Podiatry Review January/ February 2014 by The Institute of Chiropodists & Podiatrists

43100 Podiatry Rev Jan 17/12/2013 10:34 Page 1

ISSN 1756-3291

Volume 71 No. 1 January/February 2014

Podiatry Review A step in the right direction

Inside: ◆ 2014 AGM Booking Form ◆ CPD Pull out section Anatomy and Physiology ◆ Malignant Skin Tumours

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

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National Officers President Mr R Henry F.Inst.Ch.P, DChM

Vice-Chairman Board of Education Miss Joanne Casey MInstChP BSc

Chairman Executive Committee Mrs C Johnston MInstChP BSc(Hons)

Honorary Treasurer Mrs J Drane MInstChP

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

Standing Orders Committee Mr M. Hogarth MInstChP

Chairman Board of Ethics Mrs J. Dillon MInstChP

Mrs L. Pearson MInstChP BSc Pod Med

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

Secretary Miss A. J. Burnett-Hurst

MSc. Pod Surg,.PgDip Mio.Acu,.FIChPA. M.Inst.Ch.P

Area Council Executive Delegates Midland Area Council Mr S. Miah BSc. (Pod M), M.Inst.Ch.P

Scottish Area Council Mr A Reid MInstChP

North West Area Council Mrs M Allison MInstChP

Southern Area Council Mr D Crew OStJ, FInstChP, DChM, CertEd

Republic of Ireland Area Council Mrs J Casey MInstChP BSc

Yorkshire Area Council Mrs J Dillon MInstChP

Branch Secretaries Birmingham

Mrs J Cowley

01905 454116

Northern Ireland Central

Mrs P McDonnell

028 9062 7414

Cheshire North Wales

Mrs D Willis

0151 327 6113

Nottingham

Mrs V Dunsworth

0115 931 3492

Devon & Cornwall

Mr M. Smith

01803 520788

Republic of Ireland

Mrs C Oâ&#x20AC;&#x2122;Leary

East Anglia

Mrs Z Sharman

01473 830217

Sheffield

Mrs D Straw

Essex

Mrs B Wright

01702460890

South Wales & Monmouth Mrs E Danahar

01656 740772

Hants and Dorset

Mrs J Doble

01202 425568

Surrey and Berkshire

Mrs M Macdonald

0208 660 2822

Leeds/Bradford

Mr N Hodge

01924 475338

Sussex

Mrs V Probert-Broster 01273 890570

Leicester & Northants

Mrs S J Foster

01234 851182

Teesside

Mr J Olivier

01287 639042

London

Mr W G Loader

07956 962744

Western

Mrs L Pearson

01745 331827

North East

Mr A Thurkettle

0191 454 2374

West Middlesex

Mrs H Tyrrell

0208 903 6544

North of Scotland

Mrs S Gray

01382 532247

West of Scotland

Mr S Gourlay

0141 632 3283

North West

Mr B Massey

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Wolverhampton

Mr D Collett

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00353 295 1938 01623 452711

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January/February 2014 | Volume 71 No. 1 ISSN 1756-3291

Podiatry Review

Published by The Institute of Chiropodists and Podiatrists 150 Lord Street, Southport, Merseyside, PR9 0NP Tel: 01704 546141 Email bernie@iocp.org.uk Web: www.iocp.org.uk

Contents

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

Fungal infections of the feet ....................................8 Iain B McIntosh BA(Hons) MBChB Former Schools

Academic Review Team Mrs J Barbaro-Brown Ms B. Wright Mr R Sullivan Mr S. Miah Mrs J. Casey

KWILLT Project – keeping warm in later life.............9 Angela Tod et al Sheffield Hallam University

Editorial ..................................................................2 Malignant skin tumours...........................................4 Michelle Taylor M.Inst.Ch.P. BSc NHS Choices Behind the Headlines..............................................7

Inspector

The importance of clinical note writing ..................12 Claire Gallagher BSc Pod Health awareness week Cervical cancer prevention....................................13 CPD – Anatomy and Physiology for Practice Part 1 ...........................................17-20 Beverley Wright MSc., BSc(Hons) PGCE, PGDip, M.Inst.Ch.P

Branch News ..................................................21-26 Cosyfeet award application information ................25 Diabetes news......................................................27 Forthcoming Events..............................................30 Classified adverts .................................................32 2014 conference booking form.............................33 http://twitter.com/iocp_chiropody

Health awareness Cancer of the bladder...........................................35 Arthritis News .......................................................36

The Institute of Chiropodists and Podiatrists

Cosyfeet Press Release ........................................37

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

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

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Annual Subscription £30 UK/£45 Overseas

Podiatry Review Vol 71:1

EDITORIAL

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Editorial

Bernadette Hawthorn Editor

Dear Members

A very happy 2014 to each and every one of you. Welcome to a brand new year of Podiatry Review.

By now the over indulgence of Christmas will be a distant memory and minds will start to focus, once again, on the upcoming HCPC audits in June. With this in mind and taking into account requests from the membership, we are reintroducing a CPD section. This section can be pulled out and kept in your CPD folder. Each issue will contain selfassessment questions to be completed at home and added to your proﬁle. We will not be marking these questions but if you have any queries, please do not hesitate to ask. Our ﬁrst CPD article has been compiled by Beverley Wright and is a refresher on Anatomy and Physiology. Due to the length of it, the article is divided into two sections. Part two will appear in the March/April issue.

As well as the pull out section, we have other articles which contribute to continued professional development, such as Michelle Taylor’s paper on Malignant Skin Tumours. There seems to be an increase in the incidence of malignant skin tumours and raising awareness is essential. Michelle has included some very clear photographs to identify diﬀerent types. Iain McIntosh, a former chiropody school inspector has also sent us his article on fungal infections of the feet. These are a common problem encountered by most chiropodists.

EDITORIAL

Brush up on your knowledge!

How many of you are aware of the KWILLT project? This article has been devised from a lecture by Angela Tod, Professor of Health Services research centre and social care research at Sheﬃeld Hallam University. This study sheds light on why many old and vulnerable people become victims to the cold and to what extent beliefs and values play a part. Health professionals such as domiciliary chiropodists are in prime position to observe their patients and check for early signs and symptoms of potential hypothermia.

We also focus on two current awareness campaigns, cervical and bladder cancers. The earlier all cancers are detected the higher the recovery rate. Although there is a lot of information available, many people still remain ignorant about signs and symptoms. In addition we have lots of branch information and news starting from page 21. What a busy lot you have been! From personal experience and from feedback, we have seen some hugely motivating and informative lectures at branch level, all at exceptionally aﬀordable prices! Not to mention the varying but consistently delicious culinary delights on oﬀer at each! Our 2014 AGM, Conference, Trade Exhibition and Dinner Dance promises to be even bigger and better with many bookings already

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being taken. If you were unlucky and missed out on the workshops last time – get in early, the booking form is on pages 33 and 34 Finally, the journal review team would like all members to get involved in selecting the front covers and the best one in December will be awarded a prize at the following year’s conference. Get those digitals out then and start snapping. This issue features the ducks on Martin Mere in Burscough taken by Julie Aspinwall. Bernadette Hawthorn, Editor Letter to Editor

Dear Bernadette,

It was quite a surprise to receive a copy of your magazine. May I, on behalf of the family, thank you for printing such a wonderful tribute to Isabel.

Isabel was never happier than in the company of her fellow chiropodists and looked forward to meeting you all at meetings and AGM’s. May I take the opportunity to thank all the members who sent such wonderful and uplifting personal tributes to us. May God bless you all. William Barr

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D Diabetic iabetic foot ffo oot care care solutions solutions ffrom rom Algeos Algeos

Introducing In trroducing our our new new Diaped Diaped ed D Duosoft uosofftt Flow Flow IInsoles nsoles Duosoft Duosoft Flow is a unique insole designed to distribute ute w weight eight bearing b pressure while cushioning, massaging ing and and absorbing abs impact. M Medical edical grade gra PORON U Urethane rethane top to cover

122 individual gel cells from the insoles base “122 “122 in individual indiv viid du gel cells independently react to the foot striking the floor with th differing differing levels of of resistance re resis t.” levels and compression, creating a continuous pumping effect.”

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• Helps Helps improve improve blood blood circulation circulation in in feet feet via via a ‘pumping ‘pumping effect’ effect’ • Helps Helps prevent prevent ulcers, ulcers, sores sores and and calluses calluses tthrough hrough the the promotion promotion of of healthy healthy skin skin tissue tissue and and the the p prevention revention of of skin skin breakdown breakdown • Provides Provides outstanding outstanding cushioning, cushioning, offloading offloading and and shock shock absorption absorption • Alleviates Alleviates general general aches aches and and pains pains • Helps Helps prevent prevent foot foot fatigue fatigue

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Malignant Skin Tumours Michelle Taylor M.Inst.Ch.P. BSc Aged skin is dry, wrinkled, atrophic, has reduced elasticity and uneven pigmentation, which makes it more prone to both benign and malignant tumours (Gawkrodger, D.J 2012). The cause of many skin tumours are unknown, with research mainly concentrated on malignant tumours. A range of factors have been identiﬁed as being important ranging from external agents, host’s genetic make-up and excessive exposure to ultra violet radiation (mainly within the 280 – 320 mm range). Other factors include virus – HPV, while herpes virus has been noted in some cases and Kaposi’s sarcoma. Retrovirus has also been found in some T cell lymphomas. Resistance depends on the genetic individual, lifestyle and occupation (Lorimer, D. et al 2006). Malignant melanoma has an incident rate of 15 to 20 per 100,000 populations per year within the U.K. This has been rising at approximately 7% each year, and has trebled in the last 20 years (Gawkrodger, D.J. 2012). Malignant melanoma is more common among people with a pale complexion, blue eyes, and red or fair hair [WHO.org accessed 18.8.2013]. Prolonged exposure to ultra violet light within the UVB spectrum has been established as a carcinogenic factor in man. The incidence of squamous cell carcinoma rate is high within the Caucasian population. While there is strong evidence of a link between UVB and cutaneous malignant melanoma, the evidence is of a link is between UVB and squamous cell carcinoma is poor. It has been suggested that melanin pigment has a signiﬁcant role in protecting against ultra violet induced carcinoma`s within the Black or Asian populations compared to Caucasian population (MacKie, R.M.

TECHNICAL ARTICLE

1986). Cutaneous malignant melanoma arises from the melanocytes within the basal cell layer of the epidermis (Lorimer, D. et al 2006). With the majority of skin tumours being either Basel cell, squamous cell carcinoma`s or malignant melanomas (Gawkrodger, D.J. et al 2012). Some tumours produce either little or no pigmentation and are termed hypo or amelanotic melanomas. They are particularly hard to diagnosis. Features to cause concern are related to this simple check list: • • • •

A = asymmetry of the outline. B = border irregularity. C = colour variation. D = diameter enlargement.

There is no fool proof diagnosis of malignant melanoma. Very early lesions will not have developed any of the above features, but the patient should be encouraged to seek further advice if the lesions appear to change (Lorimer, D. 2006). Malignant melanoma can be enigmatic and unpredictable. To ﬁlter out malignant melanoma from begin lesions. The following questions help aid diagnosis. • Is it an existing mole getting larger or has a new one appeared? After puberty moles do not grow – this sign refers to adults. As naevi (moles) may grow rapidly in children. • Does the lesion have an irregular outline? Ordinarily moles are smooth and regular in shape. • Is the lesion irregular pigmented? Is there a mixture of shades of brown or black? • Is the lesion larger than 1 cm in diameter? • Is the lesion inﬂamed or is there a reddish edge?

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• Is the lesion bleeding, oozing or crusting? • Does the lesion itch or hurt? (Dawber, R et al 2002). The development of premalignant or malignant lesions within the foot is rare, as footwear provides the foot some protection from sun exposure. Due to the delayed or incorrect diagnosis when they do develop, may explain the higher rate of mortality in malignant lesions on the foot compared to them appearing elsewhere. Therefore knowledge and understanding of skin lesions is important (Menz, H.B 2008). There are 4 main variants of malignant melanoma: • Superﬁcial spreading malignant melanoma. • Lentigo malignant melanoma. • Acral lentiginous malignant melanoma. • Nodular malignant melanoma. (Gawkrodger, D.J. 2012).

Superficial spreading malignant melanoma is the most common form of malignant melanoma. It appears as a flat plaque with an irregular boarder (Menz, H.B 2008). This type of malignant melanoma accounts for 50% of all British cases, with females more commonly affected than males, in the 20 – 60 year

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age group. The commonest site for these tumours to occur is the lower leg. (Gawkrodger, D.J. 2012). Lentigo malignant melanoma accounts for 15% of cases within the UK. It often arises in sun damaged skin of those who have worked outdoors, with those over 60 commonly aﬀected (Gawkrodger, D.J. 2012). They occur as a broad, brown lesion commonly found on the head and neck (Menz, H.B 2008).

Acral lentiginous malignant melanoma occurs on the palms or soles, or near or under the nails. An important indication that discolouration of the nail is due to melanoma is Hutchinson’s sign – pigmentation of the nail fold adjacent to the nail (Dawber, R et al 2002). It is commonly misdiagnosed as subungal haematomas or verruca. Treatment involves surgical removal and or chemotherapy (Menz, H.B 2008). Acral lentiginous makes up 1 in 10 of all British cases and is the commonest form in those of dark skinned races. It is often diagnosed late and has poor survival rates (Gawkrodger, D.J. 2012). Nodular malignant melanoma has the appearance of a ﬁrm blueberry coloured nodule (Menz, H.B 2008). These nodules

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While a thicker tumour requires a 2 – 3cm clearance. Regular follow up is needed to detect any recurrence which includes the local area, regional lymph nodes and the blood.

may grow rapidly and ulcerate. They are commonly found in men and occur mainly on the trunk and account for 25% of cases in the 20 – 60 year age group (Gawkrodger, D.J. 2012). Evidence has shown a correlation between the thickness of the malignant tumour and its liability to spread to other areas. Metastases may spread from the original site of a malignant melanoma into nearby local nodules or the lymph nodes while distant areas of skin or subcutaneous tissue also affected. The spread of visceral metastases within the body may occur many years after the apparent cure of malignant melanoma. Organs affected are the lungs, liver, brain, bone and intestine (Lorimer, D. et al 2006). Prognosis relates to tumour depth, with approximate survival rates being: <1mm 95%, 1 – 2mm 90%, 2.1 – 4 mm 77%, >4mm 65%. Surgical excision is that the primary treatment with further re – excision of the scar depending on Brestow thickness. This measurement is assessment by calculating the measurement in millimetres of the distance between the granular cell layers to the deepest identifiable melanoma cell of the tumour. Therefore a 1mm thick tumour requires a 1cm margin, 1 -2 mm thick tumour requires a 2cm margin.

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New treatment therapies include ipilimumab, a monoclonal antibody targeting the negative T – cell regulator, CTLA – 4 has been shown to improve survival in advanced melanoma. While BRAF kinase inhibitors in BRAF mutated melanomas have shown promise (Gawkrodger, D.J. 2012). The foot is a fairly common site for the development of benign skin lesions. While many are asymptomatic and may not require treatment, all foot care specialists should be capable of establishing a provisional diagnosis and provide informed referrals where necessary. The foot is not a common site for malignant melanoma clinicians should be highly suspicious of any non – healing or changeable lesions on the foot or lower leg (Menz, H.B 2008).

References

Dawber, R. Bristow, I. Turner, W. (2002). Text Atlas of Podiatric Dermatology. Martin Dunitz.

Gawkrodger, D.J. Arden – Jones, M.R (2012). Dermatology: An illustrated colour text. Churchill Livingstone Elsevier.

Lorimer, D. French, G. O’Donnell, M. Burrow, J.G. Wall, B. (2006). Neale’s Disorders of the Foot. 7th. Ed.

MacKie, R.M. (1986). Clinical Dermatology: An Illustrated Textbook. 2ed. Menz, H.B (2008). Foot problems in older people. Churchill Livingstone Elsevier

World Health Organisation [accessed 18.8.2013] http://www.who.int/uv/health/uv_health2/e n/index1.html

TECHNICAL ARTICLE

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AGM NEWS

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NHS Choices Behind the Headlines Footballers and boxers are more likely to develop Alzheimer’s,” is the entirely spurious claim from the Mail Online.

The study it reports on did not involve footballers, or boxers, or indeed, any living humans.

It looked at how abnormal clumps of proteins found in the brains of people who have died from Alzheimer’s disease can spread between cells. This was an attempt to ﬁnd out more about the possible causes of Alzheimer’s, which while common, remains poorly understood. What is known is that in people aﬀected by Alzheimer’s there is a loss of brain cells and a build-up of abnormal ‘clumps’ and ‘tangles’ of proteins. The clumps are made up of amyloid proteins and the tangles of Tau proteins.

Both can be present because of ageing, but it is not known what causes there to be so many in people with Alzheimer’s disease.

The Tau protein forms chains with other Tau proteins. This disrupts the transport of nutrients and it is thought that this leads to cell death. This study explored how cells absorb Tau proteins and join the proteins together to make the chains that resemble neuroﬁbrillary tangles. They found that this process caused nearby cells to do the same. The researchers speculate that a traumatic brain injury could provide the opportunity for the Tau proteins to spread, causing new tangles.

However, this speculation is not proof that footballers are more likely to develop Alzheimer’s. If anything, footballers may have a reduced risk as regular physical exercise may help protect against developing the condition.

“High sodium levels in drugs 'putting patients at risk',” The Guardian reports. A study in the BMJ highlights the often overlooked fact that 'everyday' soluble drugs such as painkillers, contain high levels of salt (sodium) which may cause health problems if taken on a long-term basis. For example, the study points out, if you take the maximum recommended dosage of soluble paracetamol per day for an adult this would exceed the daily recommended salt / sodium intake of 6g, roughly equivalent to a teaspoon.

High sodium intake, on a long-term basis, is known to increase blood pressure, which in turn, can increase the risk of cardiovascular diseases, such as heart attacks and stroke.

The study in question looked at whether people who regularly took these types of soluble medications had an increased risk of cardiovascular diseases compared to their peers, who took similar medications, but without sodium.

Researchers found a link between the use of soluble medications and high blood pressure and non-fatal stroke, but no significant link was found with heart attacks as some of the reporting implied. Also crucially, the study design, a case control study, cannot prove cause and effect. The study also focused on sodium intake from medicines only, and did not account for potentially large differences in sodium obtained in the diet via salt, as well as other factors that influence disease risk. So ultimately, there is currently no evidence that soluble drugs directly cause cardiovascular diseases.

Never the less the research opens a debate about whether drug manufactures could or should include information on sodium content on drug packaging.

Further details http://www.nhs.uk/news "Steroid injections for premature babies could raise ADHD risk," reports The Daily Telegraph after a Finnish study found a link between steroid use (corticosteroids) in premature babies and developmental conditions such as attention deﬁcit hyperactivity disorder (ADHD). Steroids are sometimes given to pregnant women if they go into premature labour (particularly before 35 weeks) as they can help stimulate the development of the baby's lungs. This signiﬁcantly reduces the risk of premature babies developing a serious and potentially fatal breathing condition known as

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neonatal respiratory distress syndrome (NRDS). Because of the use of steroids and breathing equipment, deaths from NRDS are now extremely rare in the UK. However, concerns have been raised that using steroids at such an early stage of a child's development could cause problems in later life, such as ADHD. The study involved children born in Finland in 1986 who were followed up at the ages of eight and 16, when they were assessed using various behavioural scales.

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BEHIND THE HEADLINES

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Fungal Infections of the Feet

Iain B. Mclntosh BA(Hons)MBChB., Former Chiropody Schools Inspector Simple infections of the foot extremities which are often met in podiatry practice can prove difficult and sometimes Intractable problems to treat. Traditionally, dermatophyte, or ringworm infections have been described by the Latin term name tinea, and toe nail and web space infections are referred to as tinea pedis. Once acquired, they resist treatment and often recur after disappearing for lengthy periods from skin and nails. Effective topical and oral antifungal preparations can now potentially eradicate these infections over time. Fungal infections of the feet and toenails have prevalence in the UK of 15% of the general population with the highest incidence in male swimmers of 20% in male swimmers.1,2 The incidence is reported to have doubled in recent years and there are estimates that 1.2million people may currently be affected.2 Swimmers, industrial workers, elderly people, those with psoriasis and diabetics are most likely to be affected.3,4 A surveillance study of 25,000 patients with onychogryphosis showed 23% were over the age of 60 years4. Swimming pools saunas, communal changing rooms and showers are incriminated in their spread, as is the ubiquitous wearing of trainers. It can also be passed between family members who share shoes and towels. Clinically the dermatophytes Trychophyton and Epidermophyton are the most frequent causative agents. Occasionally the problem may be due to monilial yeast infection - and both can be complicated by secondary bacterial infection. Often limited to the webspace between 4th and 5th toes they can affect every nail and spread beyond the foot. In immune-compromised and diabetic

TECHNICAL ARTICLE

patients they can be severe and it is not unusual in long stay geriatric wards to find elderly people with ten affected and crumbling toe nails. These infections can potentially spread infection to the finger nails of the unwary podiatrist or nurse. lnattention to hand-washing and instrument sterilisation between patient contacts can spread infection between people. Once acquired and treated, a meticulous regimen has to be observed to prevent reinfection in patient and therapist. Dermatophytes thrive in a damp humid and warm environment and ideal conditions occur between the smaller toes when occlusive footwear is worn. Tinea pedis typically starts in the 3rd or 4th toe web space and is characterised by skin peeling, maceration, scaling and fissuring, often associated with itching. One third of people with athletes foot develop fungal nail disease. Toe-nail fungal infection -onychomycosis- usually affects the toe nail first rather than nearby skin and is often restricted to one foot. The nail plate becomes opaque onycholysis - and then yellow or brown in colour; with thickening of the nail. lnfection usually starts with distal nail bed invasion then proximal spread and later there is unattractive browning and yellowing of the nail. Untreated onychomycosis can lead to in-growing toenail or onchogryphosis Untreated tinea pedis may lead to severe reactive inflammation with painful fissuring of toes and feet. Generalised autosensitisation eruptions can occur in response to persistent fungal infection and tinea pedis merits treatment when first discovered even if asymptomatic and merely aesthetically displeasing. Differential diagnosis - Yeasts such as

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monilia (Candida) and moulds like aspergillus also affect the toenails with the former more common in diabetic patients and the latter often resulting in whitish or greenish black appearance to the affected nail .Bacterial infection with pseudomonas may occasionally have to be considered in differential diagnosis. This typically occurs in a nail that has lost its nail bed attachments and the green black pigmentation is really staining of the underside of the nail. Psoriasis can cause crumbling of the nail plate and can be confused with fungal infection and sometimes the two co-exist. Usually several nails will be affected in the psoriatic individual. There will, be evidence of the pathognomonic pitting of the superficial nail plate when psoriasis is the cause.

Conﬁrmation of Diagnosis

In an ideal world, skin and nail fragments, from suspicious lesions would always be sent for microscopy. Scrapings from the distal edge of the aﬀected nail, or the soggy skin in a toe-web, can be placed in an envelope and dispatched to the laboratory to conﬁrm identity of causative organism. In reality most lesions are assumed to be tineal, monilial or bacterial on presentation and treated accordingly. Failure to respond to treatment prompts laboratory investigation of skin and nail clippings with microscopy and culture.

Treatment

The lay public often believe that nothing can be done to alleviate the condition. Eﬃcacious topical ointments, lacquers and oral preparations have revolutionised the scene, however, topical therapy is usually used for glabrous skin lesions and infections of the nails I treated with oral medication over

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several months. A review of randomised control studies found allylamines were effective in curing fungal infections and produced a faster response than azoles but cure rates were similar.1. Traditionally Whitfield’s ointment - a combination of weak fungistatic (benzoic acid 6%) and a kerala-salicylic acid 3%) served as an inexpensive treatment. It requires prolonged administration, is messy and may cause mild skin irritation on raw skin. Tolnaftate (tinaderm) was one of the first synthetic chemical agents shown to be an effective fungicide when applied topically. With the addition of nystatin its use is extended to monilial infections as well. Clotrimazole (canestan) miconazole (daktarin) and ketoconazole (nizoral) all demonstrate anti-fungal properties and have a broad spectrum of activity. These topical applications are invaluable when laboratory mycological investigation is not available. Twice daily application of the creams is usually recommended and treatment should continue for at least two weeks after clinical cure to prevent relapse. Side effects of treatment are few and rare. Griseofulvin is derived from the penicillium species and is effective against all dermatophytes. Long courses of treatment are necessary for nail infections due to the slow rate of nail growth. A third of patients who fully comply with the treatment regimen will respond poorly to the medication. The drug is fungistatic and therefore has to be taken until all the infected tissue is lost through natural turnover. Terbinafine is fungicidal and the product can be said to murder the dermatophytes whereas fungistastics merely anaesthetise them. The former

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need only to be taken for a short time until the fungi are dead. Terbinafine and topical azoles rapidly penetrate the stratum corneum and quickly kill the infection with a high response rate, but their use is not recommended for children. A study has shown that in patient s given terbinafine for 12 weeks, there was 76% mycological cure rate after 72 weeks follow up.4 Azoles are usually effective for superficial fungal skin infections 4. Local application of amorolfine paint (loceryl) is reported as curing 65% of limited distal nail infections 4 but the majority of people with tinea infections utilise over the counter preparations before presenting to their family doctor who may be poorly informed about foot disease and will rarely seek supportive mycological evidence of the causative organism. The tendency is to treat empirically without further surveillance.5 The podiatrist has a key role in diagnosis, determining appropriate therapy, continued overview of treatment until the condition is eradicated, and in health promotion in educating patients and the general public regarding the sources of infection and avoidance of personal infection. Public awareness that there is cure for these conditions is poor and there is a tolerance of the infection which ensures that many people will continue to carry and spread the infection for many years and often over the course of a life time. Patients have to be encouraged to comply with appropriate therapy and maintain it until mycological cure has occurred. Simple precautions in avoidance of infection have to be advised. Protective flip flops and plastic pool socks should be used in swimming pools, communal saunas, baths and showers and changing

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rooms. Socks should be washed and changed frequency especially in warm humid weather and after heavy exercise. Prolonged wearing of Wellington boots, trainers and plastic shoes should be discouraged. Careful drying of feet and web-spaces is to be recommended. After washing an application antifungal foot powder is a useful precaution. People should be taught to recognise the early signs of webspace and nail infection and be encouraged to seek prompt treatment, maintained until cure has taken place. Tineal foot and nail infection is widespread in Britain. The podiatrist has a prominent role in treatment and in containing the spread throughout the community. Simple precautions, wise professional advice, appropriate therapy maintained until cure, can help to reverse the trend and improve the state of the nation’s feet.

References

1 Crawford F Hart R et al Athletes foot and fungally affected toenails 2001 Brit Med J 322288-90 2 Roberts Dt Prevalence of dermatophyte infection in the UK 1992 Br. J. Dermatology 1992 126 suopp.23-7 3 Gentles JC Evans E Foot infection in swimming baths 1973 Brit. Med. J. iii 260-2 4 Goodfield M Feet first. Geriatric Med. June.2000 57-6 5 Finucane K Berker D Management of common diseases of the nail. The Practitioner 2004 248 618-30

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Keeping Warm in Later life ProjecT (KWILLT)

Angela Tod, Professor of Health Services Research Centre of Health and Social Care Research, Sheﬃeld Hallam University The Keeping Warm in Later Life project (KWILLT) is a study to examine the knowledge, beliefs and values of older people with a focus on keeping warm at home and barriers to accessing help to keep warm.

Background

There are approximately 26,000 excess winter deaths in England every year, the majority of which are in those over 65.1-3 With anticipated increases in both fuel poverty levels and excess winter deaths there is concern that more older people will be at risk of excess winter deaths or illness brought on by cold. The study was funded by the National Institute of Health Research, Research for Patient Benefit Programme and was undertaken by a team of health service researchers at Sheffield Hallam University. The project was hosted by NHS Rotherham and conducted in partnership with Rotherham Metropolitan Borough Council, Age UK Rotherham and a lay organisation, Rotherham Older Peoples Experience of Services (ROPES). KWILLT aims to understand the influences and decisions of vulnerable older people in relation to keeping warm in winter and to identify those most at risk. 50 older people in the age range 55-95 were recruited for interview from across Rotherham. They were interviewed at home and temperature and humidity measurements taken. In addition 25 health and social care staff were interviewed face to face to gather their opinions.

Why are some older people cold at home?

The study has provided understanding of the complex environment within which vulnerable older citizens live and the factors that conspire against them being able to keep warm by taking into account situation, attitudes, values and barriers1

TECHNICAL ARTICLE

KWILLT also provides some insight into why older people at risk of being cold are not always able to make decisions to keep them warm. It reinforces and expands the ﬁndings of others.

Situation

‘Situation’ or context factors can be broken down into separate areas for example:Income: Inability to pay for fuel. Worry about other debts.

Age: if someone is of an older (80+) or younger generation (55-65) this will impact upon social norms regarding heating, familiarity to diﬀerent heating technology, expectations regarding hardship, payment methods.

Social connections: People who are isolated or have limited contact with news via newspapers or internet. The more socially isolated someone is will inﬂuence knowledge, awareness and behaviour.

Housing type and tenure: many of the most vulnerable participants were in privately rented housing as they lacked conﬁdence, control and money to change their environment. However some participants in social, privately owned and energy eﬃcient properties were still cold. Health: the underlying health status and frailty of an older person was seen to impact upon ability to keep warm.

Attitudes and values

Attitudes and values played a big part in how people behave. They are built up over a lifetime and hard to change. For instance, many elderly people were brought up to value thrift and keep a ‘stiﬀ upper lip’. Therefore, do not talk about any money problems or ask for help. The range of values and beliefs that were seen to inﬂuence behaviour interacted with contextual factors and barriers. In order to explain how these

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worked we “clustered” attitudes and experiences to illustrate how they would increase someone’s risk of being cold. The clusters were:-

• "Making ends meet": thrift, pride, struggling, competing priorities • "I can manage": thrift, hardiness, stoicism • "It’s my business": mistrust, pride, independence, privacy • "I’m frightened": independence, privacy, personal safety, vulnerability • "I’ll stay as I am": struggle with change, like routine, fear, mistrust1.

Barriers

Four main obstacles were identiﬁed for older people regarding keeping warm1.

Awareness: Across all the participants (older people and staﬀ) there were low levels of knowledge and awareness on why it is important to keep warm, what temperatures are recommended, where to get information from and how to access help. Some people believed that hot rooms were unhealthy.

Technology: Low levels of knowledge, experience and literacy regarding diﬀerent technologies put older people at a disadvantage when trying to keep warm. This was mainly regarding heating technology (boilers and programmers), information technology (internet and electronic media)and banking (direct debit and online payment systems) Disjointed systems: some of the most vulnerable participants reported that social systems and organisations had changed tremendously since their youth. This made it diﬃcult for them to understand how to access help and navigate their way to accessing information and support.

Invisibility: older people in KWILLT were used to solid fuel heating where fuel was

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tangible and payment was in cash. They found it diﬃcult to make judgements about heating fuel use as fuel use and its payment were invisible; for example gas central heating and payments by direct debit. Some older participants would selfdisconnect due to fear of fuel debt.

What do the ﬁndings mean?

KWILLT has provided understanding of the complex environment within which vulnerable older citizens live and how they struggle to keep warm at home. There is a need for organisations to work in partnership to address this complexity by identifying, assessing, referring and delivering help to those who need it. The study echoes others research indicating that the public and staﬀ lack awareness of the health risks of cold and that people are reluctant to ask for help in case they were seen to be struggling1.

Mistrust related to heating, fuel tariﬀs and schemes such as Warm Front was woven through participants’ stories alongside mistrust of related organisations (energy companies, local authorities and banks).

Importantly KWILLT indicates a need to challenge assumptions about who is at risk from a cold home. It is not only the fuel poor who are at risk. The study shows that people who were not fuel poor were also at risk because of broader social, contextual and attitudinal factors. For example people in energy eﬃcient homes were cold because they couldn't use or reach heating equipment, or didn't understand how it worked 1. Others were cold because their life had changed in such a way that they lost capacity in some way. An example is if they were bereaved and their spouse had been the person who knew and understood the heating system and fuel prices and subsequently they did not. Neither was it just the very old who were vulnerable; some of the younger

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participants (55-60 years of age) were the most vulnerable because they lived on a low income, in privately rented accommodation, had mental and physical health problems, lacked the ability to access and understand information and were ﬁercely protective of their privacy.

How can health professionals help?

As the cold weather continues and worsens we all need to be alert. Domiciliary chiropodists are in a prime position to observe their patients and check for early signs and symptoms of potential hypothermia. Does the house feel too cold? Do people know how to use their heating? Does your patient express worry about paying their heating bill? Is your patient more tired than normal? Do they seem confused? Is their skin paler than normal? Are they breathing normally? If you feel the room is too cold (below 18 – 21C), perhaps you could tactfully suggest ways of heating the room and ask if they are aware of local support that is available. They may be entitled to beneﬁts that they are currently not claiming. A healthy diet with plenty of ﬂuids, warm drinks and regular meals can help provide energy so the body can generate heat. Your patient may not be aware of this. A proportion of elderly people may be too proud and stubborn to accept advice and help, however, others will welcome outside interest and a general chat may be all that is required. Any suspicions should not be ignored, however, it may well be a matter of life and death! If a patient will not listen and you are concerned it would perhaps be advisable to contact their GP or at least a close relative. Keep a written record of any advice given and actions taken. The full report can be read at http://bmjopen.bmj.com/content/2/4/e 000922.full

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References

1. Tod AM. Lusambili A. Homer . Abbott J. Cooke JM. Stocks AJ. McDaid KA. Understanding factors influencing vulnerable older people keeping warm and well in winter: a qualitative study using social marketing BMJ Open 2012;2:e000922 doi:10.1136/bmjopen2012-000922 2. Marmot Review Team. The health impacts of cold homes and fuel poverty. On: http://www.instituteofhealthequity.org/pr ojects/the-health-impacts-of-cold-homesand-fuel-poverty Accessed October 2012 3. Public Health England (2013) Cold Weather Plan for England 2013 Protecting health and reducing harm from cold On: weather https://www.gov.uk/government/ uploads/system/uploads/attachment_data /file/252838/Cold_Weather_Plan_2013_fi nal.pdf Accessed October 2013 4. Department of Health. Cold Weather Plan for England: Why cold weather is essential to health and well-being London: Department of Health, 2011 Additional Information The Research Team (KWILLT) Jo Abbott Consultant in Public Health NHS Catherine Homer Health Promotion Specialist NHS Angela Tod Principle Research Fellow Sheffield Hallam University Adelaide Lusambili Research Fellow NHS Jo Cooke CLARHC programme Manager Kath McDaid NEA Regional Coordinator Paul Mapplethorpe Energy Efficiency, Rotherham MB Council Rotherham Older People’s Experience of Services Judy O’Brien Administrative Support NHS Winter Warmth England The Kwillt findings were used to inform the development of the Winter Warmth England website. This was a Yorkshire and the Humber co-ordinated project funded by the Department of Health’s Warm Homes Healthy People funding. The Winter Warmth England website http://www.winterwarmthengland.co.uk provides information, statistics and communication resources to help relevant organisations and staff to ensure that vulnerable people stay safe, well and warm during the winter.

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The Importance of Clinical Note Writing

Adapted from a presentation by Claire Gallagher BSc (Hons) Pod Clinical records are a legal document. They are used to :• Record assessment results and treatment for the patient • Provide evidence of consent • Outline future treatment plans • Demonstrate any podiatric needs • Assist colleagues Paperless records are becoming increasingly popular and have advantages over record cards in that they can be stored safely on computer with access by password only. They are legible and save on storage space. Electronic record cards reduce the risk of lost or misﬁled records and are accessed quickly. They are also environmentally friendly in reducing paper consumption. The disadvantages are that all electronic records need to be registered with the Data Protection Agency.

Summary

ARTICLE

All patient record forms should contain the patients full name, address, date of birth and telephone numbers including an emergency contact number, their GP’s name and address. Any foot lesions should appear on a diagram. In addition the patient records should include a medical history. This can be an additional form if required but should include the patient’s full name, date of birth, up to date medication record (and the reason why the are taking the medication), any known allergies and vascular neurological checks. This information should be updated every six months at least. The meaning of SOAP SOAP is believed to encourage a structure for medical records by capturing ‘logical’ thoughts and concise data

S – Subjective O – Objective A – Action P – Plan

Examples of SOAP

Subjective I have a pain in my big toe

Objective On examination, the patients right ﬁrst toe appeared red and swollen. At closer examination patient appeared to have onychocryptosis in medial sulcus of the ﬁrst toe.

Action Chlorhexidine gluconate spray applied to both feet. Nail spicule cut and removed from nail sulcus. Onychophosis cleared away using blacks ﬁle. Sterile dressing including inadine, melonin, tubegauze and meﬁx applied. Patient given written and verbal advice on cleaning of toe in saline foot bath after removal of dressing in 24 hrs. Also written and verbal advice given on signs of spreading infection and told to contact if any further problems. Plan Patient to return for check up in 2/12. Possible future nail surgery.

NB Standardised shorthand notes may be used

Write in black ink • Make it legible • Contain the SOAP format • Detail all aspects of treatment or assessment • Write straight away • Standardise shorthand • Print and sign • Date and time Podiatry Review Vol 71:1

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Cervical Cancer Prevention Week 19-25 January 2014

This January the European Cervical Cancer Association (ECCA) runs Cervical Cancer Prevention Week. Over six days, the organisation wants to draw awareness to cervical cancer by providing information on the development of the disease and prevention. Did you know that it is preventable? Yet 20% of women in the UK decline the invite to be tested. Furthermore, only half of all girls are oﬀered the HPV vaccine.

The Cervix

The cervix (or neck of the uterus) is the lower, narrow part of the uterus which joins to the top end of the vagina. The opening of the cervix is called the os. The cervical os allows menstrual blood to ﬂow out from the vagina during menstruation. During pregnancy, the cervical os closes to help keep the foetus in the uterus until birth. During labour, the cervix dilates, or widens, to allow the passage of the baby from the uterus to the vagina. Approximately half the cervix length is visible with appropriate medical equipment; the remainder lies above the vagina beyond view.

The cervix is covered with a layer of skin-like cells on its outer surface, called the 'ectocervix'. There are also glandular cells lining the inside of the cervix called the endocervix. These cells produce mucus. The skin-like cells of the ectocervix

can become cancerous, leading to a squamous cell cervical cancer. Or the glandular cells of the endocervix can become cancerous, leading to an adenocarcinoma of the cervix.

The ectocervix and endocervix have a three main skin layers or zones:-

• The basal layer - cells are produced here. Older cells are pushed up towards the surface. If you contract HPV, the virus will attack the basal layer cells. • Midzone - the middle layer of cells. As cells move up from the basal layer they lose their capacity to divide making them fully mature cells. • Superﬁcial zone - The uppermost surface of the cervix where mature cells eventually die and shed in the normal process of skin shedding1. Cervical screening takes cells from this area.

The area where cervical cells are most likely to become cancerous is called the transformation zone. This is the area just around the opening of the cervix that leads on to the endocervical canal (the narrow passageway that runs up from the cervix into the womb). The transformation zone is the area that your doctor or nurse will concentrate on during cervical screening.

The vagina is the tube from the outside of the body to the entrance to the womb. The skin-like cells that cover the cervix join with the skin covering the inside of the vagina, so even if you have had your womb and cervix removed, you can still have screening samples taken from the top of the vagina.

Cervical cancer

Cervix in relation to upper part of vagina and posterior portion of uterus.

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Cervical cancer forms in tissues of the cervix (the organ connecting the uterus and vagina). It is usually a slow-growing cancer that may or may not have symptoms but can be prevented through

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regular screening (a procedure in which cells are taken from the cervix and looked at under a microscope). Cervical cancer is not thought to be hereditary. 2,3,4

99.7% of cervical cancers are caused by persistent human papillomavirus (HPV) infection which causes changes to the cervical cells. HPV is an extremely common virus; around four out of ﬁve people will be exposed to the virus. Anyone who is sexually active can be infected with HPV at some time and the body’s immune system will usually clear it up. Generally, most people don’t even know they have contracted the virus at all. Cervical abnormalities are caused by persistant HPV infection. These abnormal cells found through cervical screening are not cancerous but given time (often years) they may go on to develop into cancer. However, often the cells return to normal by themselves. Information from the NHS National Screening Programmes 2010-11 showed that 7-9% of women will have abnormal cells of which only a small percentage will go on to have cancer.

The most eﬀective method of preventing cervical cancer is through regular cervical screening which allows detection of any early changes of the cervix and for younger women the HPV vaccination can help prevent 70% of cervical cancers. Cervical cancer is largely preventable and, if caught early, survival rates are high.

Human papillomavirus (HPV)

Human papillomavirus (HPV) is an extremely common virus. At some point in our life most of us will catch the virus. The world over, HPV is the most widespread sexually transmitted virus; 80% (four out of ﬁve) of the world’s population will contract some type of the virus once5. If you catch HPV, in the majority of cases the body’s immune system will clear or get rid of the virus without the need for further

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treatment. In fact you may not even know that you had contracted the virus.

There are over 100 identified types of HPV; each different type has been assigned a number. HPV infects the skin and mucosa (any moist membranes such as the lining of the mouth and throat, the cervix and the anus). Different types affect different parts of the body causing lesions. The majority of HPV types infect the skin on external areas of the body including the hands and feet. For example, HPV types 1 and 2 cause verrucas on the feet 6.

Around 40 of the HPV types aﬀect the genital areas of men and women, including the skin of the penis, vulva (area outside the vagina), anus, and the linings of the vagina, cervix, and rectum 7. Around 20 of these types are thought to be associated with the development of cancer. The WHO International Association for Research on Cancer (IARC) identiﬁes 13 of these types as oncogenic (cancer causing). This means there is direct evidence that they are associated with the development of cervical cancer and are considered high-risk 8. These high risk types of HPV are: 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68 9. A person infected with high-risk genital HPV will show no symptoms so they may never even know they have it. Additionally there are nine HPV types that may also be associated with the development of cervical cancer these are types: 26, 53, 64, 65, 66, 67, 69, 70, 73, 82.

Pic Micrograph of a cervical adenosquamous carinoma H & E Strain.

HEALTH AWARENESS WEEK

However, currently there is not enough evidence to indicate that these types are high risk for cervical cancer 10.

The remaining genital HPV types have been designated low-risk as they do not cause cervical cancer but they can cause other problems such as genital warts.

HPV and cervical cancer

HPV infection causes changes to the cells of the cervix creating abnormalities, it aﬀects the DNA in the cells meaning new cells will be abnormal. HPV attacks the basal cells of the cervix (these are speciﬁc cells found in skin that reproduce new skin cells) 11. These abnormalities can result in the production of damaged and disorganised cervical cells that cannot function correctly. Once these abnormalities become severe they can develop into cancer which is why cervical screening and HPV vaccination are important in helping to prevent cancer.

99.7% of cervical cancers are caused by HPV 12. Around 13 high-risk types of HPV are responsible for causing cervical cancers 13. Within the high–risk group types 16 and 18 are the most prevalent, causing over 70% of cervical cancers 14.

80% of women are infected with genital HPV at some point in their lives, but never know they have been infected because HPV is usually cleared (without treatment) by the body’s immune system. However, a small percentage of women do not clear the infection and it can remain ‘dormant’ (inactive) or persistent in their bodies, sometimes for many years 15,16. We still do not understand why some women are able to clear the infection while in others the virus may lead to the development of abnormal cells and possibly cervical cancer.

The HPV vaccines and preventing cervical cancer.

Each year in the UK, over 3000 women

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are diagnosed with cervical cancer and around 300,000 women are told they may have some form of cervical abnormality. Cervical cancer is caused by a very common virus called human papillomavirus (HPV). Anyone who is sexually active can contract HPV through contact with someone who already has the virus. Most people are infected with HPV at some point in their lives but may never know they have been infected. Like other viral infections such as a cold, HPV is usually cleared by the body's immune system without the need for other treatment. We do not know why a small percentage of people do not clear the infection, which can remain 'dormant' (inactive) in their bodies sometimes for many years 17.18.

There are around 13 high-risk types of HPV that are responsible for almost all cervical cancers 19. Within the high-risk group, types 16 and 18 are the most prevalent and responsible for 70% of cervical cancers 20. HPV infection can cause changes to the cells of the cervix creating abnormalities. Once these abnormalities become severe they can develop into cancer which is why cervical screening and HPV vaccination are important in helping to prevent cervical cancer.

There are two HPV vaccines which provide protection against the two high risk types of HPV (types 16 and 18) that cause 70% of all cervical cancers. One of the vaccines is also designed to provide protection against genital warts which are caused by low risk types of HPV. Low risk types of HPV do not cause cervical cancer.

Research indicates that the HPV vaccine could prevent two thirds of cervical cancers in women under the age of 30 by 2025 but only if uptake of the HPV vaccination is at 80% 21. To date, the UK has achieved this level each year in the national HPV immunisation programme.

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Cervical Screening (smear test)

Each year around ﬁve million women in the UK are invited for cervical screening (smear test). Cervical screening is NOT a test to ﬁnd cancer. It is a screening test to detect abnormalities (pre-cancer) at an early stage in the cells in the cervix. Please take up your invitation to attend your cervical screening test, it saves lives.

Cervical screening is the process of taking a sample of cells from your cervix which are then examined to detect abnormalities that might develop into cancer in the future. The sample of cells is placed in liquid so that it can be analysed in the laboratory. This process is called liquid based cytology (LBC). Screening can detect precancerous/ abnormal cells and the detection and successful treatment of these cells usually prevents the occurrence of cancer. Changes in these cells are generally caused by certain types of human papillomavirus (HPV). Testing for the HPV virus itself can also be done on the same LBC sample that is examined under the microscope, although at the moment this is not done routinely on all samples in the UK.

Around 3,000 women are diagnosed with cervical cancer in UK each year 22. Regular cervical screening provides a high degree of protection against developing cervical cancer and is oﬀered free on the NHS. It is estimated that early detection and treatment through cervical screening can prevents up to 75% of cervical cancers from developing in the UK 23. Not going for cervical screening is one of the biggest risk factors for developing cervical cancer.

Abnormal cervical cells and treatment

The cervix is covered with a layer of skin-like cells on its outer surface, called the ectocervix. The results of your cervical screening are based on the analysis of the cells from the surface of the ectocervix.

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The screening can only detect whether there are abnormal cells present. Depending on the results of your screening, you may be referred to a specialist clinic in the hospital (colposcopy) in order to get a more accurate diagnosis and have treatment if needed. You will need to have a small sample taken from your cervix to analyse the cells from the layer beneath the surface, this is called a biopsy. Usually biopsies are only a few millimetres in size.

Want to know more or want to help? Visit Jo’s cervical cancer trust at http:// www.jostrust.org.uk/about-cervicalcancer/

References

1. Dunleavey R (2009) Cervical Cancer: a guide for nurses. Wiley-Blackwell, UK. pp.9 2. Magnusson P, Sparén P, and Gyllensten UB (1999) Genetic link to cervical tumours. Nature 400, 29-30. 3. Walboomers JMM, Jacobs MV, Manos MM, Bosch FX, Kummer JA, Shah KV, Snijder PJ, Peto J, Meijer CJ and Munoz Nl (1999) Human papillomavirus is a necessary cause of invasive cancer worldwide. Journal of Pathology, 189 (1), 12–19. 4. Bosch FX et al. (2002) The causal relation between human papillomavirus and cervical cancer. Journal of Clinical Pathology 55, 244-265 5. Koutsky L. 1997. Epidemiology of genital human papillomavirus infection. The American Journal of Medicine, 102 (5A), 3-8. 6. Lacey CJ et al., 2006. Chapter 4: Burden and management of non-cancerous HPV-related conditions: HPV-6/11 disease. Vaccine, 24 (3), S3/35-41. 7. Giuliano AR et al., 2008. Epidemiology of human papillomavirus infection in men, cancers other than cervical and benign conditions. Vaccine, 26 (10), K17-28. 8. Walboomers JMM et al.,1999 Human papillomavirus is a necessary cause of invasive cancer worldwide. Journal of Pathology, 189 (1), 12–19. 9. Szarewski A. 2012. Cervarix: a bivalent vaccine against HPV types 16 and 18, with crossprotection against other high-risk HPV types. Expert Review Vaccines 11(6), 645 – 657. 10. Bouvard et al., 2009. A review of human carcinogens – Part B: biological agents. Lancet Oncology 10, 321 - 322. 11. Dunleavey R. 2009. Cervical Cancer: a guide for nurses. Wiley-Blackwell, UK, 9.

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12. Walboomers JMM et al.,1999. Human papillomavirus is a necessary cause of invasive cancer worldwide. Journal of Pathology, 189 (1), 12–19. 13. Li N et al., 2011. Human papillomavirus type distribution in 30,848 invasive cervical cancers worldwide: variation by geographical region, histological type and year of publication. International Journal of Cancer 128, 927–935. 14. Bosch FX et al., 2008. Epidemiology and natural history of human papillomavirus infections and type-speciﬁc implications in cervical neoplasia. Vaccine 26 (10), K1-16. 15. Muñoz N et al., 2009. Persistence of HPV infection and risk of high-grade cervical intraepithelial neoplasia in a cohort of Colombian women. British Journal of Cancer 100, 1184– 1190. 16. Moscicki AB et al., 1998. The natural history of human papillomavirus infection as measured by repeat DNA testing in adolescent and young women. Journal of Pediatr, 132, 277-284. 17. Muñoz N, et al., 2009. Persistence of HPV infection and risk of high-grade cervical intraepithelial neoplasia in a cohort of Colombian women. British Journal of Cancer 100, 1184– 1190. 18. Moscicki, AB, et al., 1998. The natural history of human papillomavirus infection as measured by repeat DNA testing in adolescent and young women. Journal of Pediatr 132, 277-284. 19. Li N et al., 2011. Human papillomavirus type distribution in 30,848 invasive cervical cancers worldwide: variation by geographical region, histological type and year of publication. International Journal of Cancer 128, 927–935. 20. Bosch, F.X., et al., Epidemiology and natural history of human papillomavirus infections and type-speciﬁc implications in cervical neoplasia. Vaccine, 2008. 26 (10), K1-16. 21. Cuzick J, Castanon A, and Sasieni P. 2010. Predicted impact of vaccination against human papillomavirus 16/18 on cancer incidence and cervical abnormalities in women aged 20–29 in the UK. British Journal of Cancer 102, 933-939. 22. Cancer Research UK website: http://www.cancerresearchuk.org/cancerinfo/cancerstats/types/cervix/mortality/. Accessed 30.05.2013. 23. Peto et al., 2004. The cervical cancer epidemic that screening has prevented in the UK. Lancet, 35, 249-56. Additional thanks to Jo’s cervical cancer trust. http://www.jostrust.org.uk/about-cervicalcancer/ National Awareness Days http://www.nationalawareness-days.com Photographs http://en.wikipedia.org/wiki/Cervical_cancer

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Exercise therapy 'can help osteoarthritis patients avoid surgery' Osteoarthritis (OA) patients who undertake a programme of exercise therapy could improve their chances of avoiding or delaying the need for total hip replacement (THR) surgery. This is according to a new study conducted by Dr Ida Svege and a team at Oslo University Hospital in Norway, which aimed to determine the impact of exercise on the long-term need for THR among hip OA patients. Involving 109 patients with symptomatic and radiographic hip OA, a long-term follow-up study was conducted for a randomised trial investigating the eﬀect of exercise therapy and patient education on the six-year cumulative survival of native hips. According to results published in the

Annals of the Rheumatic Diseases, patients who took part in both the educational sessions and the exercise programme experienced a 44 per cent decrease in the need for hip replacement, compared with those who only received the educational support.

The study authors stated: "We argue that for patients with tolerable pain who are able to maintain their desired activity level and who are relatively young, postponing surgery is appropriate and may reduce the future need for THR or repetitive revision surgery."

Meanwhile, among those who did require joint surgery, median time to hip replacement was measured at 5.4 years for the exercise group, compared to only 3.5 years for the education group.

A spokeswoman for Arthritis Research UK welcomed the study's ﬁndings.

This is a potentially important discovery as rates of total hip arthroplasty have been on the rise over the past four decades, creating signiﬁcant costs for healthcare services, while also putting patients at risk of suﬀering from the complications often associated with surgery.

"Although the success and satisfaction rates for hip replacement surgery are high, an artiﬁcial hip can never been as good as the real thing," she added. "For those people who are not in too much pain, to know that exercise could help stave oﬀ the need for surgery is a very positive message." See more at: http://www.arthritisresearchuk.org/news

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PRESS RELEASE

Podiatry Review Vol 71:1

$ $

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43100 Podiatry Rev Jan 17/12/2013 10:34 Page 19

CONTINUING PROFESSIONAL DEVELOPMENT

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

Anatomy and Physiology for Practice Part 1 Beverley Wright MSc, BSc(Hons), PGCE, PGDip, MInstChP An Introduction to the Organisation of the Human Body.

This Continual Professional Development (CPD) will introduce you to some of the fundamental biological principles and terminology that underpin the structure and function of the human body. Although you have undertaken anatomy and physiology studies in the past and as part of your professional health training, over time some of our basic understanding of biological sciences diminishes. While hopefully much of what had been learnt has remained with us, the following activities will be a reminder of some of the basic science and structures of the body, including the terminology or professional language and terms used by health professionals in our daily working lives. Mastering and understanding the terminology was a part of the process of learning and evolving into a professional health practitioner and therefore, we are all aware that without a good understanding of this terminology it can often be difficult to communicate effectively with colleagues, other health professionals and patients. Hopefully, you will find that this introduction to anatomy and physiology useful to help you build upon the key concepts you were introduced to during your original training and in respect of other anatomy and physiology CPD you have since undertaken. This CPD is divided in sections and each section has a set of self assessment questions to help you assess what you know or learnt to identify any areas that you may need to study further to support your practice. Following completion of this CPD you should be able to: • Define anatomy & physiology. • Describe how these are commonly subdivided. • Name the different levels of structural organisation that make up the human body. • Identify anatomical position by describing body directions, regions and body planes or sections. • Locate the major cavities of the body. • List and briefly describe the meaning of the Applied Biological Science subjects.

Introduction to Applied Biological Science: Anatomy & Physiology

The study of Applied Biological Science involves the study of Anatomy and Physiology. With reference to a dictionary or biology related textbook, briefly define anatomy and physiology in your own words. It is possible to study anatomy & physiology in isolation however, they are really inseparable because function always reflects structure i.e. what the body as a whole or a specific part of the body can do (it’s function) is dependant on how it is built (structure). We can relate this to aspects of every-day life in order to understand this concept. When we examine a tin of soup, where it is apparent that the structure of the tin is related to its function e.g. the tin is hard to resist damage in order to transport the food safely from the factory to the purchaser’s home. The tin is an air tight container to prevent the food decaying or becoming contaminated. This relationship between structure and function is called the principle of complementarily of structure and function. Anatomy and physiology are both broad fields with many subdivisions or topics.

Subdivisions of Anatomy

Gross or macroscopic anatomy is the study of large body structures visible to the naked eye. Gross anatomy can be studied either regionally i.e. looking at all body structures in a particular region e.g. the arm or abdomen, or studied systematically i.e. looking at all the body structures in a speciﬁc body system e.g. the cardiovascular system. Surface anatomy is the study of internal body structures as they relate to the overlaying skin surface e.g. this would be used to locate the appropriate artery over which to feel a pulse. Microscopic anatomy is the study of structures that are too small to be seen by the naked eye. These structures are usually viewed using microscope e.g. individual cells. The study of cells is a speciﬁc subdivision of microscopic anatomy known as Cytology. Groups of similar cells that have a common function are known as tissues and the study of tissues is another branch of microscopic anatomy known as Histology.

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CONTINUING PROFESSIONAL DEVELOPMENT

Developmental Anatomy is the study of the structural changes that occur in the body throughout the lifespan. Embryology is a subdivision of developmental anatomy that studies the speciﬁc change in the structure of the body prior to birth i.e. while the baby is growing in the mothers uterus. Radiographic Anatomy studies internal structures as visualised by x-rays and other imaging techniques such as Magnetic Resonance Imaging (MRI). You may come across other references to radiographic imaging in television programmes and the media. Pathological Anatomy studies structural changes that are caused by disease. Molecular Biology studies structure at a sub cellular level i.e. it involves the study of chemical substances.

Subdivisions of Physiology

The subdivisions of physiology usually consider the functioning of speciﬁc body systems e.g. renal physiology = study of the kidney function. Physiology like anatomy may focus at a gross level i.e. how the overall system works (what is its general function) or it may focus on events at molecular or chemical level. An understanding of physiology is dependant on you developing an understanding of physical principles e.g. electrical currents to explain how cells conduct electrical impulses in the nervous system, pressure and gravity to explain how the blood circulates in the blood vessels and how air moves into and out of the lungs to facilitate breathing, temperature and heat to explain how the body regulates temperature.

medical language and using the same terms when discussing biological sciences. Below there are a few basic questions to answer, just to refresh your knowledge on some of the terms used in biological science.

Levels of body organisation

The human body is extremely complicated. It is useful to organise the human body systematically. One way of doing this is to divide the body into levels based on the size of its structures: Chemical level - includes the study of atoms and molecules. Atoms are the smallest units of matter that participate in chemical reactions. Molecules are two or more atoms joined together such as water, sugar and proteins. Molecules then combine in specific ways to form cells and organelles. Cellular level - molecules combine to form cells, which are the smallest basic structural and functional units of a human body. There are many different types of cells. Cells vary in their size and shape, in order to reflect their unique function. Cells specialise to perform specialist function e.g. red blood cells to carry oxygen. However, in order identify some of the general structures and hence functions of a cell the following diagram of a cell has been included.

The aim of this CPD is to facilitate your learning and understanding of the structure and function of the human body. It therefore, seems appropriate to ensure that we are talking the

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

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CONTINUING PROFESSIONAL DEVELOPMENT

Self-Assessment – Part 1 Biological Science Terms (answers to be continued on separate sheet of paper) 1 What is Anatomy? 5 What is Osteology?

2 What is Physiology? 6 What is Mycology?

3 What is Biology? 7 What is a Cell?

4 What is Dietetics? 8 What is Tissue?

Self-Assessment – Part 2 Match the organ systems (A to L) with the following organs or body structures (1 to 12). A

Skeletal

Blood vessels, blood & heart

Urinary

Testes, vas deferens

Muscular

Digestive

Male reproductive

G H I

K L

Cardiovascular Nervous

Endocrine

Female Reproductive Integumentary Respiratory Lymphatic

2 4 5 6 7 8 9

10 11 12

Trachea, bronchi, alveoli

Adrenal glands, pancreas Oesophagus, stomach

Kidneys, bladder, ureters Skin, hair, nails

Brain, spinal cord, nerves

Lymph nodes, lymph vessels Bones, ligaments, joints

Skeletal muscles, tendons

Ovaries, uterus, fallopian tubes

Self-Assessment - Part 3

Now that you have matched the organs with the relevant organ system can you match the organ system (A to L) to its most important function below (1 – 12) 1. Rids the body of nitrogen containing waste, conserves body water and eliminates excesses. 2. Responds to environmental changes by transmitting electrical impulses.

3. Provides support and levers for the muscular system to work. 4. Breaks down undigested food into smaller absorbable units that can enter the blood stream.

5. A transportation system, delivers oxygen and nutrients to the tissues and cells. 6. Moves the limbs, allows you to smile

7. Is damaged if you cut your ﬁnger or get sunburnt

8. Allows exchange of gases between small air sacs (alveoli) and the blood stream. 9. Produces sperm, has ducts and glands to deliver sperm to female reproductive tract. 10. Consists of glands, which produce hormones.

11. Returns to the bloodstream tissue ﬂuids containing substances that cannot re-enter at the vein end of capillaries.

12. Produces eggs and provides a site for fertilisation and development of a foetus.

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CONTINUING PROFESSIONAL DEVELOPMENT

Reference List

Brewer, S. 2011. The Human Body A Visual Guide to Human Anatomy. 2nd Ed. London. Quercus Publishing Plc. Clancy, J. and McVicar, A. 2009. Physiology & Anatomy for Nurses and Healthcare Practitioners: A Homeostatic Approach. 3rd ed. London: Arnold

Coyle, F., Davis, J., Geddes, L., Meredith, G., Parker, S., Price, D., Walker, R. & Roberts, A (ed). 2010. The Complete Human Body The Deﬁnitive Visual Guide. London. Dorling Kindersley Limited. Davidson, S., Preston, P., Williams, F & Peters M (ed). 2008. The British Medical Association Illustrated Medical Dictionary. 2nd Ed. London. Dorling Kindersley Limited. Foss,M. & Farrine,T. 2000. Science in Nursing and Health Care. Prentice Hall.

Self-Assessment - Part 4

Use the labels of the cell diagram and brieﬂy describe the function of each part of the cell - an example is given in the table below. (answers to be continued on separate sheet of paper) The Cell Parts (Organelles) Nucleus

Function

Generally spherical or oval and is the largest structure in the cell. It is a central mass surrounded by its own membrane. It contains the hereditary factors, the ‘genes’, of the cell, which control cellular structure and direct many cellular activities. Mature red blood cells do not have a nucleus, as they carry only limited types of chemical activity, which are not capable of growth or reproduction.

Tissue level - groups of cells with similar structure and function. There are four types of tissue; epithelial, connective, muscular, and nervous tissues. Organs are composed of two or more tissues that have unique shape and function, for examples; the heart, the kidneys, and the lungs. Organ system level - consists of a group of organs that all contribute to a particular function. For example the urinary system is composed of the kidneys, the bladder, the ureters and the urethra.

Part 2 in March/April 2014 issue

Kapit, W., Elson, ML, 2001. The Anatomy Coloring Book. 3rd Ed. San Francisco. Benjamin Cummings. Marieb, E. N. 2012. Essentials of Human Anatomy and Physiology International Edition. 10th ed. London: Pearson Education Marieb, E. N. and Hoehn, K. 2010. Human Anatomy and Physiology International Edition. 8th ed. London: Pearson Education

Martini F. H., Nath, J. L. and Bartholomew, E.F. 2012. Fundamentals of Anatomy and Physiology. 9th ed. London: Pearson Education. Rampton, S. 2007. Applied Biological Sciences workbook, APU: Chelmsford.

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

Tortora, G. J. and Derrickson, B. 2006. Principles of Anatomy and Physiology. 11th ed. New Jersey: Wiley and Sons Inc. Watson, R. 2011. Anatomy and Physiology for Nurses. 13th edition. London, Elsevier.

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

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

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North West Area Council Seminar Sunday 13th October 2013

The mystery of the Hallux Valgus was unveiled by Anthony Waddington, Consultant Podiatric Surgeon who talked about the wide range of surgical options available, balanced with the importance of realistic patients expectations.

The University of Central Lancashire in Preston is a fantastic venue to hold a seminar. It is easy to reach by road or rail being in the centre of town and there is plenty of room to park your car –for free! The auditorium is a perfect size too, ensuring that everybody can see and hear the lectures in total comfort. On the 13th October, the North West Area Council held their 15th full day CPD seminar.

Blood pressure, a common and complex condition aﬀecting many of our patients was presented by Dr Emma Allison. She also described the multiple treatment plans and consequences of uncontrolled hypertension.

In keeping with previous years, this event proved to be informative and interesting, even to a lay person like myself! Who isn’t interested in the treatments for blood pressure and preventative measures? Decontamination also carries on into everyday life in the kitchen for instance. The organisers work hard to select speakers who deliver their topics in a friendly, humorous manner. All lecturers made themselves available afterwards to answer individual questions.

The choice for lunch was excellent with some tasty puddings! The day concluded with a lecture on decontamination methods by Craig Mackintosh an experienced microbiologist whose background in hospital infection control translated well to our practice.

In addition to the three lectures, there were numerous trade stands which delegates had the opportunity to browse before, during and after! The traders are more than happy to discuss and demonstrate products and again answer any questions.

These educational opportunities would not be possible without the support and hard work of the members of the North West Council. We were proud to have raised £102 for the Institute’s Benevolent fund with our raﬄe. Thanks to Michelle Taylor and Chris Carrington for selling so many tickets.

As CPD is compulsory for podiatrists, I am amazed that many give up an opportunity like this to increase their knowledge, gain certiﬁcates and meet up with their peers at such a small cost. Also included in the price were teas/coﬀees/ biscuits/water and a two course Sunday roast (plus veggie option if required).

The day was an overall success and we have already made good plans for the 2014 seminar which will be held on 5th October. Put the date in your diary and spread the word!

I understand that the 2014 seminar has already been booked for 5th October. I shall be putting it in my diary and hope many more of you will do the same!

Michèle Allison Cheshire North Wales Branch

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Bernie Hawthorn Head Oﬃce

Podiatry Review Vol 71:1

BRANCH NEWS

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Wolverhampton Branch’s 1st Seminar, Sunday 13th October 2013 put into practice what they had learned.

Well, it all started back in February at our Midland Area Council meeting where it was decided that Wolverhampton Branch should host a seminar on behalf of the Midland Area. The Seminar that the MAC held last year was a great success with all branches helping so it was a little bit daunting, to say the least, to be hosting our first seminar on our own. The branch chose the date at our March meeting and then booked the venue which was ideal as it was five minutes off the M6, M54 and the toll road making it easily accessible for everyone. We phoned around the trade houses and were delighted to find that they would love to attend our day. In total we had five trade stands in attendance. DLT, Canonbury, Cuxson Gerrard, Hilary Supplies and Heel Fix. Our Speakers for the day were Mr Michael Radcliffe, head of the school of podiatry at Birmingham Metropolitan College, Gareth Hicks and our very own Somuz Miah. The Day had a great response from all Podiatry organisations with approximately 50 delegates in attendance from all parts of the country. They enjoyed the lectures and the workshops where everyone could mingle and get to know each other and

BRANCH NEWS

We were delighted to have as our guest, Mrs Beverley Wright from the Board of Education. Beverley arranged to bring along some information to promote the Institute and to tell all present that we are a democratic, forward thinking organisation with education with the welfare of all our members being paramount. A number of delegates were very interested in joining the Institute and were going to get in contact with head office. The response we received from those in attendance was heart warmingly encouraging to say the least. Our first seminar could not have gone any better with all present requesting that we make this a regular annual event. Our branch invited all those present to attend the educational part of our branch meeting to show them what we do to keep our CPD up to date. At our next branch meeting we are holding a first aid training session and also having our autoclaves calibrated. This interested a number of delegates who have already asked to attend, and hopefully showing them what the Institute has to offer its members. All those present gave their email addresses so we can set up a data base of podiatrists in our area and to keep them informed as to what the Institute arranges in the way of educational events in the future. Here’s hoping we have many more events like this. David Collett Wolverhampton Branch

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BRANCH NEWS

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Essex Branch News A few Essex Branch members visited the Hunterian Museum at the Royal College of Surgeons (RCS) in Lincoln’s Field, London on the 4th November, 2013 to commemorate Derek Bird. Derek was the Chairman of Essex Branch for many years and had visited the museum in the past. He had often talked about how a trip to the London museum would be a fantastic opportunity for branch members to socialise with each other, while doing some all-important continuing professional development (CPD). Sadly, Derek passed away before the trip could be organised, but eight of the regular members decided at a recent branch meeting to book a group visit to the RCS and its museum. The RCS visit itself was heralded by a beautiful, sunny autumn day, where the members had a private tour through the College and onto the museum. Everyone found the exhibits very interesting, with a lot of opportunities to discover and learn some fascinating facts about the body, its structure, diseases and conditions through the exhibits of gross anatomy on display. There were also some fascinating case studies to view along with the relative anatomy of the conditions on exhibit. Of course the section housing the lower limb was a popular beginning to the journey around

BRANCH NEWS

the museum, but there were also lots of other really interesting and some startling sights on display that gave everyone a lot to talk about. The trip to London was rounded oﬀ with a lovely meal together that really helped everyone get to know each other better than just meeting and attending branch meetings every other month. Plus of course there was a toast to the memory of Derek Bird.

Essex Branch also provides annual ﬁrst aid update and skills sessions to keep members abreast of their skills and to the changes in ﬁrst aid that seem to occur every year. Best wishes Beverley Wright Essex Branch Secretary

On the following weekend, Sunday, 10th November, 2013 Essex Branch put on a First Aid at Work Certiﬁcate course at Southend General Hospital’s Education Centre, where 14 members attended. It was an enjoyable day, which is indicated by the photographs, where it appears everyone was trying to imitate the ‘I am a celebrity…’ Joey Essex look during their bandaging skills session! Fortunately, they all were unscathed from their practice endeavours and completed the required elements of the course and received their First Aid at Work certiﬁcates.

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News from the Southern Area Council

The Southern Area Council (SAC) is looking forward to providing their next spring seminar on Saturday, 22nd March 2014. This hopes to be an interesting and enjoyable experience to gain some allimportant Continuing Professional Development (CPD) and networking. Particularly, as 2014 is the renewal for registration with the HCPC, and there is the likelihood that some of us will be among those chosen by the HCPC in their next round of random auditing. So attending the SAC spring seminar, as well as other seminars, branch meetings and CPD events will help us build our allimportant portfolios of CPD, reﬂection and other veriﬁcations of our standards of practice, which could come under scrutiny this year.

The SAC spring seminar will have a variety of speakers such as Dr Andrew McVicar, who has presented at a previous SAC spring seminar and is a prominent bio-science author and University Reader and Researcher; Leice Claydon a physiotherapist; Angela Cobbald an Operating Department Practitioner, providing a presentation on decontamination and issues surrounding infection. In addition there will be a presentation on Lymphoedema and an Acupuncture workshop alongside other interesting information and presentations; plus of course a trade show and buﬀet lunch. I hope I get an opportunity to see many of you there. Kindest regards and best wishes

Beverley Wright Chairperson, Southern Area Council

BRANCH NEWS

Institute of Chiropodists and Podiatrists contributes to Health Freaks

Essex Branch member Beverley Wright has recently contributed to the information and research show Health Freaks recently shown on Channel 4. Beverley’s contribution to the programme came after the producers contacted the Institute of Chiropodists and Podiatrists last summer. Beverley consulted with the producers, giving advice on the various conditions of the feet, and their allopathic and natural remedy treatments. This advice focussed on which treatments and actions work or not. One of the highlights of the ﬁrst episode of Health Freaks was of someone using a home remedy involving the common treatment of duct tape on a verruca. This treatment was put on clinical trial for a month by the panel of GPs Dr Pixie McKenna (better known from the Channel 4 series Embarrassing Bodies), Dr Ellie Cannon and Dr Ayan Panja to examine whether the treatment and many of the other homespun cures in this and later episodes of the programme actually work. There was also a focus on other remedies for the feet in following episodes of the show.

Beverley contributed information and research to the show, predominately as a podiatrist, but also with the knowledge she has as a Senior Practitioner in Complementary Medicine.

Do we have your email address?

With soaring costs of consumable items such as paper and ink, combined with record rises in postage prices over the past two years, we are committed to saving your money wherever and whenever we can.

With this in mind we are concentrating on working towards a paperless oﬃce. This will reduce costs enormously, save space and the need to purchase more ﬁling cabinets, make it easier to retrieve information and boost productivity. It will also keep your personal information more secure and help the environment.

For this to be effective we need your help! If you haven’t already done so, create an email address. If you are unsure how to do it, enlist a younger member of your family or contact the staff at head office.

It is our intention to communicate fully by email in the future and we have a web team working on a payment system to enable subs to be paid on line in future. Receipts are already being sent via email wherever possible. Have you visited our website recently? Over the past couple of years the website has undergone at least two major changes but we need input from many more of you. Do you have any suggestions for bettering it? Remember this is YOUR website, what can you contribute? and in the main has been very well accepted, but as in all things it appears to be only a minority who use it and a minority who have input. With this in mind we the web team need your opinions, what do you want to see included, what can you contribute? Due to popular request by members, the members’ forum was set up. Why not open a discussion or join in one? Come on everyone the success of this is entirely in your hands. Please be assured that the Institute of Chiropodists and Podiatrists will not share your email address with any third parties without your prior permission save for those necessary in the line of Institute business such as branch secretaries. The Website Team

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Animation to encourage people with diabetes to get the 15 Healthcare Essentials

Animation to encourage people with diabetes to get the 15 Healthcare Essentials Diabetes UK has developed an animation to help deliver the potentially life-saving message that everyone with diabetes needs to access the checks and services they are entitled to. The 15 Healthcare Essentials, which include annual eye and foot checks to help prevent complications, as well as things like good hospital care or psychological support if people need it, are vital for ensuring people with diabetes have the best possible chance of a long and healthy life.

But at the moment too few people with diabetes are getting their annual health checks, while services like hospital care and psychological support are often inadequate. According to Diabetes UK, one of the

problems is that people with diabetes do not know what healthcare they are entitled to. The charity hopes the animation, which is being released to mark the second anniversary of the launch of the 15 Healthcare Essentials, will help raise awareness of what constitutes good quality care and so give people the conﬁdence to challenge healthcare professionals if they are not being oﬀered it. Barbara Young, Chief Executive of Diabetes UK, said: “The animation is a fun way of getting the message across but we also hope it communicates the serious message that people need to know about the healthcare they are entitled to receive.

few people with diabetes are getting consistently high-quality care at the moment and one of the ways of addressing this is for people to compare the care they are getting to the standard of care set out in the 15 Healthcare Essentials. “We hope that both this animation and the 15 Healthcare Essentials in general can be the starting point of a conversation between people with diabetes and their healthcare professional about the care they are getting.” To view the animation go to www.diabetes.org.uk/15-essentials

“We hope this animation will make people with diabetes and their healthcare professionals take another moment to think about the kind of care they should be getting. We know that too

Visitors to the website who have diabetes are also encouraged to complete the Diabetes UK 15 Healthcare Essentials survey, which contains questions about their health care experience over the past 12 months.

H E A LT H C A R E

Gold VITAL CONDITIONING RANGE

SOOTHING GEL SOOTHING & COOLING

HYDRATING RATING CREAM CR PROTECTING & MOISTURIZING

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DIABETES NEWS

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New online diabetes programme launched for healthcare professionals A new e-learning programme has been launched to ensure healthcare professionals have easy access to the latest information and guidance on diabetes. Developed by Diabetes UK and Bupa, Diabetes in Healthcare is the first free elearning programme designed for healthcare professionals that provides a broad overview of diabetes care. More than five per cent of people in the UK now have diabetes, and this figure is rising. This course has been designed because diabetes is a complex condition, but much of the healthcare for people living with diabetes is given by generalist healthcare professionals. Everyone working in a general health setting needs access to the necessary up-to-date information on diabetes to ensure those living with the condition receive the right advice and care. Developed by clinicians and diabetes specialists, the programme includes information and guidance on:

people developing diabetes in the UK means that all healthcare professionals, from practice nurses to occupational health workers, need to know about the condition, particularly the similarities and the diﬀerences between Type 1 and Type 2 diabetes. "We hope Diabetes in Healthcare can provide the most up-to-date diabetes information and help ensure people with diabetes receive good-quality care from all healthcare professionals."

Access to up-to-date information

Paula Franklin, UK Medical Director, Bupa, said, "The number of people with diabetes continues to rise, with ﬁve million people predicted to have the condition by 2025. We know that having access to all the necessary up-to-date information at the right time can be diﬃcult. With the launch of our new e-learning programme we hope that everyone caring for people with diabetes can access the information

they need and enable those living with the condition to make the best decisions."

Continuing professional development requirements

Amanda Cheesley, Long Term Conditions Adviser at the Royal College of Nursing, said, "Healthcare professionals completing the Diabetes in Healthcare course can use it towards their continuing professional development requirements. And the training they receive via Diabetes in Healthcare can form part of their NHS KSF (Knowledge and Skills Framework) or be a foundation for any healthcare professional who may want to go on to specialise in diabetes later in their career."

"All healthcare professionals need to know about diabetes"

• how the condition should be diagnosed, treated and monitored • how to care for patients with diabetes eﬀectively • the risk factors and potential health complications associated with diabetes • how to recognise patients at risk of diabetes-related health complications and how to support them to reduce their risk of those complications. The e-learning programme has been accredited by the Royal College of Nursing and counts towards ongoing professional development. Barbara Young, Chief Executive Diabetes UK said, "We understand that healthcare professionals cannot specialise in everything, but the rising number of

DIABETES NEWS

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Obituary: Frederick Sanger Biochemist Frederick Sanger is unique in

being the only Briton to win two Nobel Prizes

Sanger sequencing

The technique he developed in 1977,

and the only scientist to win the Nobel prize

known as "Sanger sequencing", allowed long

the structure of proteins and nucleic acids

sequenced. It was used to complete the ﬁrst

for Chemistry twice. His work to understand

(such as DNA) helped to bring about a genetic revolution in biology and medicine.

But he is best remembered by people with

diabetes for his work to uncover the basic

structure of insulin – a vital step in the

production of synthetic human insulins that have since led to major advances in the treatment of diabetes worldwide.

Born in 1918, Sanger studied natural

sciences at St John's College Cambridge and graduated in 1940 after specialising in biochemistry. As a paciﬁst and conscientious

objector he was granted unconditional

stretches of DNA to be rapidly and accurately ever human genome sequence in 2003 and is

still in widespread use today, since it allows scientists to read the human DNA code and understand

how

particular

sequence

variations inﬂuence the risk of conditions

such as diabetes, cancer and heart disease. For this achievement Sanger was awarded his

second Nobel Prize in 1980. In 1992, the

Sanger Centre (now the Sanger Institute) was founded in his honour only a few miles from

his home. Today it is one of the world's foremost genomic research centres.

An incredibly modest man despite his

exemption from military service during the

many achievements, Sanger avoided the

his PhD.

chap who messed about in his lab." He

Second World War, allowing him to complete

First Nobel prize

He remained in Cambridge after the war

ended, where his ﬁrst major accomplishment was to establish the complete sequence of amino acid building blocks that make up cow

insulin – one of the very few proteins available commercially in pure form. His work proved for the ﬁrst time that proteins – molecules key to life – have a precise chemical composition.

It earned him his ﬁrst Nobel prize for

Chemistry in 1958 and was key to the subsequent realisation of the mechanisms by which DNA codes for proteins.

In 1962, Sanger moved to the new Medical

Research Council Laboratory of Molecular

Biology and turned his attention to the problem of sequencing DNA. His research

group was the ﬁrst to produce a whole

genome sequence (over 5,000 nucleic acid

limelight and claimed that he was merely "a declined a knighthood because he did not

want to be called "Sir" but was awarded the Order of Merit – one of Britain's highest

honours – in 1986. He retired at the age of 65 to devote more time to his garden and to "messing about in boats".

"One of the greatest ﬁgures in the history of chemistry"

Dr Alasdair Rankin, Diabetes UK Director of

Research said, "As well as being one of the

greatest ﬁgures in the history of chemistry and

one of the greatest British scientists of the 20th century, Fred Sanger also made a diﬀerence to the lives of millions of people with diabetes around the world. By sequencing the insulin

protein, he helped advance our understanding of diabetes and kickstarted the development of man-made human insulins, which ended reliance on insulin from cattle. Everyone with

Type 1 diabetes, and many with Type 2, needs

bases from the virus phiX174) and the ﬁrst to

to take insulin to manage their condition and

16,500 bases from human mitochondria – the

those that come from animals as there is less

sequence human genetic material (over tiny power stations that energise living cells).

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today most people prefer human insulins to chance of allergic reactions."

Podiatry Review Vol 71:1

"A unique contribution to the modern world"

Colin Blakemore, Professor of neuro-science and philosophy at the School of Advanced Study in London and former chief executive of the Medical Research Council, said, "The death of a great person usually provokes hyperbole, but it is impossible to exaggerate the impact of Fred Sanger's work on modern biomedical science. His invention of the two critical technical advances – for sequencing proteins and nucleic acids – opened up the ﬁelds of molecular biology, genetics and genomics. He remains the only person to have won two Nobel prizes in chemistry – recognising his unique contribution to the modern world. Fred Sanger was a real hero of 21st century British science."

"The father of the genomic era"

Jeremy Farrar, director of the Wellcome Trust, said, "Fred can fairly be called the father of the genomic era: his work laid the foundations of humanity's ability to read and understand the genetic code, which has revolutionised biology and is today contributing to transformative improvements in healthcare."

Dr Frederick Sanger, one of the greatest research pioneers: born Rendcomb 13 August 1918; married 1940 Margaret Joan Howe; (two sons, Robin and Peter, and a daughter, Sally Joan); died 19 November 2013. Image: Wikimedia Commons. www.diabetes.org.uk/About_us/News

DIABETES NEWS

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DIARY OF EVENTS

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Podiatry Review Vol 71:1

DIARY OF EVENTS

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Every year, around 16,600 people in England are diagnosed with bladder or kidney cancer. Around 7,500 people die from bladder or kidney cancer in England each year, but this needn't be the case. Knowing what to look out for saves lives. Both cancers aﬀect men and women, although they are more common in men. Most people diagnosed with these cancers are over 50. Those who have worked in manufacturing jobs that involved the use of rubber, dyes, textiles, plastics or certain other chemicals are more prone to developing bladder cancer. People on kidney dialysis are more at risk of developing kidney cancer. If you notice any blood in your pee, even if it is just once, tell your doctor straight away. The chances are its nothing serious, but these cancers are more treatable if they are found early.

How to spot it

Blood in your pee is the most common symptom of both types of cancer, other kidney cancer symptoms include; a pain below the ribs that doesn’t go away; A lump in your stomach. Other bladder cancer symptoms include; needing to pee very often or very suddenly; pain while peeing.

See your doctor

You are not wasting anyone’s time by getting your symptoms checked out and if its not serious your mind will be put at rest, but if it is a condition such as kidney or bladder cancer, early detection makes it easier to treat. Seeing your doctor early could save your life.

Having symptoms doesn’t mean its cancer

Some symptoms may be caused by an infection or kidney or bladder stones, all of which may need treatment but don’t try and diagnose yourself. Go and see your doctor now to ﬁnd out for sure. If you know anyone who has any of these symptoms, insist they see their doctor.

Reduce your chances of getting kidney or bladder cancer by:-

Stopping smoking - its never too late to quit. No matter what age you stop smoking it reduces your chances of developing kidney or bladder cancer. Maintain a healthy weight and keep active - swim, walk, dance, cycle Eat Healthily - more vegetables and fruit, ﬁsh and wholegrain foods

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Podiatry Review Vol 71:1

HEALTH AWARENESS

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New research reveals prevalence and impact of chronic pain in ethnic communities Arthritis Research UK

A new study in the London Borough of Tower Hamlets, funded by medical research charity Arthritis Research UK, may help improve GPs’ understanding of chronic musculoskeletal pain amongst diﬀerent ethnic groups and develop better strategies for self-management as a result.

The two-year study is the ﬁrst of its kind to directly compare the prevalence and characteristics of chronic pain in White and Bangladeshi people living in the same geographical area and attending the same GP surgeries. The prevalence and impact of chronic pain is known to diﬀer between ethnic groups with previous research identifying a need for better management of chronic pain across ethnic groups.

Researchers from the Queen Mary University of London looked at whether the features and effects of chronic pain are similar or different in the Bangladeshi and White populations living in Tower Hamlets. The results of a sample of 4,480 patients registered at 16 general practices in the area showed that chronic pain is both more common and more severe in people who grew up in Bangladesh than in either British Bangladeshis who grew up in the UK, or the White British. However, quality of life was adversely affected by chronic pain in all ethnic groups. People with chronic pain were six times more likely to have poor quality of life than those with no pain. Chronic pain was very common in all three groups, occurring in 50% of Whites and British Bangladeshis and over 70% of people who grew up in Bangladesh.

whilst other treatments can include physical and occupational therapy, psychological treatments such as counseling, and treatment of other illnesses such as depression.

Lead researcher, Professor Martin Underwood, who originally started the project at Queen Mary University of London but has now moved to Warwick Medical School said: “It has been suggested through previous research that pain can be more common in South Asians than Whites and that South Asians living in the UK have diﬀerent ways of communicating their pain to health professionals and to their families.”

“But the challenge for us was determining the impact of chronic pain in different ethnic communities living in a deprived area of East London. We found that chronic pain was very common and had a major adverse effect on quality of life in all the groups we tested, and have shown for the first time that there are important differences in the health impact

of chronic pain between Bangladeshis who grew up in the UK and those who grew up in Bangladesh. Next, we plan to explore the reasons for these differences. This is important in designing services that are appropriate and effective for all patients suffering from chronic pain.” Dr Tom Margham, GP lead at Arthritis Research UK and a practising GP in Tower Hamlets, said: “Living with chronic pain can be a devastating experience and steals quality of life from too many people in the UK. While some people are able to manage their pain effectively, others become isolated and suffer from a reduced quality of life. This new study gives a real insight into the large numbers of people living with long-term pain in the area where I work and the impact it has on different ethnic groups. Understanding the burden of disease in a local area should help those delivering care and commissioning services in their planning to improve outcomes for people affected by chronic pain”.

Around 10 million people in the UK struggle with chronic pain almost every day resulting in a major impact on their quality of life and more days oﬀ work (British Pain Society). Chronic pain, deﬁned as pain being present for three months or more, also represents a major challenge to GPs and places a large cost burden on the health service. However, research shows that chronic pain may be preventable and that GPs have an important role in its assessment, management and treatment. Pain relieving drugs are the most common treatments for chronic pain

ARTHRITIS RESEARCH UK

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Applications for Cosyfeet Podiatry Award 2014

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The new Pixie ankle boot by Cosyfeet is specially designed for ladies who need an extra roomy fit due to swollen feet or ankles. Perfect for winter weather, this lightweight style comes in an EEEEE+ fitting as standard. Luxuriously soft to the touch, the Pixie ankle boot is made from water resistant, suedelook fabric and stretchy elastane to fit a range of swellings in comfort. The neat, double touch-fastening strap is fully adjustable for a perfect fit. Easy to pull over trousers or warm tights, this practical boot has a flexible rubber sole for active days out. It also has a seam-free toe area to protect sore or swollen toes. Every pair comes with a removable insole and comfort footbed, which offers extra depth if needed.

The Cosyfeet Podiatry Award supports one person each year in developing their professional knowledge and skills while beneﬁtting others. The £1000 award is open to any podiatrist or podiatry student who is planning voluntary work, a work placement or research, whether in the UK or abroad. It is designed to contribute to travel and living expenses. Former winners have undertaken a wide range of projects including those relating to wound management, Lymphatic Filariasis and Talipes Equinovarus. Some have travelled to Asia or Africa while others have conducted voluntary work or research here in the UK. If you would like to apply for the award, visit www.cosyfeet.com/award for further information and to enter online before the closing date of April 25th 2014. The winner will be expected to submit a report and photographs of their experience, and to be included in Cosyfeet publicity relating to the award. Cosyfeet is the UK’s leading supplier of footwear, socks and hosiery for extra wide, swollen or problem feet. 11,000 health professionals recommend Cosyfeet products to their patients. For more information email prof@cosyfeet.com or call 01458 449070.

The Pixie ankle boot is available in Latte, Loganberry, or Black and comes in sizes 3 to 9, priced £49.00 (or £40.83 if you qualify for VAT relief due to a chronic medical condition). For more information see www.cosyfeet.com/pixie or call 01458 447275. For editorial queries call Marianne Wilson on 07796 690326. Cosyfeet was the ﬁrst British company to make shoes for people with swollen feet. 30 years on they still oﬀer the biggest range of extra roomy shoes on the market. page 37

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Podiatry Review Vol 71:1

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