous cell carcinoma include: 1 Crusted or scaly area on the skin with a red, inflamed base 2 Persistent, non-healing, ulcerated (skin not covering) bump or thickened skin on the lower lip 3 Wart-like growth or plaque 4 Sores that does not heal 5 Red, scaly patches or bumps The tumours can reach ¾ to 1 inch in size and develop into large masses. Since squamous cell carcinoma has the potential to metastasize (spread), this form of skin cancer can be lethal if not treated. In aggressive cases, the tumour can spread to the lymph nodes or internal organs. This is especially true when a tumour begins on a lip or ear, or the patient has a weakened immune system.

Conditions that weaken the immune system include an organ transplant, lymphoma, and human immunodeficiency virus (HIV), also some immune modifying drugs such as those given to people with psoriasis, for example Methotrexate, may play a role.

3. Why is sickle cell anaemia so called?

A. Sickle cell anaemia is a serious disease in which the body makes sickle-shaped red blood cells. They have the appearance of an old fashioned reaping hook, or sickle, which was ‘C’ shaped Sickle cell anaemia is most common in people whose families come from Africa, South or Central America (especially Panama), Caribbean islands, Mediterranean countries (such as Turkey, Greece, and Italy), India, and Saudi Arabia.

Normal red blood cells are disc-shaped and look like doughnuts without holes in the centre. They move easily through your blood vessels. Red blood cells contain the protein haemoglobin. This iron-rich protein gives blood its red colour and carries oxygen from the lungs to the rest of the body.

Sickle cells contain abnormal haemoglobin that causes the cells to have a sickle shape. Sickle-shaped cells don’t move easily through your blood vessels. They’re stiff and sticky and tend to form clumps and get stuck in the blood vessels. (Other cells also may play a role in this clumping process.)

The clumps of sickle cells block blood flow in the blood vessels that lead to the limbs and organs. Blocked blood vessels can cause pain, serious infections, and organ damage.

32

Cd bdgZ VchlZge]dcZ Cd bdg Z Vchl Zge]dcZ M[ M [ Wdim[h Wdim[h ooekh ekh YWbbi YWbbi \eh \eh ooek ek 7ffe_djc[dji Xeea

7ffe_djc[dji Xeea[Z [Z C[i C[iiW][i \ehmWhZ[Z iW][i \ehmWhZ[Z 7 fh 7 fhe\[ii_edWb ÉÓhij e\[ii_edWb ÉÓhij

_cfh[ii_edÊ \eh oekh _cfh [ii_edÊ \eh oekh Xki_d[ii Xki_d[i i

7 \kbb j_c[ h[Y[fj_ed_ij Wj W \hWYj_ed e\ j^[ Yeij

&.*+ .-))(+' lll#gZVai^bZgZXZei^dc#Xdb ^c[d@gZVai^bZgZXZei^dc#Xdb

AMBER CHIROPODY SUPPLIES

Serving the chiropodist/podiatrist with all the essential daily consumable items for a busy practice, including: * Instruments & Equipment * Padding & Appliances * Dressings & Adhesives * Biomechanics

* Domiciliary * Sterilization * Diagnostics * Retail Products

To view our website/online store please visit:

www.ambersupplies.co.uk

Chiropody Supplies

BUSINESS CARDS printed 1 side: 1,000 = £40, 10,000 = £96.

Appointment Cards printed two sides: 10,000 = £99. Record Cards, Continuations, Sleeves all 8” x 5” x 1,000 = £59. Small Receipts: 2,000 = £48, 4,000 = £68. Des Currie: 01207 505191.

Established Practice for sale in busy Derbyshire Town 2-3 Days plus 1 dom - Turnover 28K - Business offers around 22K. Comes complete with 3 bed property including 2 treatment rooms. Hope to sell as one - property valued around 220K. Telephone: 07786 851990

The Institute Strongly advises any applicants seeking employment to obtain a formal “Contract of Employment”

Recruitment

PRESTON Lancashire Chiropodist - Busy multidiscipline Practice, looking to recruit a key team member. Suitable candidate to be interested in future growth incorporating all areas of business. Customer parking open 6 days per week.

Please send C.V. to info@thefootworks.net CLECKHEATON – CHIROPODIST/PODIATRIST to join a busy, modern, well established practice 3 days per week. Must possess good clinical and interpersonal skills and be HPC registered. This is an excellent opportunity for an enthusiastic candidate on a self-employed fee sharing basis.

Send CV to Helen Topham at thetophams@ntlworld.com or telephone 01924 505593 evenings after 7:00pm.

Practice for Sale

LEEDS – EMIGRATION FORCES SALE OF MOBILE ROUND case load varied includes domiciliary, nursing homes and practice within blue chip companies.

Sale includes goodwill and all equipment. Full hand over provided. 25K annual income over 3 days. Good growth potential. Telephone 07899 848318 or email Lydia.dodd1@ntlworld.com

33

Diary of Events September 2010

West of Scotland Branch Meeting

Birmingham Branch 23rd September at 8:00 p.m.

Red Cross Centre, Vine Street, Evesham Tel: 01905 454116

East Anglia Branch Meeting plus CPD 19th September at 10:00 a.m.

Newmarket Day Centre, Fred Archer Way, Newmarket CB8 8NT Tel: 01223 881170

Essex Branch Meeting 19th September - Education Centre, Southend University Hospital, Carlingford Drive, Southend-on-Sea Tel: 01702 460890

London Branch Meeting 8th September at 7:30 p.m. - Victory Services Club, 63-79 Seymour Street, London W2 2HF Gordon Loader to give training in the use of Otoform to make silicon appliances Tel: 01895 252361

Sunday 19th September at 11:00 a.m.

The Express By Holiday Inn, Springkerse Business Park, Stirling FK7 Tel: 01796 473705

October 2010 Chester North Wales Staffs and Shrops Branch Meeting 3rd October 2010 at 11:00 a.m. - Comfort Inn Hotel, 74 Hoole Road, Chester CH2 3NL. Presentation: Diabetic Assessment by Gareth Hicks (Part One) Tel: 01244 327542

Devon and Cornwall Branch Meeting Please phone secretary for details The Exeter Court Hotel, Kennford, Exeter Tel: 01805 603297

Leeds/Bradford Branch Meeting

Midland Area Council Meeting

3rd October - 10:00 a.m.

The Oakwell Motel, Birstall, Nr. Leeds WF17 9HD Tel: 01653 697389

Sunday 12th September 10:00 a.m. - Kilsby Village Hall, Kilsby, CV23 8XX Tel: 01865 434756

Midland Area Council Seminar

North West Branch Meeting 26th September

Tel: 0161 486 9234

Saturday 30th October - Hilton Hotel, Braunstone, Leicestershire LE19 1WQ. Please see inside Podiatry Review for details Tel: 01386 47695

Nottingham Branch Meeting

North of Scotland Branch Meeting

Thursday 2nd September at 7:00 p.m. - The Red Cross Centre, Nottingham Tel: 0115 932 8832

Please phone secretary for date and time The Heugh Hotel, Stonehaven, Aberdeenshire Tel: 01382 532247

Southern Area Council meeting 11th September at 1:00 p.m. - Victory Services Club 63-79 Seymour Street, London W2 2HF Tel: 01992 589063

Oxford Branch Meeting

South Wales and Monmouth Branch Meeting

Sheffield Branch Meeting

5th September - Taffs Well Ex Service Mans Club, Taffs Well Tel: 02920 331927

October at 7:30 p.m. (date to be confirmed please phone secretary) SWD Sports Club, Heeley Bank Road, Sheffield Tel: 01623 452711

9th October at 10:00 a.m.

89 Rose Hill, Oxford OX4 4HT

Tel: 01993 883397

Surrey & Berkshire Branch CPD meeting 20th September at 7:30 p.m.

Pirbright Village Hall

Surrey & Berkshire Branch meeting Tel: 0208 660 2822

11th October at 7:30 p.m.

Pirbright Village Hall

Tel: 0208 660 2822

Western Branch Meeting 5th September 12 noon Blair Bell Education Centre

Sussex Branch Meeting Tel: 01745 331827

24th October at 9:30 a.m. - The Bent Arms, High Street, Lindfield, RH16 2HP Tel: 01273 890570

West Middlesex Branch meeting 13 September at 8:00 p.m.

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

34

Wolverhampton Branch Meeting Sunday 31st October 10:00 a.m. - 4 Selmanâ&#x20AC;&#x2122;s Parade, Selmanâ&#x20AC;&#x2122;s Hill Bloxwich WS3 3RN Tel: 0121 378 2888

November 2010 Birmingham Branch 25th November at 8:00 p.m. - Red Cross Centre, Vine Street, Evesham Tel: 01905 454116

Essex Branch Meeting 28th November at 2:00 p.m. - Education Centre, Southend University Hospital, Carlingford Drive, Southend-on-Sea Tel: 01702 460890

London Branch Meeting 17th November at 7:30 p.m.

Victory Services Club, 63-79 Seymour Street, London W2 2HF Tel: 01895 252361 Leeds/Bradford Branch Meeting 7th November - 10:00 a.m. - The Oakwell Motel, Birstall, Nr. Leeds WF17 9HD Tel: 01653 697389

Leicester & Northants Branch 28th November - Branch Seminar Lecture on Dermatology - Ivan Bristow, Southampton University - Trade support from Canonbury Autoclave servicing (by appointment) Lutterworth Cricket Club Registration and Refreshment 9:45 a.m.

Further details Tel: Sue 01530 469816

Essex Branch Meeting and A.G.M. 30th January 2:00 p.m. - Education Centre, Southend University Hospital, Carlingford Drive, Southend-on-Sea Tel: 01702 460890

London Branch Meeting 19th January at 7:30 p.m.

Victory Services Club, 63-79 Seymour Street, London W2 2HF Tel: 01895 252361

Leicester & Northants Branch A.G.M. 23rd January A.G.M. plus meeting - Kilsby Village Hall 9:45 a.m. Registration and Refreshment 9:15 a.m.

Further details Tel: Sue 01530 469816

Midland Area Council A.G.M. Sunday 30th January 10:00 a.m.

Kilsby Village Hall, Kilsby, CV23 8XX Tel: 01865 434756

North West Branch A.G.M. 16th January

Tel: 0161 486 9234

Nottingham Branch A.G.M. 16th January at 10:00 a.m. - The Red Cross Centre, Nottingham MG8 6AT Tel: 0115 932 8832

Oxford Branch A.G.M. South Wales and Monmouth Branch Meeting 7th November - Taffs Well Ex Service Mans Club, Taffs Well Tel: 02920 331927

15th January at 10:00 a.m.

89 Rose Hill, Oxford OX4 4HT

Tel: 01993 883397

Southern Area Council A.G.M. West Middlesex Branch meeting 8th November at 8:00 p.m.

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

15th January at 1:00 p.m.

Victory Services Club 63-79 Seymour Street, London W2 2HF Tel: 01992 589063

Surrey & Berkshire Branch A.G.M. West of Scotland Branch Meeting Sunday 14th November at 11.00 a.m.

The Express By Holiday Inn, Springkerse Business Park, Stirling FK7 Tel: 01796 473705

December 2010 Leeds/Bradford Branch Meeting 5th December - 10:00 a.m. - The Oakwell Motel, Birstall, Nr. Leeds, WF17 9HD Tel: 01653 697389

8th January 10:00 a.m.

Greyfriars Centre, Reading

Tel: 0208 660 2822

Sussex Branch A.G.M. 15th January at 9:30 a.m. - The Bent Arms, High Street, Lindfield, RH16 2HP Tel: 01273 890570

Western Branch A.G.M. and Branch Meeting 9th January 12 noon - Blair Bell Education Centre, Seminar room 1 Tel: 01745 331827

West of Scotland Branch A.G.M.

January 2011 Birmingham Branch A.G.M.

Sunday 16th January at 11.00 a.m.

The Express By Holiday Inn, Springkerse Business Park, Stirling FK7 Tel: 01796 473705

13th January at 7:30 p.m. - Red Cross Centre, Vine Street, Evesham Tel: 01905 454116

East Anglia Branch A.G.M. followed by meeting plus CPD 30th January at 10:00 a.m.

Newmarket Day Centre, Fred Archer Way, Newmarket CB8 8NT Tel: 01223 881170

March 2011 Wolverhampton Branch A.G.M. Sunday 21st March - 10:00 a.m.

4 Selmanâ&#x20AC;&#x2122;s Parade, Selmanâ&#x20AC;&#x2122;s Hill Bloxwich WS3 3RN

Tel: 0121 378 2888

35

National Officers

Branch Secretaries

President Mrs. F. H. Bailey M.Inst.Ch.P

Birmingham

Mrs. J. Cowley

01905 454116

Bradford

Mr. N. Hodge

01924 475338

Cheshire North Wales

Mrs. D. Willis

0151 327 6113

Devon & Cornwall

Mrs. M. Reay

01805 603297

East Anglia

Mrs. S. Bennett

01223 881170

Chairman Board of Ethics Mrs. C. Johnston M.Inst.Ch.P.,BSc(Hons)

Essex

Mrs. B. Wright

01702 460890

Hants and Dorset

Mrs. J. Doble

01202 425568

Chairman Board of Education Mr. W. J. Liggins F.Inst.Ch.P., F.Pod.A., BSc(Hons)

Kent

Mrs. C. Hughes

01303 269186

Leeds

Mr. M. Hogarth

01653 697389

Leicester & Northants

Mrs. R. Rose

01582 668586

London

Mrs. L. Towson-Rodriguez 01895 252361

North East

Mrs. E. Barwick

0191 490 1234

North of Scotland

Mrs. S. Gray

01382 532247

North West

Mr. B. W. Massey

0161 486 9234

Northern Ireland Central

Miss G. Sturgess

0289 336 2538

Northern Ireland Regional

Mrs. T. Patterson

0289 145 6900

Area Council Executive Delegates

Nottingham

Mr. S. Gardiner

0115 932 8832

Midland Area Council Mrs. V. Dunsworth M.Inst.Ch.P. D.Ch.M

Oxford

Mrs. S. Harper

01993 883397

Republic of Ireland

Mr. R. Sullivan

00353 5856 059

Northern Ireland Area Council Mrs. T. Patterson M.Inst.Ch.P

Sheffield

Mrs. D. Straw

01623 452711

Sth Wales & Monmouth

Mrs. J. Nute

02920 331 927

Surrey and Berkshire

Mrs. M. Macdonald

0208 660 2822

Sussex

Mrs. V. Probert-Broster

01273 890570

Teesside

Mr. J. Olivier

01287 639042

Western

Mrs. L. Pearson

01745 331827

West Middlesex

Mrs. H. Tyrrell

0208 903 6544

West of Scotland

Mrs. J. Drane

01796 473705

Wolverhampton

Mr. D. Collett

0121 378 2888

Yorkshire Library

Mrs. J. Flatt

01909 774989

Chairman Executive Committee Mr. R. Beattie Hon. F.Inst.Ch.P Vice-Chairman Executive Committee Mr. D. A. Crew OstJ, F.Inst.Ch.P., DCh.M

Vice-Chairman Board of Education Mr. J. W. Patterson BSc(Hons)., M.Sc., M.Inst.Ch.P Honorary Treasurer Mr. S. Gardiner M.Inst.Ch.P. BSc(Hons)PGDip Standing Orders Committee Mr. M. Hogarth M.Inst.Ch.P Mrs. L. Pearson M.Inst.Ch.P Secretary Miss A. J. Burnett-Hurst

North West Area Council Mr. M. J. Holmes M.Inst.ChP., D.Ch.M, BSc.Pod Republic of Ireland Area Council Mr. R. Sullivan M.Inst.Ch.P Scottish Area Council Mrs. A. Yorke M.Inst.Ch.P Southern Area Council Mrs. M. Newnham M.Inst.Ch.P Yorkshire Area Council Mrs. J. Dillon M.Inst.Ch.P

ORDER ONLINE for FREE DELIVERY and much more…

www.canonbury.com is open for business 24-7 Q Ordering or researching products is easy at any time Q Extensive product information, reviews from other practitioners and videos help you make informed decisions Q Account managment tools help you manage your business at a time that suits your schedule

Email info@canonbury.com or call 01280 706661 to request a web account logon.

RealCHOICE Find it

www.canonbury.com

Call 01280 706661 * UK only, minimum order value £20 + VAT excludes equipment.