Podiatry Review May/June 2014 by The Institute of Chiropodists & Podiatrists

ISSN 1756-3291

Volume 71 No. 3 May/June 2014

Podiatry Review A step in the right direction

Inside: ◆ Results Laser Therapy Trial ◆ Conference information ◆ Baby steps to saving lives

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

National Officers President Mr R. Henry FInstChP DChM

Honorary Treasurer Mrs J. Drane MInstChP

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

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Mrs L. Pearson MInstChP BSc Pod Med

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

Scottish Area Council Mrs H. Jephcote MInstChP

North West Area Council Mrs M. Allison MInstChP

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May/June 2014 | Volume 71 No. 3 ISSN 1756-3291

Podiatry Review

Published by

Contents

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

Editorial ..................................................................2 Baby steps to saving lives ...................................4-6 Anna Lacey Erchonia lunula laser therapy (cold laser) in the treatment of onychomycosis – the results........7 - 13 Robert Sullivan BSc.(Hons) Podiatry, MSc. Pod. Surgery.

Editor Mrs B Hawthorn

PGC. Myo. Acup. FIChPA. M.Inst.ChP. Clinical Director Midleton Foot Clinic, (Ireland)

HMInstChP

The ageing foot – a challenge for the chiropodist and podiatrist ..........................14-16 Iain B. McIntosh BA(Hons). MBChB. FFTMRCPS(Glas)

Academic Review Team Mrs J Barbaro-Brown MSc PGDip PGCE BSc (Hons) BA (Hons) DPodM MChS HMInstChP

Ms B Wright MSc BSc (Hons) PGCE PGDip MInstChP

CPD Review of cleaning and sterilisation used in practice.............................17-20 Joanne Casey MInstChP, BSc

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

The Institute’s profile in Europe .............................21

Mr S Miah Health article Vitamin D deficiency ........................22

BSc(PodM) MInstChP

Mrs J Casey Branch news .................................................25 - 27

BSc (Pod) MInstChP

Diabetes news......................................................28 Cosyfeet news......................................................30 Diary of events......................................................32 http://twitter.com/iocp_chiropody

Conference booking form .............................35 & 36 Nominations for national office ............................IBC

The Institute of Chiropodists and Podiatrists-Southport

© 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 71:3

CONTENTS

Editorial Dear Readers

As you will have noticed from the front cover we are looking forward to welcoming you all to Southport for our annual conference on 30th and 31st May (please see page 21). For those still yet to book we have included a booking form at the back of the journal and all information including details of hotels and guest houses is on our website www.iocp.org.uk. We do hope that as many of you as possible will come and meet us (this includes non-members too). The trade show entry is free of charge and everybody is welcome to wander around and ask questions. The lectures are very reasonably priced at £15 each.

We are pleased to publish results from the onychomycosis cold laser study using Erchonia Lunula system by Robert Sullivan on page 7 and following. The

preliminary trial produced a lot of interest from various countries especially America and Spain, and requests for copies of the article and journal came ﬂooding in. This is all good news for the Institute of Chiropodists and Podiatrists as we were the ﬁrst to conduct in-depth research into this product.

In addition we have a very interesting article by Anna Lacey explaining the ‘footprint scheme’ in Tanzania. With most mothers in aﬄuent countries being giving the utmost care during pregnancy and childbirth, it is easy to overlook the fact that many thousands of woman in poorer countries will do so without any help and thus encounter many more problems including often being unaware of gestation or when they should be due to give birth. We thank the BBC for allowing us to reproduce this article.

In March, Head Oﬃce held an Emergency First Aid at Work, Level 2 QCF. This was hugely successful as you will see on page 25. Julie Aspinwall is hoping to arrange another one in the near future so if you are interested, give her a call.

Finally - HCPC renewals! The dreaded audits are upon us once again. I think by now most of you are aware of your responsibilities and requirements. We have set out on page 31 a reminder of the types of CPD activity that is acceptable, which is practically anything that enhances your practice and knowledge! Do remember that HCPC require you to demonstrate a mixture and how you and/or your patients have beneﬁtted from undertaking that activity. If in doubt give the oﬃce a call.

Bernadette Hawthorn, Editor

A note from your President, Roger Henry FInstChP, DChM

As President of the Institute of Chiropodists and Podiatrists I look forward to welcoming all chiropodists / podiatrists and foot care professionals to the annual general meeting, seminars and chiropodial trade show to be held in Southport, Merseyside on 30th and 31st May 2014 I have been going to these ‘dos’ since 1967 so I must think that they are worthwhile. If, for no other reason, you can get your continuous professional development requirements! You can network with other chiropodists/ podiatrists /foot health professionals and make

friends. You can also visit the trade show and pick up some bargains, see what’s new in equipment, have a hands-on experience with the chairs, trolleys and instruments and ﬁnally you can enjoy the dinner and let your hair down at the disco afterwards. To sum up you can charge your chiropodial battery for the year ahead and enjoy yourself! Do not miss this opportunity of relaxing and enjoying yourself and who knows? You might just learn something and increase your armoury of knowledge.

Raymond and Peggy Ward It is with great sadness that I report the passing of both Raymond and Peggy Ward within weeks of each other. I ﬁrst met them in the late 1960’s. They were from Manchester and dedicated to the Institute. They were particular friends of Stanley Harrison, past President of the Institute and also Eileen Braithwaite, past Treasurer of the Institute. They were ‘all for’ education

EDITORIAL

and very kindly they left a sum of money to the Institute.

The Executive have decided, quite rightly in my view, to commemorate their memory by naming the new education centre at head oﬃce ‘The Ward Centre for Chiropodial Excellence’. I know Raymond and Peggy would have been ‘tickled pink’ as the saying

Podiatry Review Vol 71:3

Roger Henry

goes to be remembered in this way. They both were very kind to me and to many other chiropodists starting out on their career.

Rest in Peace Raymond and Peggy – you certainly made your mark in the world of chiropody and the Institute in particular.

Roger Henry, President

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Baby steps to saving lives By Anna Lacey

Each year, one in 10 babies around the world will be born prematurely and over a million of those will die. But could measuring the size of a baby's feet help save lives?

In the final weeks of pregnancy, the idea of going into early labour might not seem like such a bad thing. But giving birth prematurely - officially classed as before 37 weeks gestation can lead to long-term health effects. Depending on quite baby is born, infants completely unaffected permanent disability difficulties.

how early the can either be or left with and learning

In contrast, around 40% of women giving birth in low-income countries will do so without the help of a trained medical professional.

And due to inaccurate dating of pregnancy, many of those women will have no way of telling if their baby is too early or too small.

However, measuring the baby's footprint could be used as a simple proxy for birth weight.

"There's this grey area when the baby is between around 2.4kg (5lbs 5oz) and 2.1kg (4lbs 10oz) when the baby is more vulnerable to infection and other issues," says Dr Joanna Schellenberg of the London School of Hygiene and Tropical Medicine.

"But when a baby is born at home, there is no way of weighing them," she told the BBC.

The issue of prematurity is particularly pronounced in South Asian and SubSaharan Africa, which accounts for over 80% of the deaths caused by pre-term birth complications. In rural Tanzania, for example, about one in every 30 premature babies won't make it past four weeks.

However, most of those lives could be saved with simple advice for mothers.

And that advice, says an international group of researchers, could start with just a footprint.

Sizing up

Most mothers in high-income countries will give birth surrounded by medical equipment or with the support of a highly-skilled midwife.

This means that any problems, such as a low birth-weight or the mother's waters breaking early, can be dealt with immediately.

HEALTH ARTICLE

I've measured the child's footprint and seen that the child is smaller than usual, then I instruct them to carry the child skin-to-skin so that the child can share and feel the mother's warmth," says Ulaya.

The BBC's Tulanana Bohela has been to see the project in action. To help solve the problem, Schellenberg and her colleagues at the Ifakara Health Institute in Tanzania have implemented a strategy called Mtunze Mtoto Mchanga - which means "protect the newborn baby".

It includes using a picture of two footprints on a piece of laminated card and a local volunteer placing the baby's foot against the images.

If the baby has feet smaller than the smallest foot, around 67mm, then the mother is advised to take the baby to hospital immediately. If it measures in between the big and the small image, then the mother is told about the extra care she needs to provide to increase the baby's chances of survival. Although the card is fairly accurate for ﬁve days after birth, it should be used it to identify small babies in their ﬁrst two days of life, which is when they're most at risk of dying without specialist care. Mariam Ulaya is one of the volunteers at Namayakata shuleni village and visits the women before and after the birth. "If

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"I also carry a small doll with me called Opendo. I use the doll to illustrate the proper way to breastfeed the child."

'It has helped my child to survive'

Such advice may seem simple but can really be the diﬀerence between life and death.

A report by the World Health Organization (WHO) says that of the 15 million premature births globally each year, more than 80% will occur between 32 and 37 weeks' gestation.

Most of these babies will survive if given extra warmth through skin-to-skin contact and very regular breastfeeding to help fight off infection. In fact, the report states that an estimated 75% of deaths in preterm infants can be prevented in this way - without the cost and emotional upset of intensive care. Salima Ahmad is 25 and has three children who live with her in Namahyakata dinduma village, Tanzania. Her youngest son, Alhaji, was born prematurely. "I was a little bit shocked because many premature babies end up dying but I was also happy because I had a live baby," says Salima. Although Alhaji was born at the local hospital, Salima was given advice and support by volunteers from Mtunze Mtoto Mchanga about how to care for him once she got home. "Carrying skin-to-skin was good but difficult in the beginning. But when the

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volunteer was visiting me and encouraging me, I could see myself managing it slowly. It is good, it has helped my child to survive," she says.

home. Dr Isa Lipupu works at the nearby Nangururwe health centre. "In the last two years, we had about 20 deliveries at the health centre.

But this time we have already delivered more than 40 babies. This is about 60-80% of all the mothers that were pregnant," he says.

encouraging me, I could see myself managing it slowly. It is good, it has helped my child to survive," she says.

Salima also feels that understanding more about premature birth helps mothers like herself to deal with it properly.

If the strategy proves successful, then there are already plans to roll out the footprint scheme to the rest of Tanzania, giving more health volunteers the ability to quickly spot at-risk babies.

Salima also feels that understanding more about premature birth helps mothers like herself to deal with it properly.

"It helps a lot for the mother not to be surprised when having a premature birth. It is useful to know in advance as you get good knowledge on how to handle the premature. Myself, I do thank the volunteer who talked about it when I was pregnant and she even taught me how to carry skin to skin."

The project is still underway and it will take another six months before it's clear whether measuring feet has the ability to save thousands of lives. However, it is already having a positive eﬀect on the way mothers in the area are preparing for childbirth.

"When I had my ﬁrst child, she was small and was not breastfeeding well and I did not know where to get help," says Rukia Twarib, who is currently pregnant with her second child. "Now I have information, if the situation ever happens again, I know can go to the health centre to get help." Advice from volunteers like Miriam also appears to be contributing to the increase in women now choosing to deliver at a health centre rather than at

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"Right now many people are aware of the work I do. All the families have been very welcoming and have accepted me and this programme," says Mariam Ulaya. "I have seen a lot of changes in the area. I can see that there are more mothers visiting the clinic and giving birth there much more than they used to do - and so I am grateful for that." Most of these babies will survive if given extra warmth through skin-to-skin contact and very regular breastfeeding to help ﬁght oﬀ infection.

In fact, the report states that an estimated 75% of deaths in preterm infants can be prevented in this way without the cost and emotional upset of intensive care.

Salima Ahmad is 25 and has three children who live with her in Namahyakata dinduma village, Tanzania. Her youngest son, Alhaji, was born prematurely.

"I was a little bit shocked because many premature babies end up dying but I was also happy because I had a live baby," says Salima.

Although Alhaji was born at the local hospital, Salima was given advice and support by volunteers from Mtunze Mtoto Mchanga about how to care for him once she got home.

"Carrying skin-to-skin was good but diﬃcult in the beginning. But when the volunteer was visiting me and

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• There is no clear cause of premature birth and there tend to be many diﬀerent risk factors involved.

• These include infections of the genital and urinary tract, preeclampsia, problems with the placenta and gestational diabetes. • Obesity is another major risk factor for premature birth.

• Fetal ﬁbronectin is a protein which can be used as a reliable indicator of preterm birth. It normally appears around 22 weeks and then again at the end of pregnancy. If it appears between these dates, early labour often follows.

• Research also suggests that low levels of the hormone progesterone in the saliva could also help spot women at risk of sudden premature labour.

Source: Tommy’s

Acknowledgement

This article is courtesy of the BBC News Online which appeared on 9th November 2013 http://www.bbc.co.uk/news/health24728460

HEALTH ARTICLE

Chinese herbal medicine 'can be eﬀective in treating rheumatoid arthritis' A traditional Chinese herbal remedy has shown similar eﬃcacy to an approved drug therapy for the treatment of rheumatoid arthritis in a new clinical study.

Led by a team at the Peking Union Medical College Hospital, the research revealed that Triptergium wilfordii Hook F - or TwHF for short - can relieve joint pain and inﬂammation just as well as methotrexate, a standard drug treatment that is frequently prescribed to control the symptoms of active rheumatoid arthritis in the West.

TwHF is used in traditional Chinese medicine to treat joint pain, swelling and inﬂammation, and is already approved for the treatment of rheumatoid arthritis in China. It contains more than 300 compounds, including diterpenoids, which are thought to be able to suppress genes controlling inﬂammation and dampen immune responses.

ARTHRITIS NEWS

To formally evaluate its safety and eﬃcacy, the scientists randomly assigned 207 patients with active rheumatoid arthritis to one of three treatment groups - methotrexate 12.5 mg once a week, TwHF 20 mg three times a day or a combination of the two over a period of 24 weeks.

Results published in the Annals of the Rheumatic Diseases revealed the proportion of patients achieving the target of a 50 per cent improvement in the number of tender or swollen joints and other criteria including pain, disability and disease severity was just under 46.5 per cent among those treated with methotrexate alone, compared to 55 per cent of those receiving TwHF.

Moreover just under 77 per cent of those treated with both reached the treatment goal, suggesting a combination of treatments could yield the best results. However, it was also noted that 24 weeks is too short a time to evaluate disease

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progression, and that the dose of methotrexate used in the trial was lower than the typical dosage.

A spokeswoman for Arthritis Research UK commented: "Previous trials of TwHF, also known as thunder god vine, have shown it has some anti-inﬂammatory properties and immunosuppressive actions, making the compound a potentially useful substance for treating rheumatoid arthritis.

"However, it has well-documented side eﬀects such as stomach pain, diarrhoea, nausea, headaches, skin rash, hair loss, infertility in men and failure to menstruate in women. There are serious safety concerns about this substance and its risks appear to outweigh its beneﬁts."

See more at: http://www.arthritisresearchuk.org/news /general-news/2014/april

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Erchonia Lunula Laser Therapy (Cold Laser) in the Treatment of Onychomycosis Robert Sullivan1

BSc.(Hons) Podiatry, MSc. Pod. Surgery. PGC. Myo. Acup. FIChPA. M.Inst.ChP. Clinical Director Midleton Foot Clinic, (Ireland)

1 1

Abstract

Onychomycosis is a common disorder of the nails and affects all ages. Treatment modalities include oral and topical antifungals, surgical treatment and/or a combined use of these therapies. Cure rates remain low with relatively high relapse rates seen after successful treatment. The purpose of this study is the evaluation of the treatment of onychomycosis using the Erchonia Lunula cold. The study has to date been carried out on 323 patients both male and female with an average age of 40. The laser treatment, in this protocol, consists of 4 treatments at weekly interval. This is a laser that combines two different wavelengths of laser light - one at 405 nm for direct fungicidal activity and one at 635 nm to stimulate a natural immune response - to provide effective clearing of the nail bed. Unlike other lasers used for the treatment of this condition, the Erchonia Lunula laser is reported to cause no pain and no temperature change in the area exposed to the lights. The follow up intervals are 12, 24,36, and 48, further data will be collected in the none treatment phase at 52, 64 and 76 weeks and published at conclusion, as it is the aim of the researchers to observe the nail up to seventy six weeks to ascertain the long term efficacy of the treatment. In the treatment to date there has been 36 reports of side effects and the majority 93% of patients are happy with the treatment. It is the primary aim of this study to present laser as an effective treatment for onychomycosis with a good evidence base. Key words: low-level laser therapy, photochemistry, onychomycosis

Introduction

Onychomycosis (OM) is a chronic fungal infection of the nail plate, nail bed, or both, and has been estimated to affect 310% of the general population, with the incidence rising sharply, to nearly 30%, in patients over age 60 (Welsh, Vera-Cabrera, and Welsh 2010). Although OM is categorized into five different types, distal

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lateral subungual onychomycosis (DLSO) is the most common clinical presentation (Weinberg et al 2003). It has been reported that the instance of OM is as high as 90% in a 4,096 patient cohort (Weinberg et al 2003, Romano, Gianni and Difono 2000). If left untreated, DLSO can lead to subungual hyperkeratosis, which, in turn, can lead to substantial keratinous debris and induce both nail pressure and pain (Mahoney, Bennett and Olsen 2003). Additionally, OM has been reported to predispose patients to more serious comorbidities, such as bacterial infection, foot ulceration, cellulitis, thrombophlebitis, and gangrene (Thomas et al 2010, Taylor and Boyle 2003, Gupta and Shear 2000, Roberts, Elewski 2000, Levy 1997. Successful treatment of OM has been hindered by inappropriate therapeutic solutions, with poor clinical outcomes, high rates of recurrence, low patient compliance, or risks of adverse events (Thomas et al 2010). Low-level laser therapy (LLLT), which adheres to the tenets of photochemistry, is emerging as an alternative treatment which may have positive clinical outcomes in the treatment of OM, given effects of light on intracellular reactions (Ying-Ying et al 2009, Karu 2007, Lubart et al 2005, Karu and Afanasyeva 1995). Laser’s influence on cell behaviour follows modulation of the cell’s bioenergetics: specifically, upregulation of adenosine triphosphate and reactive oxygen species (ROS) synthesis (Ying-Ying 2009). This mechanism can be likened to the agonist effect of a drug, which describes the use of a certain molecule to start a secondary cascade. Laser therapy uses photonic energy to modulate secondary cellular reactions. Supported by nearly four decades of clinical research, LLLT has led to favourable clinical outcomes without serious adverse events (Karu 2007).

Podiatry Review Vol 71:3

In the treatment of OM, LLLT, when delivered with specific parameters, has been shown to decrease dermatophyte colonisation and to strengthen the function of phagocytes, such as neutrophils and macrophages (Dolgushin, Markova and Gizinger 2010, Morgan and Rashid 2009, Dolgushin, and Gizinger 2008, Hemvani, Chitnis and Bhagwanani 2005, Dube et al 2003). Accordingly, stimulation of the body’s endogenous defence systems and antimicrobial effects suggest LLLT as a potentially suitable treatment for OM. This study, evaluates patients presenting with OM to examine the efficacy of a dual-wavelength laser device.

Materials and Methods:

A prospective, non-randomized, noncontrolled study was conducted from February 2011 to February 2012. Participants who presented with typical clinical patterns of OM of the great toenail and lesser digits were evaluated and mycology samples taken and cultured. All participants with a positive mycology qualified for and were enrolled in the study. In total, 323 subjects were qualified and enrolled and 2320 toes were subject to treatment. As all participants had a positive mycology and no placebo was used a control group was not required. One hundred and fifty patients were chosen at random for mycology testing one week post first treatment. It is worth noting that core sampling showed negative mycology in all patients screened

Inclusion criteria:

• OM in at least one great toenail with an involvement of at least 10%. Spikes of disease extending to the matrix of the eﬀected great toenail and or digits nails.

TECHNICAL ARTICLE

• Proximal Subungual Onychomycosis (PSO). • Distal Lateral Subungual Onychomycosis (DLSO). • White Superﬁcial Onychomycosis (WSO). • Endonyx Onychomycosis (EO). • Candidal Onychomycosis (CO). • Participants willing and able to refrain from the use of nail cosmetics, such as clear and/or coloured nail lacquers throughout the active treatment stage of the study. • Participants had not used a clinical nail treatment in the past 3 months. • Study was restricted to patients aged 18 years or older.

Exclusion criteria:

• Participants who have used oral antifungal medicines within 3 months prior to the administration of the ﬁrst laser treatment. • Participants who have used nail lacquers in the past three months. • Those who are unable to abstain from the use of nail cosmetics. • Pregnant or receiving fertility treatments. • Metal surgical pins or plates below the knee. • Chronic plantar (moccasin) tinea pedis, • Trauma to the aﬀected toenail, or any toenail to be treated. • Cancer and/or treatment for any type of cancer within the last 6 months, • History of uncontrolled diabetes mellitus. • Other exclusions are nevoid subungual formation, psoriasis of the nail plate, atopic dermatitis and lichen planus.

Subject Demographics

In total, 323 subjects were enrolled with percent nail infected with onychomycosis between 12% and 100%. Based on initial percent nail involvement, subjects were allocated into ﬁve distinct categories. For measurement methods and calculations

TECHNICAL ARTICLE

intensity of ~32 mW (Erchonia Lunula Laser speciﬁcations in appendix 2).

please refer to appendix 1. Category of % Nail Infected With Onychomycosis at Baseline < 20% 21% - 40% 41% - 60% 61-80% > 80%

n 81 71 110 41 20

Table 1. Subject allocation based on baseline percent disease involvement Patients were not compensated ﬁnancially to participate in the clinical study. Furthermore, patients were recruited from the clinicians existing patient pool who, at one time, actively sought treatment of OM. The study was approved by the Institute of Chiropodists and Podiatrists Ethical Review Board. Outcome measured included the change in the percent of nail infection. Pre-procedure (baseline) images were taken (as outlined) of the infected nail, which were then compared with procedure and post-procedure images. Toes were evaluated at ﬁve separate time points: baseline and week 12, 24, 36, and 48.at which time results were produced. Participants are invited to take part in further follow ups and 52, 64 and 76 weeks post treatment in order to chart any re infection in this 18 month study. Nail assessments were made by the study’s principle investigators and measurements were calculated independently and converted to a percentage in keeping with the methods outlined in appendix 1.

Device Intervention

Subjects received treatment with a dual-diode low-level laser device that emitted two independent, rotating linegenerated coherent beams, each emitting a separate and discrete wavelength (405 nm and 635 nm) with a total output

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Treatment Administration

The treatment administration phase consisted of four independent 12-min treatments separated by 7 days ± 1 day. All patients were treated as outlined below at each of their four visits. 1. The foot to be treated was cleansed using a clinell wipe. 2. Nails were clipped and reduced using a bur where necessary. 3. The foot was cleansed to remove any debris and dust. 4. The forefoot was photographed using a high resolution digital camera. 5. Infected shoes, socks and hosiery were sterilised. 6. Laser administered in the therapy unit, these are programmed to deliver constant therapy for 12 minutes and then turn oﬀ. All toes of the infected extremity, regardless of clinical presentation of OM, received equal exposure to the emitted laser energy. It is important to note that no chemicals were used to pre soften thickened nails as the researchers wanted to remove any possibility of interference from outside sources.

Data Analysis

The study is an 18 month study with evaluations planned at Baseline (pretreatment); 12 weeks; 24 weeks; 36 weeks; 48 weeks; 52 weeks; 64 weeks; and 76 weeks post-procedure. The current analysis is based on measurements recorded at Baseline; 12 weeks, 36 weeks and 48 weeks post-procedure. A repeated-measures ANOVA was used to assess the ﬁve independent sample means along with mean and standard deviations. Calculation of percent nail clearance at each evaluation point showed the changes

page 8

in mean percent nail clarity to be statistically signiﬁcant across the four correlated samples (F =199.2; p < 0.0001).

Results

All study participants (n = 323) were categorized into ﬁve groups based on BASELINE CATEGORY % ONYCHOMYCOSIS INCLUSION

< 20%

Mean

21% - 40%

Mean

41% - 60%

Mean

61% - 80%

Mean

> 80%

Mean

TOTAL

Mean

their initial percent of nail involved. Compared with baseline, statistically signiﬁcant mean change in the percent of nail involved was observed at weeks 12, 36 and 48 for each baseline category. Table 2 below shows the mean and standard deviation % of nail Baseline

SD SD SD SD SD SD

18.12% 2.13

34.94% 5.34

54.29% 4.80

75.51% 5.49

97.40% 3.49

46.33% 23.25

onychomycosis inclusion at each of the 4 evaluation points of Baseline, 12 Weeks, 36 Weeks and 48 Weeks Post-Procedure for nails within each of the 5 categories of % Baseline inclusion and for all subjects combined.

% NAIL ONYCHOMYCOSIS INCLUSION 12 Weeks 36 Weeks Post-Procedure Post-Procedure 3.52% 2.90

10.42% 6.56

14.59% 7.08

0% 0

1.20% 3.30

1.92% 2.69

32.61% 11.26

12.17% 9.58

15.81% 15.39

4.37% 8.92

57.05% 10.13

30.9% 6.87

48 Weeks Post-Procedure 0% 0

0.18% 0.80

0.40% 0.97

6.98% 9.62

17.75% 10.77 2.16% 6.32

Table 2: % Nail Onychomycosis Inclusion across Study Evaluation by % Baseline Inclusion Category

Analysis of four correlated samples found the changes in mean % nail onychomycosis inclusion across the three evaluation points of Baseline, 12, 36 and 48 Weeks Post-Procedure to be statistically signiﬁcant for all toes combined, and for toes within each of the 5 individual categories of Baseline % nail onychomycosis inclusion. For each individual baseline category, a statistically signiﬁcant mean change was observed from baseline at weeks 12, 36 and 48 Chart 1: % Nail Onychomycosis Inclusion by Evaluation Visit by Baseline % Onychomycosis Inclusion Category

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As can be seen in Table 2 and Chart 1 above, regardless of the extent (%) of nail onychomycosis involvement at baseline, by 48 weeks post-procedure, almost all nails with 80% or less onychomycosis involvement at baseline were completely or almost completely disease free. The highest incidence of residual onychomycosis at 48 weeks postprocedure occurred for toes in the > 80% Baseline onychomycosis inclusion category, although the mean % disease

TECHNICAL ARTICLE

involvement did decrease from 97.4% at baseline evaluation to less than a onefifth of this baseline % to 17.75% at 48 weeks post-procedure evaluation. It is not surprising that this category wherein the toes were almost completely disease involved at baseline showed more residual disease involvement at 48 weeks post-procedure, as given the relative greater severity of baseline inclusion, it would be anticipated and expected that it would take longer for the nail to grow and clear regardless of the type or efficacy of treatment intervention. In fact, the finding that less than 18% of each toe on average remained disease involved at 48 weeks post-procedure is quite significant.

CHANGE IN % NAIL ONYCHOMYCOSIS INCLUSION ACROSS EVALUATION POINTS

ANOVA analysis for 4 correlated samples found the changes in mean % nail onychomycosis inclusion across the 4 evaluation points of Baseline, 12 Weeks, 36 Weeks and 48 Weeks Post-Procedure to be statistically signiﬁcant for all toes combined, and for toes within each of the 5 individual categories of Baseline % nail onychomycosis inclusion, as follows. All Toes Combined (n=323) F=1442.27; p<0.0001

Subsequent Tukey HSD Test analysis found the changes between each of the 4 evaluation points for all toes combined to be statistically signiﬁcant: • Baseline to 12 Weeks Post-Procedure: p<0.01 • Baseline to 36 Weeks Post-Procedure: p<0.01 • Baseline to 48 Weeks Post-Procedure: p<0.01 • 12 Weeks to 36 Weeks Post-Procedure: p<0.01 • 12 Weeks to 48 Weeks Post-Procedure: p<0.01

TECHNICAL ARTICLE

• 36 Weeks to 48 Weeks Post-Procedure: p<0.05 < 20% Baseline % Nail Onychomycosis Inclusion (n=81) F=2045.42; p<0.0001

Subsequent Tukey HSD Test analysis found the changes between each of the 4 evaluation points for toes with < 20% onychomycosis inclusion at Baseline to be statistically signiﬁcant, at p<0.01: • • • • •

Baseline to 12 Weeks Post-Procedure Baseline to 36 Weeks post-Procedure Baseline to 48 Weeks Post-Procedure 12 Weeks to 36 Weeks Post-Procedure 12 Weeks to 48 Weeks Post-Procedure

21% - 40% Baseline % Nail Onychomycosis Inclusion (n=71) F=1397.05; p<0.0001

Subsequent Tukey HSD Test analysis found the changes between each of the 4 evaluation points for toes with 21% - 40% onychomycosis inclusion at Baseline to be statistically signiﬁcant, at p<0.01: • • • • •

Baseline to 12 Weeks Post-Procedure Baseline to 36 Weeks post-Procedure Baseline to 48 Weeks Post-Procedure 12 Weeks to 36 Weeks Post-Procedure 12 Weeks to 48 Weeks Post-Procedure

41% - 60% Baseline % Nail Onychomycosis Inclusion (n=110) F=4718.06; p<0.0001

Subsequent Tukey HSD Test analysis found the changes between each of the 4 evaluation points for toes with 41% - 60% onychomycosis inclusion at Baseline to be statistically signiﬁcant, at p<0.01: • Baseline to 12 Weeks Post-Procedure: p<0.01 • Baseline to 36 Weeks Post-Procedure: p<0.01 • Baseline to 48 Weeks Post-Procedure: p<0.01 • 12 Weeks to 36 Weeks Post-Procedure: p<0.01

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• 12 Weeks to 48 Weeks Post-Procedure: p<0.01 • 36 Weeks to 48 Weeks Post-Procedure: p<0.05

61% - 80% Baseline % Nail Onychomycosis Inclusion (n=41) F=1220.32; p<0.0001

Subsequent Tukey HSD Test analysis found the changes between each of the 4 evaluation points for toes with 61% - 80% onychomycosis inclusion at Baseline to be statistically signiﬁcant, at p<0.01: • • • • • •

Baseline to 12 Weeks Post-Procedure Baseline to 36 Weeks post-Procedure Baseline to 48 Weeks Post-Procedure 12 Weeks to 36 Weeks Post-Procedure 12 Weeks to 48 Weeks Post-Procedure 36 Weeks to 48 Weeks Post-Procedure

> 80% Baseline % Nail Onychomycosis Inclusion (n=20) F=619.93; p<0.0001

Therefore, the mean % nail onychomycosis inclusion decreased progressively and signiﬁcantly across the current 48 Week Post-Procedure evaluation phase, indicating progressive ongoing positive treatment eﬀect of the Erchonia Lunula laser.

COMPLETE NAIL CLEARANCE AT 48 WEEKS POST-PROCEDURE

Table 3 below shows the number and percentage of toes that attained complete

page 10

nail clearance (0% nail onychomycosis inclusion), and 5% or less nail onychomycosis inclusion, at 48 weeks post-procedure for all study toes combined and within each of the 4 individual Baseline % onychomycosis inclusion categories.

complete nail clearance decreased progressively across the categories of increasing % baseline nail onychomycosis inclusion, from 93% of nails showing complete clearance at about 11 months post-procedure for toes with 21% - 40% Baseline onychomycosis inclusion, through 83% of nails showing complete

95%-99% nail clearance at 48 weeks postprocedure, a 100% rate was attained for toes in each of the 3 Baseline nail onychomycosis inclusion categories of < 20%, 21%-40% and 41%-60%. Sixty-six per cent (66%) of toes in the 61%-80% Baseline nail onychomycosis inclusion category and 5% of toes in the >80%

Table 3: Toes Attaining Complete and Toes Attaining 95% or Greater Clearance at 48 Weeks Post-Procedure. Nails With Complete Clearance at 48 Weeks

Baseline % Onychomycosis Inclusion Category

< 20% (n=81)

Nails With 95%-99% Clearance at 48 Weeks

100%

41% - 60% (n=110)

83%

110

> 80% (n=20)

21% - 40% (n=71)

61-80% (n=41)

ALL TOES (n=303)*

* Does not include toes in >80% category Overall, more than 8 out of every 10 toes (83%) attained complete clearance of onychomycosis at 48 weeks postprocedure. Not surprisingly, the greatest incidence of complete clearance was attained for toes with the least percentage of Baseline nail onychomycosis inclusion (< 20%), with all 81 (100%) of those toes attaining 100% clearance. Likewise, the incidence of

251

93%

32% 83%

clearance at 48 weeks for toes with 41% - 60% Baseline onychomycosis inclusion, through 32% of nails showing complete clearance at 48 weeks for toes with 61% - 80% Baseline inclusion to 5% of nails (0%) showing complete clearance at 48 weeks for toes with > 80% Baseline inclusion. When evaluating toes that demonstrated

100%

66%

289

100% 5%

95%

Baseline nail onychomycosis inclusion category attained 95%-99% nail clearance. Again, this ďŹ nding is not surprising given that greater degree of disease involvement will naturally take longer to demonstrate complete clearance regardless of the type or eďŹ&#x20AC;ectiveness of treatment intervention.

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

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Podiatry Review Vol 71:3

TECHNICAL ARTICLE

Discussion

Dermatophytes cause infections of the skin, hair and nails due to their ability to obtain nutrients from keratinised material. The organisms colonize the keratin tissues and inﬂammation is caused by host response to metabolic by-products. They are usually restricted to the non-living corniﬁed layer of the epidermis because of their inability to penetrate viable tissue of an immunocompetent host. Invasion does elicit a host response ranging from mild to severe. Acid proteases, elastase, keratinase and other proteinases reportedly act as virulence factors (Rosenberg and Gallin 1999).

Dermatophytes are transmitted by direct contact with infected host (human or animal) or by direct or indirect contact with infected exfoliated skin or hair in clothing, combs, hair brushes, theatre seats, caps, furniture, bed linens, shoes, socks, towels, hotel rugs, sauna, bathhouse, and locker room ﬂoors (Ajello and Getz 1954). Depending on the species the organism may be viable in the environment for up to 15 months. There is an increased susceptibility to infection when there is a pre-existing injury to the skin such as scars, burns, excessive temperature and humidity. Increasingly Onychomycosis is being viewed as a more cosmetic problem as people become ever more conscious of their appearance. Fungi from the nails may happen before secondary bacterial infections such as cellulitis, idiopathic reactions and chronic urticarial. Infected toenails may act as a reservoir for fungi, facilitations their transmission to other parts of the body and potentially to other people. Clinical diagnosis of Onychomycosis is based on physical examination, microscopy and culture of nail specimens. Factors such as diabetes, hyperhidrosis, nail trauma,

TECHNICAL ARTICLE

poor peripheral circulation; can contribute to the condition. Differential diagnosis for onychomycosis, as mentioned earlier, should be considered so as to allow the clinician to choose the most appropriate treatment. It has been found to date, in this study, that 4 treatments for nails up to 60% inclusion has a satisfactory outcome and that nails with over 60% benefit from further pain free treatments. The two discrete laser light wavelengths used here have been reported to cause specific biological outcomes that are believed to provide a multifaceted treatment for DLSO. First, 635 nm (within the red visible spectrum) has been shown to activate PI3 kinase / eNOS signalling pathways, and to induce endothelial cell migration and neovascularisation (Schindler et al 1999, Lim et al 2011). Furthermore, red light has been shown to improve phagocyte function and to induce a respiratory burst in neutrophils (Duan et al 2001). Conversely, 405 nm has been demonstrated to have an antimicrobial effect by up-regulating the production of ROS, leading to the generation of hydrogen peroxide, hypochlorous acid, and hydroxyl radicals (Lavi et al 2012). When applied concurrently, the combined antimicrobial and biostimulative effects appear to provide a therapeutically beneficial combination, as demonstrated by the mean percent changes in clarity. A potential photo target for the 405 nm wavelength is also a system responsible for catalyzing the generation of ROS, nicotinamide adenine dinucleotide phosphate oxidase (NOX) (Lavi et al 2012). NOX transfers electrons from cytosolic NADPH to flavin adenine dinucleotide (FAD), then to extracellular molecular oxygen to generate superoxide (Streeter et al 2012, Lamberth 2004). The third and fifth transmembrane domains

Podiatry Review Vol 71:3

of NOX bind two prosthetic heme groups that shuttle electrons from FAD to oxygen (Streeter et al 2012, Lamberth 2004). It has been suggested that the prosthetic heme, which has been recognized as a photosensitizer, responds to the delivery of blue light. Stimulation of NOX could potentially provide two benefits: first, phagocytes are activated, and second, dermatophytes are susceptible to the toxic effects of ROS. Furthermore, squalene epoxidase, the therapeutic target for numerous antifungal medications, depends on the presence of NADPH or NADH and uses FAD to shuttle electrons from NADPH cytochrome P450 reductase. Loosely binding with FAD, SE may be subject to functional aberrations after light exposure (Ono and Bloch 1975).

Conclusion

The data coupled to-date, with the absence of adverse events, substantiated LLLT as a safe and effective treatment for OM. Furthermore, the data demonstrate that LLLT is effective at treating varying degrees of OM. In more severe cases of OM, with an accumulation of keratinous debris, it might be expected that light attenuation would dampen the clinical effect, with active debridement this has been seen not to be the case. Nevertheless, the successful treatment of nails with an initial percent involvement 100% demonstrates the laser’s ability to permeate down to the nail bed. However, to understand the full utility of this procedure, further follow-up data is being collected to evaluate the rate of reoccurrence and or reinfection. Additionally, fungal cultures were obtained and evaluated during the study that along with the visual improvement in nail clarity demonstrate the benefits of this cold laser treatment in destroying Dermatophytes. Clinical success is defined by the absence of clinical signs or

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the presence of negative nail culture, and not necessarily both (Scher et al 2007). Nevertheless, future studies evaluating LLLT will diagnose OM using microscopy and measure success based on clinical and mycological observations

References

Welsh O, Vera-Cabrera L, Welsh E. Onychomycosis. Clin Dermatol. 2010:28(2):151-9.

Gupta AK, Jain HC, Lynde CW. Prevalence and epidemiology of unsuspected onychomycosis in patients visiting dermatologists’ oﬃces in Ontario, Canada – a multicenter survey of 2001 patients. Int J Dermatol. 1997;36:783-787. Finch JJ, Warshaw EM. Toenail onychomycosis: current and future treatment options. Dermatol Ther. 2007;20(1):31-46.

Weinberg JM, Koestenblatt EK, Tutrone WD, Tishler HR, Najarian L. Comparison of diagnostic methods in the evaluation of onychomycosis. J Amer Acad Dermatol. 2003;49:193-197.

Romano C, Gianni C, Difonzo EM. Retrospective study of onychomycosis in Italy: 1985-2000. Mycoses. 2005;48:42.

Mahoney JM, Bennett J, Olsen B. The diagnosis of onychomycosis. Dermatol Clin. 2003;21(3):463-467.

Thomas J, Jacobson GA, Narkowicz CK, Peterson GM, Burnet H, Sharpe C. Toenail onychomycosis: an important global disease burden. J Clin Pharm Ther. 2010;35(5):497-519.

Gupta AK, Shear NH. A risk-beneﬁt assessment of the newer oral antifungal agents used to treat onychomycosis. Drug Safety. 2000;22:33-52. Elewski BE. Onychomycosis: treatment, quality of life, and economic issues. Amer J of Clin Dermatol. 2000;1:19-26.

Roberts DT, Taylor WD, Boyle J. Guidelines for treatment of onychomycosis. Brit J Dermatol. 2003;148:402-410.

Levy LA. Epidemiology of onychomycosis in specialrisk populations. J Amer Podiatric Med Assoc. 1997;87:546-550.

Ying-Ying H, Chen ACH, Carroll JD, and Hamblin MR. Biphasic dose response in low level light therapy. Dose Response 2009;7:358-383.

Karu T. Ten Lectures on Basic Science of Laser Phototherapy. Gangesber, Sweden: Prima Books AB (2007)

Lubart, R., Eichler, M., Lavi, R., Friedman H. and Shainberg A. Low-energy laser irradiation promotes cellular redox activity. Photomed Laser Surg. 2005;23(1):3-9.

Karu, T.I., Afanasyeva, N.I. Cytochrome oxidase as primary photoacceptor for cultured cells in visible

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and near IR regions. Doklady Akad. Nauk (Moscow) 1995;342:693-695.

Hemvani N, Chitnis DS, Bhagwanani, NS. Heliumneon and nitrogen laser irradiation accelerates the phagocytic activity of human monocytes. Photomed Laser Surg. 2005;23(6):571-4.

Dube A, Bansal H, Gupta PK. Modulation of macrophage structure and function by low level HeNe laser irradiation. Photochem Photobiol Sci. 2003;2(8):851-5

Dolgushin II, Gizinger OA. Eﬀect of low-intensity laser radiation on neutrophils from cervical discharge of women with mycoplasma infection. Vopr Kurortol Fizioter Lech Fiz Kult. 2008;4:29-31.

Dolgushin II, Markova VA, Gizinger OA. Monitoring of the eﬀect of low-intensity laser radiation with constant pulse generation on neutrophil granulocytes in vitro. Bull Exp Biol Med. 2010;150(2):222-4.

Morgan MC, Rashid RM. The eﬀect of phototherapy on neutrophils. Int Immunopharmacol. 2009;9(4):383-8.

Duan R, Liu TC, Li Y, Guo N, Yao L. Signal transduction pathways involved in low-intensity He-Ne laserinduced respiratory burst in bovine neutrophils: a potential mechanism of low-intensity laser biostimulation. Lasers Surg Med. 2001;29(2):174178. Zheng H, Qin JZ, Xin H, Xin SY. The activating actions of low-level helium neon laser radiation on macrophages in the mouse model. Laser Therapy. 1992;4:55-59. Young S, Bolton P, Dyson M, Harvey W. Diamantopoulos C. Macrophage responsiveness to light therapy. Lasers Surg Med. 1989;(5):497-505.

Emmons CW, Hollaender A. The action of ultraviolet radiation on dermatophytes. II. Mutations induced in cultures of dermatophytes by exposure of spores to monochromatic ultraviolet irradiation. Amer J Botany. 1939;26:467-475.

Scher RK, Tavakkol A, Sigurgeirsson B, Hay RJ, Joseph WS, Tosti A, Fleckman P, Ghannoum M, Armstrong DG, Markinson BC, Elewski, BE. Onychomycosis: Diagnosis and deﬁnition of cure. J Am Acad Dermatol. 2007;56(6):939-944.

Dogra S, Kumar B, Bhansali A, Chakrabarty A. Epidemiology of onychomycosis in patients with diabetes mellitus in India. Int J Dermatol. 2002;41(10):647-51. Campos MR, Russo M, Gomes E, Almeida SR. Stimulation, inhibition and death of macrophages infected with Trichophyton rubrum. Microbes Infect. 2006;8(2):372-9.

Blake JS, Dahl MV, Herron MJ, Nelson RD. An immunoinhibitory cell wall glycoprotein (mannan) from Trichophyton rubrum. J Invest. Dermatol. 1991;96:657-661.

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Schindl M, Kerschan K, Schindl A, Schon H, Heinzl H, Schindl L. Induction of complete wound healing in recalcitrant ulcers by low-intensity laser irradiation depends on ulcer cause and size. Photodermatol Photoimmunol Photomed. Feb 1999;15(1):18-21.

Schindl A, Schindl M, Schindl L, Jurecka W, Honigsmann H, Breier F. Increased dermal angiogenesis after low-intensity laser therapy for a chronic radiation ulcer determined by a video measuring system. J Am Acad Dermatol. Mar 1999;40(3):481-484.

Lim WB, Kim JS, Ko YJ, Kwon H, Kim SW, Min HK, Kim O, Choi HR, Kim OJ. Eﬀects of 635 nm light-emitting diode irradiation on angiogenesis in CoCl2-exposed HUVECs. Lasers Surg Med. 2011;43(4):344-52.

Eichler M, Lavi R, Shainberg A, Lubart R. Flavins are source of visible-light induced free radical formation in cells. Lasers Surg Med. 2005;37:314-319.

Lavi R, Ankri R, Sinyakov M, Eichler M, Friedmann H, Shainberg A, Breitbart H, Lubart R. The plasma membrane is involved in the visible light-tissue interaction. Photomed Laser Surg. 2012;30(1):14-19.

Streeter J, Thiel W, Brieger K, Miller FJ. Opportunity NOX: The future of NAPH oxidases as therapeutic targets in cardiovascular disease. Cardiovasc Ther. 2012:Epub.

Lambeth JD. NOX enzymes and the biology of reactive oxygen. Nat Rev Immunol. 2004;4:181-189.

Ono T, Bloch K. Solubilization and partial characterization of rat liver squalene epoxidase. J Biol Chem. 1975;250(4):1571-9.

Note

In order to assess and measure the amount of nail included high resolution digital photographs were taken using a jig into which the patient foot was placed and on which a camera was mounted. A scale measure marked Left and Right is ﬁxed to the jig in order to have an idea of scale. Once the photographs were processed they were independently measured using a micrometer measuring from the nail fold to the base of the fungus. Where irregular lines or included area were found, triangulation was used to calculate the area involved.

TECHNICAL ARTICLE

Podiatry Review Vol 71:3

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Podiatry Review Vol 71:3

TECHNICAL ARTICLE

Health and Care Professions Council meeting in London I was invited to attend a Health and Care Professions Council (HCPC) meeting in London with approximately 30 other people from all over the country. The purpose of the meeting was to rewrite the standards of conduct, performance and ethics.

and Michael Guthrie, director of policy and standards gave us a talk on HCPC’s standards of conduct, performance and ethics. This was followed with a talk by Becki Meakin, general manager on shaping our lives. We then split into four or ﬁve groups and discussed what we thought should be in the handbook. Some people felt the handbook was

too wordy but it was pointed out that it had to be legally correct.

HCPC have previously updated on the progress of government plans to introduce legislation which will require registrants to have appropriate professional indemnity arrangements in place as a condition of their registration with the HCPC.

the HCPC will publish full guidance on the requirements, based on feedback from their consultation on the draft guidance available at www.hcpcuk.org/aboutus/consultations/closed/i ndex.asp?id=158

this requirement and will not need to take any action. This is because they are covered by their employers’ arrangements or they have already made their own arrangements – for example, through a professional body, defence organisation, union or insurer.

Anna Van de Gaag, Chair of the HCPC welcome us all to the meeting

It was anticipated that this legislation would be in place at the end of October 2013. However, this has not been the case and we understand this will not now happen until at least July 2014. Once the legislation is in place,

HCPC ARTICLE

The requirement to have a professional indemnity arrangement in place will not mean that all registrants need to take out individual professional indemnity insurance to meet the requirements. The majority of registrants are likely to already meet

Podiatry Review Vol 71:3

As requested we all gave the HCPC our views and by all working together I felt that it was a worthwhile and productive day. Roger Henry, President

Further information about how this requirement may aﬀect you, along with some ‘Frequently Asked Questions’, is available at www.hcpcuk.org/registrants/indemnit

page 16

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.

Review of cleaning and sterilisation used in practice Joanne Casey MInstChP, BSc

The following is a review of the cleaning and sterilisation techniques you use in your practice. As podiatrists, chiropodists and foot health practioners we work in a wide variety of locations ranging from our own clinics to temporary rooms and of course domiciliary. However by auditing and reviewing our infection control procedures regularly we can maintain effective infection control. Following a literature review there is little specific to podiatry and infection control, therefore we must refer to the Minimum Standards of Clinical Practice which every member should have a copy of and which is available to download from the IOCP website www.iocp.org.uk. The standards specific to podiatry have been developed by the professional bodies and podiatry and foot health training agencies. Of course many procedures are common to many disciplines and are standard in health care settings. When conducting a practice audit with regard to cleaning and sterilisation the key questions are • • • •

What is my procedure? What is the function of the procedure? Does it achieve the outcome required? Does it comply with the required outcome? Put simply, what do I do? why do I do it?, and is it ﬁt for purpose? The prevention of all treatment-associated infection both in patients and ourselves is an integral part of the professional responsibility of podiatrists. It is impossible to dictate a single infection control regime suitable to all practitioners as working conditions vary widely, however we can select and implement measures most appropriate to our workplaces. (Lorimar et al 2006) The following is a brief recap on the deﬁnitions and requirements of infection control in your workplace.

Infection

Infection is typically described as the multiplication of microorganisms in or on the body. This is diﬀerent from contamination which is the presence of microorganisms which may or may not cause infection.

Sterilisation

A process where all living organisms including spores are eliminated

Disinfectants

Disinfectants are substances that are applied to non-living objects to help destroy the microorganisms that are living on them. Disinfection does not necessarily kill all microorganisms, especially non-resistant bacterial spores; it is therefore, less eﬀective than sterilisation. Chlorine based products are well known eﬀective disinfectants

Antiseptics

Destroy microorganisms on living tissue.

Cross Infection

This term is used to describe the spread of infection from patient to patient, practioner to patient or transfer of organisms via clinical instruments. There are three basic strategies of infection control 1. Elimination of sources and reservoirs of infection 2. Disruption of transmission routes of infection 3. Increasing or restoring host resistance to infection. A standard operating procedure for cleaning should be in place in every clinic and it should be as important as any other part of clinic operation. All medicaments and dressings should be in covered containers and not accessible to dust or debris. Disinfectants play an important role in infection control. Disinfectants are chemical compounds which need to be used correctly, as prescribed by the manufacturer, at the correct dilution, for a prescribed time. Therefore the disinfectant needs to be carefully chosen for the job it is required to do, in other words ﬁt for purpose. The following is a list of disinfectants and their uses

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

CONTINUING PROFESSIONAL DEVELOPMENT

Disinfectant type

Antimicrobial spectrum

Toxicity

Corrosiveness

Use

Brand name

Phenols eﬀective against spores

Moderate but not at low concentrations

Relatively mild

limited household disinfection

General

As Phenol

General household disinfectant and sold as wound disinfectant for mild cuts and grazes

TCP, Dettol

Halogenated phenols

Slightly more active

Crude phenolic products

Good activity

toxic

Slightly corrosive

Toilets, drains

Lysol, Jeyes ﬂuid

Bisbiguanides

Ok against gram +, less activity against gram- and none against spores

Mild

Non-corrosive

General antiseptic, little use as a general disinfectant

Hibitane (chlorhexidine) Savlon is chlorhexidine+ cetrimide

Wide spectrum of activity with some sporicidal activity

Fairly irritant, care must be taken

corrosive

Good general disinfectant at a variety of concentrations, very useful when blood spillages occur to eliminate any viral activity

Domestos, Milton, chlorine bleach all types

Good spectrum of activity but weak with spores endospores less so

Fairly non toxic on skin, iodine stains,

May corrode metals

Skin antiseptic prior to surgery

Iodex, Betadine

Wide spectrum, except spores, most eﬀective @ 40-70% with water

Mild on skin

Non corrosive

Cleaning surfaces

As alcohol

Good except for spores

irritant

Non corrosive

Used for wound irrigation and desloughing

Hydrogen peroxide

Chlorine releasing agents: chlorine hypochlorites, chlorine dioxide, chloramines

Iodine and endospores

Alcohols

Oxidising agents

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

CONTINUING PROFESSIONAL DEVELOPMENT

Sterilisation

All equipment used during treatment of a patient must be sterile. This means that all the instruments including scalpel handles will have been subjected to steam cleaning under pressure. This will occur in an autoclave. The instruments will have spent three minutes at 134°C at 27 psi. This will ensure that all microorganisms and spores present on the instruments are dead.

Prior to autoclaving, clean the instruments with soapy water and a brush to remove all debris. An ultrasonic cleaner will also do this task. Then place the instruments in the autoclave. The instruments will emerge sterile and dry. To ensure performance, equipment must be maintained and tested as per Health Technical Memorandum (HTM) 2010*. Each steriliser/autoclave

must have a log book in which the results of routine monitoring, examinations, tests, faults, repairs etc., are recorded. (NHS Lanarkshire Health Protection Committee)

Conducting an audit

Audits give us a picture of where we are, what we are doing and how we can improve. Please use the following templates as a guide and take a snapshot of your practice. If you wish perhaps we can start a discussion on the web forum to discuss outcomes and actions.

Hand washing

Please complete the following

Criteria Hand washing technique

Yes

Hands are wet under continuously running warm water Dispensed liquid soap is used Liquid soap is applied to wet hands Hands rubbed to create a lather A copy of the ten steps to eﬀective hand hygiene is on the wall The wall chart is followed Hands are rinsed Hands are dried using a paper towel When we have to use alcohol hand rub ( only eﬀective if hands are visibly clean)

Alcohol based rub is dispensed onto hands Alcohol hand rub is rubbed onto the hands ensuring all surfaces are covered by the alcohol Hands are rubbed until the alcohol has evaporated Cleaning procedures for instruments prior to autoclaving Criteria Cleaning of instruments prior to autoclaving

All visible debris removed using a clean brush and running water Dry the instruments Use manufacturer’s instructions to ﬁll ultrasonic bath Run the ultrasonic bath to allow the solution to degas prior to loading with instruments Empty clean and dry the bath for the next session Visually inspect instruments for debris and repeat if necessary Document all servicing and repairs

The above are guidelines only. But audits and reviews are useful methods of ensuring that we as professionals provide the best care for our patients.

CONTINUING PROFESSIONAL DEVELOPMENT

Hand Washing Technique 1. Wet hands and wrists, apply soap.

2. Rub right palm over left hand, and left palm over right hand.

3. Rub palm to palm, ﬁngers interlaced.

4. Rub ﬁngers to ﬁngers, interlaced.

5. Rotational rubbing of right thumb clasped in left hand, and vice versa. 2

6. Rotational rubbing, palm to palm. After this full circumference of the wrists should be rubbed with the palm of the opposite hand.

3 Note * Health Technical Memorandum 2010 was replaced by

References

www.iocp.org.uk. Member page http://www.nice.org.uk/

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

NHS Lanarkshire Health Protection Committee SECTION I – Decontamination of Equipment and the Environment (including the use of single-use and single-patient use items) October 2013 National Public Health Service Wales HAND HYGIENE

Quality improvement toolkit for Infection Prevention & Control in General Practice 2008

Photograph courtesy of Judith Barbaro-Brown www.judithbrowncpd.co.uk

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

INSTITUTE OF CHIROPODISTS AND PODIATRISTS 2014 ANNUAL CONFERENCE AND MEDICAL TRADE SHOW From your Conference Organisers Malcolm Holmes and Julie Aspinwall

This year’s conference is almost upon us again. We do not know where the last twelve months have disappeared to but hey ho, that seems to be the way of life these days!

Now, what is happening at the conference and trade show this year? We read and took on board your comments from last year and hopefully we have managed to address almost everything you expressed concerns over.

Firstly, the dinner dance this year will be held in the same building as the conference and trade show. We have acquired a much bigger room for the dinner dance, so numbers will not be a problem this year. We are assured by the venue that they are used to dealing with large numbers of guests, so the quality of the food will be of a much higher standard than was last years. There is also a much larger dance ﬂoor, so bring your dancing shoes, and since so many of you were very complimentary about the D.J. (I mean Disc Jockey not Dinner Jacket) we have, at great expense, asked him to return this year. The dinner dance will again take place on the Friday evening where all attendees are invited to join the President for his reception and a free drink! This event has kindly, once again, been sponsored by Canonbury Products Ltd.

What can you expect from the CPD that has been organised for the Conference? If you look at pages 35 and 36 all the information is there or on our website www.iocp.org.uk. but do not waste time before you book, as most of the workshops are ﬁlling up fast.

We have four workshops on the Friday and a lecture after the Conference closes.

On the Saturday we have workshops running throughout the day. Ever had a problem that you cannot find the answer to? Well here is your chance to find it, there will be a “question and answer in clinical practice” work shop run by the two heads of education for the Institute. If you have an interest in Diabetes, then there are two wonderful lectures being presented, a must for all practicing chiropodists. Also on the Saturday we are running a first aid course, as this was something else that you asked for last year.

So now let’s talk about the trade show, so far we have 23 exhibitors attending and are hopeful of a few more, we have some new ones you will not have seen before and some who you will be familiar with. Please visit these traders and spend your hard earned cash on the many bargains that I am sure will be available.

Please make every eﬀort to attend this year and support the traders who make the whole event possible, also to give support to the members of the Executive Committee, who give up their free time to keep the Institute of Chiropodists and Podiatrists solvent and moving forward, but most of all support YOUR INSTITUTE, for with your support all the hard work is worth it.

Institute becomes more visibly active in Europe A report article by Robert Sullivan

Mention the Institute of chiropodists and Podiatrists in the United Kingdom or the Republic of Ireland and most people know the organisation you are talking about. Over the years the Institute has trained and accepted, into membership, lots of people and as an organisation it is well represented by its members.

Occasionally our members become involved in projects, or even lead projects that produce information that is inﬂuential in informing best practice and or promoting change. When this happens, not just the individuals responsible for what ever it is that got noticed have the opportunity so make a diﬀerence, but this Institute as a whole gets the opportunity to be at the forefront for a time.

A number of years ago my team and I were offered an opportunity to develop a research proposal around the treatment of onychomycosis and its treatment using lasers. This proposal was submitted to ethics and the research was conducted. From this research an evidence paper was produced and now a scientific paper has been written. The evidence paper attracted a lot of interest, as a result it was published in a number of languages, on the 14th of March the finding of the research were presented at the 25 anniversary conference of the College of Podology of Barcelona at the World Trade Centre there. The presentation was extremely well attended and the Institutes ‘Podiatry Review’ has been sought after online as a publication to watch.

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Podiatry Review Vol 71:3

INSTITUTE NEWS

Vitamin D – All you need to know Vitamin D is essential for strong bones because it helps the body use calcium from the diet. Traditionally, vitamin D deficiency has been associated with rickets, a bone disorder in which bones soften leading to skeletal deformities, but increasingly, research is revealing the importance of vitamin D in protecting against a host of health problems. The most effective way of acquiring vitamin D is through the sun, however, most dermatologists will recommend using sunscreen which has the effect of protecting the skin from harmful rays of the sun but prevents the skin’s ability to produce vitamin D, consequently a large proportion of the world’s population are now potentially at risk from low vitamin D levels. Here, The Royal College of Paediatrics and Child Health explains all about Vitamin D and the part it plays in keeping our bodies healthy.

Introduction

There are many different recommendations for the prevention, detection and treatment of Vitamin D deficiency in the UK. The following is a practical interim guide laid out for paediatricians and their teams. The guide will be developed and updated when other bodies such as the Scientific Advisory Committee on Nutrition, the National Institute for Health and Care Excellence, the National Osteoporosis Society and the British Paediatric and Adolescent Bone Group evaluate research and publish their consensus opinions.

What is the natural source of Vitamin D?

Most people get little Vitamin D in their diet. Only a few natural foods such as oily fish and eggs (20 – 40 units per egg) contain significant amounts of Vitamin D. A few foods are fortified with small amounts of Vitamin D (eg margarine and some breakfast cereals). All formula milks are fortified, but plain cow’s milk is not fortified in the UK. Breast milk generally contains little Vitamin D. Sunshine is the main source of Vitamin D. However, Vitamin D can only be made in our skin by exposure to sunlight when the sun is high in the sky. Therefore, in most of the UK from November to February, and in Scotland from October to March, Vitamin D can not be made from sunshine. Whether ingested orally or made in the skin under the action of Ultraviolet light, Vitamin D is converted to 25hydroxyVitaminD in the liver and then on to 1,25-dihydroxyVitaminD in the kidney. It is this which has potent metabolic effects.

There are two types of Vitamin D: Ergocalciferol (Vitamin D2) a plant product and Colecalciferol (Vitamin D3) which is a fish or mammal product. The BNF and many other authorities regard them as interchangeable. However, ‘Activated Vitamin D’ preparations such as Calcitriol or Alfacalcidol should not be used for the treatment of simple Vitamin D deficiency. They should only be used for the treatment of complex cases by specialists. They are ineffective in treating simple Vitamin D deficiency and can cause severe adverse effects, particularly hypercalcaemia. Simple Vitamin D is safe and is the treatment for D deficiency.

Vitamin D deﬁciency

Vitamin D deficiency historically has been defined as a blood level of 25hydroxyVitaminD below 25nmol/L. There is scientific debate about the optimal Vitamin D blood level. Current practice in the UK, as recommended by the British Paediatric and Adolescent Bone Group, is to continue to use that as the defined level of deficiency, and to define ‘insufficiency’ as between 25 and 50 nmol/L. Some laboratories and authorities use higher levels but this current practice is based on robust evidence of benefits to bone health when levels are more than 50nmol/L. Vitamin D deficiency can cause seizures and cardiomyopathy in infants, rickets and poor growth in children and muscle weakness at any age.

HEALTH ARTICLE

Podiatry Review Vol 71:3

Who is likely to get Vitamin D deficiency?

People particularly at risk are those with:

1. Increased need:

• pregnant and breastfeeding women • infants • twin and multiple pregnancies • adolescents • obesity

2. Reduced sun exposure:

• northern latitude, especially above 50 degrees latitude (eg UK) • season – in winter and spring • Asian and African people – dark skin needs more sunshine to make Vitamin D • wearing concealing clothing • immobility, eg inpatients or those with conditions like cerebral palsy • excessive use of sun block – most block UVB more than UVA

3. Limited diet (but remember

sunshine is most important source of Vitamin D):

• vegetarians and vegans • prolonged breastfeeding – even if mother has suﬃcient Vitamin D • exclusion diets – eg milk allergy • malabsorption • liver disease • renal disease • some drugs – eg Anticonvulsants, Anti-TB drugs page 22

Although sunshine is the usual source of Vitamin D, diet is of course the source of Calcium. It is particularly important to prevent Vitamin D deﬁciency in children with limited Calcium intake.

Prevention

The Department of Health and the Chief Medical Oﬃcers recommend a dose of 7-8.5 micrograms (approx 300 units) for ALL children from six months to ﬁve years of age. This is the dose that the NHS ‘Healthy Start’ vitamin drops provide. The ‘Healthy Start’ programme aims to provide vitamins free to people on income support. The British Paediatric and Adolescent Bone Group’s recommendation is that exclusively breastfed infants receive Vitamin D supplements from soon after birth.

Adverse eﬀects of Vitamin D overdose are rare but care should be taken with multivitamin preparations as Vitamin A toxicity is a concern. Multivitamin preparations often contain a surprisingly low dose of Vitamin D. Standard prevention doses Category

Dose and Frequency

1 month – 18 years

400 Units – 1,000 units daily

Newborn up to 1 month

300 - 400 units daily

Examples of preparations

Abidec, Dalivit, Baby D drops and ‘Healthy Start’ Vitamins

Over the counter preparations e.g. Abidec, Dalivit, Boots high strength Vitamin D, Ddrops, Holland & Barrett Sunvite D3, DLux oral spray, SunVitD3 and Vitabiotics tablets

Treatment of deﬁciency with symptoms Category

Vitamin D dose and frequency

Duration

6 months - 12 years

6,000 units daily

4 – 8 weeks

Up to 6 months

12 -18 years

1,000 units - 3,000 units daily

10,000 units daily

4 – 8 weeks

Vitamin D had been diﬃcult to obtain in treatment doses, but is now prescribable as Colecalciferol Liquid 3,000 units/ml. Tablets or capsules of 400, 1,000, 10,000, 20,000 units are also prescribable. Combined ‘Calcium and Vitamin D’ tablets usually contain only 200 or 400 units of Vitamin D which is a relatively low Vitamin D dose. Unless the patient has insuﬃcient Calcium intake it is often better, and cheaper, to prescribe a pure Vitamin D product.

The same eﬀect may be achieved by multiplying the dose by seven and giving it weekly. In older children, especially if compliance is a concern, some recommend a single dose (multiply daily dose by 30).

It is essential to check the child has a suﬃcient dietary Calcium intake, and that a maintenance Vitamin D dose follows the treatment dose and is continued long term (see standard prevention doses overleaf).

Follow-up: Some recommend a clinical review a month after treatment starts, asking to see all vitamin and drug bottles. A blood test can be repeated then, if it is not clear that suﬃcient vitamin has been taken. Current advice for children who have had symptomatic Vitamin D deﬁciency is that they continue a maintenance prevention dose at least until they stop growing. Dosing regimens vary and clinical evidence is weak in this area. The RCPCH has called for research to be conducted.

Assessing the patient Characteristics

Management

No risk factors

No investigations, lifestyle advice* and consider prevention

Risk factors and symptoms or signs

Blood tests and/or xray, treatment and long-term prevention

Risk factors, no symptoms

Lifestyle advice* and prevention

*Lifestyle Advice: Vitamin D and the Sun Consensus statement 2010, www.bad.org.uk//site/1221/default.aspx

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Podiatry Review Vol 71:3

HEALTH ARTICLE

The consensus statement represents the unified views of the British Association of Dermatologists, Cancer Research UK, Diabetes UK, the Multiple Sclerosis Society, the National Heart Forum, the National Osteoporosis Society and the Primary Care Dermatology Society: ‘Vitamin D is essential for good bone health and for most people sunlight is the most important source of Vitamin D. The time required to make sufficient Vitamin D varies according to a number of environmental, physical and personal factors, but is typically short and less than the amount of time needed for skin to redden and burn. Enjoying the sun safely, while taking care not to burn, can help to provide the benefits of Vitamin D without unduly raising the risk of skin cancer. Vitamin D supplements and specific foods can help to maintain sufficient levels of Vitamin D, particularly in people at risk of deficiency.’ Symptoms and signs in children Infants

Children Adolescents

Seizures, tetany and cardiomyopathy

Aches and pains; myopathy causing delayed walking; rickets with bowed legs, knock knees, poor growth and muscle weakness Aches and pains, muscle weakness, bone changes of rickets or osteomalacia

Blood tests

25hydroxyVitaminD is the standard blood test, and is an excellent marker of body stores. People with risk factors and symptoms of hypocalcaemia or D deficiency should have a check of their blood level. The blood test requires about 2ml of serum and does not need to be transported to the laboratory urgently. The cost of this test is approximately £20. Basic bone biochemistry (Calcium, phosphate and alkaline phosphatase) is often normal despite significant Vitamin D deficiency. High alkaline phosphatase implies rickets. 25hydroxyVitaminD is measured in nmol/L in the UK, but in ng/ml in the USA. 50nmol/L = 20ng/ml. Parathyroid hormone (PTH) PTH is produced in the neck glands when the parathyroid Calcium-sensing receptors detect a low level of blood Calcium. PTH levels are a helpful measure of Calcium and Vitamin D status. In children a high level of PTH is usually due to Vitamin D deficiency or a lack of Calcium in the diet. Other causes (eg parathyroid tumours or renal failure) are rare.

Treatment of relatives

If a patient is diagnosed with Vitamin D deficiency the family should be screened or treated. At least screening by history taking should take place, and prevention advice given. Investigation of other family members by blood testing may be indicated. Alternatively, prescribe a Vitamin D supplement to those sharing the same sun exposure and diet. After treatment, children who were deficient or insufficient should continue long-term low-dose supplements until completion of growth, unless lifestyle changes (diet/sun exposure) are assured.

Acknowledgements:

Prof Mitch Blair, RCPCH Oﬃcer for Health Promotion Dr Benjamin Jacobs, Royal National Orthopaedic Hospital Dr Colin Michie, Ealing Hospital NHS Trust RCPCH Nutrition Committee and specialty groups BAPM and BACCH For more information visit www.rcpch.ac.uk/vitamin-d or contact Dr Benjamin Jacobs at bj@nhs.net ©2013 Royal College of Paediatrics and Child Health, 5-11 Theobalds Road, London, WC1X 8SH The Royal College of Paediatrics and Child Health is a registered charity in England and Wales (1057744) and in Scotland (SCO38299)

Useful links

www.gov.uk/government/publications/vitamin-d-advice-on-supplements-for-at-risk-groups www.healthystart.nhs.uk http://bpabg.co.uk/position-statements/vitamin-d-and-fractures www.rcpch.ac.uk/positionstatements Disclaimer: The RCPCH does not endorse any particular commercial product; those listed are examples of products in the UK. Check your local Trust guidelines for speciﬁc recommendations.

HEALTH ARTICLE

Podiatry Review Vol 71:3

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HEAD OFFICE NEWS

Cheshire and North Wales Branch Meeting Phil Yeomans

On 2nd March 2014, twenty-three branch members turned out to enjoy the March meeting at the Dene Court Hotel, Chester. An interesting programme had been compiled by Janet Trow with guest speaker being an acupuncturist. Gillian Lockwood had travelled all the way from Shrewsbury, where her practice of 21 years is based, to educate members. She gave us an overview of what acupuncture is about and how it can help people at large enjoy a better quality of life by helping to alleviate the discomfort of various physical

BRANCH NEWS

ailments and help minimise or even eliminate emotional/psychological issues. Particularly for us Gillian pointed out certain aspects which are related to common foot disorders such as gout, arthritis, rheumatism etc. Various pieces such as charts, needles, books were passed around while being educated about this discipline and how manipulation of the 360 acupuncture points has serious health beneﬁts for people from all walks of life.

Shireen volunteered her painful hand to be the ‘guinea pig’ without suﬀering any undue eﬀects. The members were very

Podiatry Review Vol 71:3

interested in the subject and the Q & A session could have gone on for long past the allotted time allowed. Gillian was a very accomplished speaker and a pleasure to have as our guest.

We also had the beneﬁt of chiropody suppliers C & P Medical who set up a trade stand for members to eagerly snap up some special bargains oﬀered on the day.

Following the usual coﬀee break, raﬄe and chit-chat the branch meeting took place discussing various on-going and forthcoming events within the IOCP. Particular focus being on the AGM in Southport and the fantastic programme of seminars and eminent speakers it has this year. A show of hands was asked for to see who was attending and a majority was counted. Excellent result and illustrates commitment to obtaining quality CPD and supporting IOCP events by the branch members.

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Western Branch Meeting Hazel Carruthers

On 12th January this year 20 members of the Western branch joined together for its AGM and branch meeting at the Women's Hospital in Liverpool. During the AGM all the important decisions and information from head oďŹ&#x192;ce were discussed in detail and voted on. We also asked for new volunteers to join the happy band of brothers (and sisters) ,who all work tirelessly during the year to keep the branch running meticulously and ensure all the loyal members who make the eďŹ&#x20AC;ort to support us at meetings are given the CPD they deserve.

page 27

Business details over, we then had the chance to browse and purchase goods on oďŹ&#x20AC;er from Ben Stead (Canonbury), James Cree (Algeos) and Anne from Prosser Uniforms. As a branch we are all particularly grateful to Ben and James for giving up their Sunday afternoons to support us. They are a credit to the relevant companies they work for and we would like to thank them for giving up their time for us.

After a well-deserved break we then were treated to a very interesting talk from the prominent consultant foot and ankle

Podiatry Review Vol 71:3

surgeon Mr Andy Molloy who works from BMI University Hospital, Aintree in Liverpool. His informative lecture gave us an insight into the latest surgical techniques and devices used to rectify foot deformities by the orthopaedic foot surgeons in his team. He also explained when surgery would be recommended as an intervention to help our own patients and his patients continued future comfort.

The meeting concluded there until our next gathering on 13th April

BRANCH NEWS

1 million people with diabetes “at risk of a foot attack” There are currently an estimated 1 million people with diabetes who are at high or increased risk of a diabetes-related foot attack and too many of these people do not understand that delays to treatment could result in amputation, says Diabetes UK today at their Professional Conference. As many as a third of the 3.2 million people diagnosed with diabetes in the UK are deemed to be at high or increased risk of a foot attack, which is an injury to a foot which has reduced feeling or reduced blood circulation. This can lead to a lower limb amputation. Amputations are over 20 times more common in people with diabetes. Diabetes UK has warned that many of the 6,000 diabetes-related amputations a year in the UK are a result of poor services and a lack of awareness, leading to many people delaying seeing their doctor for months and so missing the chance to save their foot. 85 per cent of these amputations are preceded by an ulcer. The charity has today launched at its annual Diabetes Professional Conference a new patient information booklet, “How to Spot a Foot Attack”, about the signs of active foot disease that will be sent to every GP surgery in the country. It includes a card that people at high risk of a foot attack can display in their home to remind them that they need to seek urgent medical attention if: • Their foot is red, warm or swollen;

DIABETES NEWS

• There is a break in the skin or any discharge or oozing onto their socks or stockings. • If either of these is accompanied by feeling unwell. Diabetes UK is urging healthcare professionals to make sure everyone with diabetes not only gets a good quality foot check at least once a year but, importantly, is told whether they are at high or increased risk. At the moment, about 15 per cent of people with diabetes do not get this check and others get a check but are not told their risk status. In some cases, there are reports of people having a foot check that is so cursory they are not even asked to take their shoes oﬀ. The charity wants healthcare professionals to make sure people who are at high or increased risk to know their risk status, understand the importance of good foot care and understand the urgent need to see a doctor if they have any signs of a foot attack. Barbara Young, Chief Executive of Diabetes UK, said: “When you consider that 1 million people with diabetes are at high risk of a foot attack, it is really worrying that many of these people are being left in the dark about what to look for and when they need to seek urgent medical help. “This means that all too often, people are seeing the signs of foot disease but not acting on it and potentially losing their foot

Podiatry Review Vol 71:3

as a result. The NHS needs to shift its approach to diabetic foot disease so that making people understand the importance of addressing foot problems quickly is seen as being as important as what happens once they are seen by a doctor. “This lack of focus on giving people the tools they need to know when to raise the alarm means people are experiencing the devastation of amputation because of a toxic mix of stoicism and lack of awareness. It is shocking that people with foot disease are suffering in silence for months on end, often because they simply do not know that every day they put off seeing a doctor, their risk of amputation goes up. “We hope our leaflet will help make people more aware of what they need to look out for, and we would urge GPs to give it to every patient who is at high or increased risk of a foot attack. But a leaflet can only do so much. We also need to see more people with diabetes getting a good quality annual foot check and more healthcare professionals taking the time to talk to these patients about their feet. For example, many people with diabetes experience loss of feeling in their foot, so it is crucial that they understand the importance of regularly checking their own feet for changes or getting a carer to do so, as they may be having a foot attack but not be experiencing any pain or discomfort.

page 28

New diabetes driving proposals launched Thousands of people with diabetes could avoid lengthy delays and disruptions when reapplying for their licence under proposals announced today to extend the licensing period for people with the condition.

The Driving Vehicle Licensing Agency (DVLA) has put forward proposals to extend the licensing period for people who treat their diabetes with insulin to up to 10 years. Currently, people who have Group 1 Licences (cars and motorbikes) have to reapply at least every three years. It is hoped the proposals will form part of the Government’s Deregulation Bill, which is expected to get Royal Assent by the autumn and the changes could be introduced as early as next year.

Diabetes UK has welcomed the proposal as the current system is unfair and puts an unnecessary burden on both people with diabetes and the system.

The charity is often contacted by people with diabetes who are experiencing lengthy delays, which can cause anxiety and uncertainty about whether they will lose their licence and possibly their livelihood. It is hoped that the changes will improve the DVLA’s communications with people with diabetes and help to reduce delays.

Robin Hewings, Head of Policy for Diabetes UK, said: “The announcement by the DVLA that it is seeking to extend the licence period for people who treat their diabetes with insulin will be welcomed by the thousands of people with the condition who currently have to reapply for their driving licence at least every three years.

“We are delighted to see this as we know that many people with diabetes ﬁnd the current system unfair and intrusive and that delays are causing real distress

and anxiety and in the very worst cases their jobs are at risk so we are pleased that the DVLA has listened to our concerns.

“We will continue to work with the DLVA on the implementation of these proposals so that people with diabetes get a fairer deal when it comes to driving.”

The DVLA is consulting with diabetes stakeholders on its proposals. We will be seeking the views of its members and supporters to inform its response to the consultation. People with diabetes have to notify the DVLA if they develop impaired awareness of hypos (where you are unable to recognise the hypo when it starts), if they have more than one severe hypo in a 12month period and if they have any changes or complications to their condition that aﬀect their ability to drive safely.

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PRESS RELEASE

Podiatry Review Vol 71:3

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Podiatry Review Vol 71:3

HCPC INFORMATION

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

May 2014 11

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

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

27/28

West Middlesex Branch Meeting 8 p.m. - The Harvester, Croxley Green, Rickmansworth WD3 3RX Tel: 0208 903 6544

Hants and Dorset Branch First Aid Course Open to all; members of other branches and non members Location to be confirmed Further details email juliacdoble@gmail.com Tel: 01202 425568

Midland Area Council Meeting Kilsby Village Hall Contact Barbara 01536 269513

19 30/31

Western Branch Meeting 12.00 noon – 5.00 pm - Blair Bell Education Centre, Room 1, Liverpool Women’s Hospital, Crown Street, L8 1SS Presentation by Kays Medical 11.30 and First Aid Course by Roy Aldcroft 1.00 – 5.00 Tel: 01745 331827 Birmingham Branch Meeting 8.00pm - Red Cross Centre, Vine Street, Evesham, Worcs Tel: 01905 454116 Executive Committee Meeting in the Board Room at Head Office 150 Lord Street, Southport, PR9 0NP Tel: 01704 546141

July 2014 7

Surrey and Berkshire Branch Meeting Pirbright Village Hall, GU24 0JE Tel: 01252 514273

Surrey and Berkshire Branch Meeting Pirbright Village Hall, The Green, Pirbright, GU24 0JE

Wolverhampton Branch Meeting 9.30 a.m. - 4 Selmans Parade, Selmans Hill, Bloxwich W53 3RN Tel: 0121 378 2888

The Institute of Chiropodists and Podiatrists AGM Workshops and CPD Conference Southport theatre and convention centre The Promenade, Southport PR9 0DZ Tel 01704 546141

West Middlesex Branch Meeting 8 p.m. - The Harvester, Croxley Green, Rickmansworth WD3 3RX Tel: 0208 903 6544

Leicester & Northants Branch Meeting 10 a.m. - Kilsby Village Hall (refreshments 9.45) CPD Lecture: Understanding Ultrasound therapy Tel: Sue 01530 469816

June 2014

September 2014

Essex Branch Meeting 2 p.m. - Southend University Hospital Education Centre Carlingford Drive, Southend on Sea SS0 0RY Tel: 01702 460890

Leeds/Bradford Branch Meeting 10 a.m. - Oakwell Motel, Birstall, WF17 9HD Tel: 01423 819547

6&7

Surrey and Berkshire Branch CPD Meeting 7.30 p.m. - Pirbright Village Hall, Pirbright GU24 0JE Tel: 01252 514273

Foot Mobilisation Course 150 Lord Street, Southport PR9 0NP Tel: Julie 01704 546141

Southern Area Council Meeting Victory Services Club, 63-79 Seymour Road Tel: 07947 435114

West Middlesex Branch Meeting 8 p.m. - The Harvester, Croxley Green, Rickmansworth WD3 3RX Tel: 0208 903 6544

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

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

Southern Area Council Meeting Victory Services Club For details Tel: 07947 435114

Western Branch Meeting 12.00 noon – 4.30 pm - Blair Bell Education Centre, Room 1, Liverpool Women’s Hospital, Crown Street, L8 1SS Autoclave calibration; Presentions“Inclusion matters” by a NHS Nurse and “Diagnostic Equipment by Ben Stead. Tel: 01745 331827

North of Scotland Branch Meeting will be meeting in September please contact Sheena Gray on 01382 532247 For further details

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

South Wales and Monmouth Branch Meeting 2 p.m. - Meeting Room at Asda Store, Coryton, Cardiff CF14 7EW Tel: 01656 740772

DIARY OF EVENTS

Podiatry Review Vol 71:3

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

Essex Branch Meeting Includes a First Aid Course in the morning 2 p.m. - Southend University Hospital Education Centre Carlingford Drive, Southend on Sea SS0 0RY Tel: 01702 460890

26/27

Executive Committee Meeting in the Board Room at Head Office 150 Lord Street, Southport, PR9 0NP Tel: 01704 546141

Leicester & Northants Branch Meeting 9 a.m. - Lutterworth Golf Course (refreshments 8.45) CPD Lecture: TBC Trade Stands to be arranged. Tel: David 01455 550111

December 2014

October 2014

Hants and Dorset Branch Christmas Social Event Details to follow Tel: 01202 425568

Leeds/Bradford Branch Meeting 10 a.m. - Oakwell Motel, Birstall, WF17 9HD Tel: 01423 819547

Hants and Dorset Branch Meeting 8 p.m. - Crosfield Hall, Broadwater Road, Romsey SO51 8GL Canonbury will be available to answer questions and display various products of interest with discounts. Tel: 01202 425568

2015 January

Birmingham Branch Meeting 8.00 p.m. - Red Cross Centre, Vine Street, Evesham, Worcs Tel: 01905 454116

Leeds/Bradford Branch Meeting 10 a.m. - Oakwell Motel, Birstall, WF17 9HD Tel: 01423 819547

Western Branch AGM & Meeting 12.00 noon - Blair Bell Education Centre, Room 1, Liverpool Women’s Hospital, Crown Street, L8 1SS Business meeting followed by presentation - TBA. Also John Rose will be calibrating autoclaves and traders will be invited. Tel: 01745 331827

North West Area Council Seminar – Details to follow

Devon & Cornwall Branch will be meeting in October at the Exeter Court Hotel, Kennford EX6 7UX Please telephone Mark Smith 01803 520788 or email mrkjoanne@aol.com for details.

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

Wolverhampton Branch Meeting 9.30 a.m. - 4 Selmans Parade, Selmans Hill, Bloxwich W53 3RN Tel: 0121 378 2888

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

Essex Branch AGM 2 p.m. - Southend University Hospital Education Centre Carlingford Drive, Southend on Sea SS0 0RY Tel: 01702 460890

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

Nottingham Branch AGM 10.00 a.m. - Feet and Co 85 Melton Road, West Bridgford, NG1 6EN Tel: 0115 931 3492

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

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

Cheshire North Wales, Staffs and Shropshire Branch Meeting 10 a.m. - The Dene Hotel, Hoole Road, Chester, CH2 3ND Presentation to be confirmed Tel: 0151 327 6113

Surrey and Berkshire Branch Meeting Pirbright Village Hall, GU24 0JE Tel: 01252 514273

Leicester & Northants Branch Meeting 10 a.m. - Lutterworth Cricket Club (Refreshments 9.30) CPD Lecture: Wound care – TBC Plus Autoclave service by MDS – reservation required as limited places. Tel: Sue 01530 469816

November 2014 2

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

Leeds/Bradford Branch Seminar Oakwell Motel, Birstall WF17 9HD Tel: 01423 819547 – Details to follow

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

Essex Branch Meeting 2 p.m. - Southend University Hospital Education Centre Carlingford Drive, Southend on Sea SS0 0RY Tel: 01702 460890

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February 9

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

Podiatry Review Vol 71:3

DIARY OF EVENTS

Classified

www.iocp.linkupltd.com

Since its launch in summer 2012, our web shop has become a popular Our bestselling medical instrument has been nippers supplied by DLT place for members to order a variety of work related items from especially for IOCP members, these have been keenly priced and have stationery to medical instruments. Selling via the web shop has proved to be a real web hit with IOCP members. and supply items more competitively. enabled us to cut costs much If you think there is an item ideally suited to sell on our web shop drop Our range of IOCP stationery well is now extremely priced. LINKUP ltd a line who run the shop for us on sales@linkupltd.com The new Tonia medical tunic available with the IOCP logo has also been popular with members, along with other clothing that can be David Cliﬀord branded with individuals names and not just the IOCP logo. The latest LINKUP Ltd (01252 343127) Branding matters clothing addition is a cardigan after valuable feedback from our Unit GU12 F Holder Road, ALDERSHOT, Hampshire 4RH members. http://www.linkupltd.com

Chiromart UK “WHY PAY MORE?”

Suppliers of Autoclaves and Chiropody Surgery Equipment. Single Items to full surgery set-ups. Quality used and new. Also your equipment wanted. Surgery clearances, trade-ins and part exchange CASH WAITING… www.chiromart.co.uk Tel: 01424 731432 (please quote ref: iocp)

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

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

FOR SALE PRACTICES

MDS 12L Autoclave and water distiller

Domiciliary Practice - Chelmsford

Currently working 3 days by choice. Established 10 years. Retirement sale.

Contact Colin Elliott 01245 474715 Email: colin@ce-foothealth.co.uk

Torquay, Devon - Retirement Sale

Surgery and Domiciliary. Established 25 years. Income £16K over 3 days. Plenty of Scope for expansion. Price £11K

Telephone 07739 041919

Surgery established 26 years. Income £22K p.a. over 3 days. Plenty of scope for expansion. Price £10K

Excellent condition £650.00 ono. Buyer collects Contact Linda: Work; 0781 500 9917 Home: 01745 331827

Telephone 07885 400832

POSITION WANTED

Apology

with 25 years experience looking for part-time work in a practice within the North West Area. Please contact 07813 969006 CLASSIFIED

Shipley, West Yorkshire - Retirement Sale

EQUIPMENT FOR SALE

Foot Health Practitioner

In an article Volume 71. No.2 p.25 we inadvertently stated that Helen Lloyd was a member of Cheshire North Wales branch. Helen has asked that it be made clear she is a member of Western branch. We apologise for any upset this may have caused.

Podiatry Review Vol 71:3

page 34

THE INSTITUTE OF CHIROPODISTS AND PODIATRISTS 2014 NATIONAL PODIATRY CONFERENCE Southport Theatre & Convention Centre, The Promenade, Southport. PR9 0DZ BOOKING FORM ʹ TO BE USED BY NON OFFICIAL BRANCH/EC DELEGATES ALL DELEGATE/LECTURES AND THE AWARDS DINNER/DANCE MUST BE BOOKED ON THIS FORM PLEASE COMPLETE THE FORM CAREFULLY IN BLOCK LETTERS AND CHECK PRIOR TO POSTING AS NO AMENDMENTS CAN BE MADE ONCE FORM RECEIVED

Name: .................................................................................................................................................................................................. Address:................................................................................................................................................................................................ ..........................................................................Postcode͙͙͙͙͙͙͙͙͙͙͙͙͙͘͘Telephone Number................................................ NAME(S) OF ATTENDEE(S) ͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙MEMBER OF WHICH PROFESSIONAL BODY͙͙͙͙͙͙͙͙͙͙͙͙͙͙. th

Friday, 30 May 2014 (Limited places ʹ Book early to guarantee choice) 1.00pm ALL OFFICIAL DELEGATES TO BE PRESENT AT VENUE 1.00pm Standing Orders (main conference room) 2.00pm Annual General Meeting Opens (main conference room) 2.00pm Workshop: Padding & Strapping (syndicate room 1) Suzanne Ostler

£15

2.00pm Workshop: Demonstration of Footbalance Foot Analysis equipment (Syndicate room 2) David Sleigh, Footbalance director

£15

3.00pm Refreshment Break and look around the Trade Exhibition £15

4.00pm Workshop: Padding & Strapping (syndicate room1) Suzanne Ostler

FULL

4.00pm Workshop: ŽƉƉůĞƌ͛Ɛ and Diabetes (Syndicate room 2) Michelle Weddell 5.00pm Lecture: Forefoot Pain, what Podiatrist's need to Know (main conference room) Abid Ali

£15

6.00pm Conference closes for the day 7.30pm until midnight Dinner and Disco in The Lakeside Suite (Ticket Only) and Awards Ceremony (Dress: Black Tie) ǁĂƌĚƐ ŝŶŶĞƌ dŝĐŬĞƚƐ Λ άϯϱ ƉĞƌ ƉĞƌƐŽŶ ǆ͙͙͙people - PLEASE NOTE THERE ARE LIMITED PLACES

£35

E D ^ dd E /E' t Z ^ Z DKEz ͙.͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͘͘ Names of persons with whom you would like to be seated at the Awards Dinner (Friday) ʹ Whilst we will endeavour to meet your request, we cannot guarantee this....................................................................................... Special Requirements Vegetarian Vegan KƚŚĞƌ ZĞƋƵĞƐƚƐͬ ŝĞƚĂƌǇ ŶĞĞĚƐ͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙͙ st

Saturday, 31 May 2014 (Limited places ʹ Book early to guarantee choice) 9.00am Annual General Meeting Resumes followed by Question Time 11.00am Refreshment Break and look around the Trade Exhibition £15 11.30am Lecture: Why is Footcare important with Diabetes (main conference room) Judith Barbaro-Brown ŽŶƚŝŶƵĞĚ ŽǀĞƌůĞĂĨ͙͙ Rates include VAT @ current rate

VAT No 712 5290 59

REF: AGMDD2014

12.30pm Look around Trade Exhibition Optional Saturday Bagged ůƵŶĐŚ Λ άϭϬ ƉĞƌ ƉĞƌƐŽŶ ǆ ͙͙͙͙͙͘ WĞŽƉůĞ

£10

1.30pm Lecture: Infection control in Clinical Practice (main conference room) Joanne Casey

£15

FULL

1.30pm Workshop: First Aid 2 hour (Syndicate room 1) David Crew 1.30pm Workshop: Cryopen, its use in treating sĞƌƌƵĐĂĞ͛Ɛ (Syndicate room 2) Maurice Smeets

£15

2.30pm Lecture: Update on Current Glucose Lowering Options in Type 2 Diabetes (main conference room) Paul Dromgoole

£15

2.30pm Workshop: Question and Answers in Clinical Practice (Syndicate room 2)

£15

In this workshop you are invited to present a case or a clinical issue you may have to the group who will together try to solve the issue. Workshop Chaired by Robert Sullivan and Joanne Casey

3.30pm Refreshment Break and final look around the Trade Exhibition 4.00pm Lecture: DIABETES AND THE LOWER LEG /E KZWKZ d/E' ͞ / d ^ h<͟ (main conference room) Robert Sullivan

£15

4.00pm Workshop: Sports Injury (Syndicate room 1) Somuz Miah

£15

4.00pm Workshop: Footwear and the high risk foot. Improving fit, improving function (Syndicate room 2) Martin Nunn

£15

5.00pm Conference Closes

TOTAL COST £

MDS Medical are offering an autoclave service at our 2014 conference. Their highly trained engineers will be on hand to service your autoclave whilst you attend the conference. The cost of a service will be £95 + VAT. Please contact MDS medical on 01536 201467 as soon as possible to book for autoclave servicing as places will be limited.

To book accommodation log on to: http://iocp.org.uk/AGM_and_National_Conference_2014.php Payment 1. Credit Card - Credit card charge of 2% applies and Debit Card charge of 50p applies ප DĂƐƚĞƌ ĂƌĚ ප sŝƐĂ ප DĂĞƐƚƌŽ Card Type:

ප ^ǁŝƚĐŚ

Card Number: ....................................................................................... House Number͗ ͙͙͙͙͙ Postcode....................... sĂůŝĚ &ƌŽŵ͗ ͙ͬ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ ǆƉŝƌǇ ĂƚĞ͗ ͙ͬ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ ϯ ĚŝŐŝƚ ƐĞĐƵƌŝƚǇ ĐŽĚĞ͗ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ Maestro/Switch issue no: ................. Named Cardholder: .............................................................. ĂƌĚŚŽůĚĞƌ͛Ɛ ^ŝŐŶĂƚƵƌĞ͗ ͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ 2. Cheque / ĞŶĐůŽƐĞ Ă ĐŚĞƋƵĞ ĨŽƌ ά͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘͘ ŵĂĚĞ ƉĂǇĂďůĞ ƚŽ ͞dŚĞ /ŶƐƚŝƚƵƚĞ ŽĨ ŚŝƌŽƉŽĚŝƐƚƐ ĂŶĚ WŽĚŝĂƚƌŝƐƚƐ͟ Please note that full payment must be received before confirmation can be sent ʹ Please feel free to contact us should you not receive confirmation within two weeks Please return your completed form with payment to: The Institute of Chiropodists & Podiatrists, 150 Lord Street, Southport, Merseyside, PR9 0NP Telephone number 01704 546141 TERMS AND CONDITIONS If a booking is cancelled and no replacement participant can be found, the following cancellation charges will be incurred: x x x x

Cancellation 31 days or more before the event takes place: no charge Cancellation between 14 days and 31 days before the event takes place: 50% of total price Cancellation less than 14 days before the event takes place: 100% of total price The Institute of Chiropodists and Podiatrists reserves the right to cancel or reschedule seminar location or times, or to arrange a substitute lecture if this is absolutely necessary and out of our control. In these cases The Institute of Chiropodists and Podiatrists are not required to compensate travel or accommodation costs, loss of working time or other damages.

Rates include VAT @ current rate

VAT No 712 5290 59

REF: AGMDD2014

page 37

Podiatry Review Vol 71:3

NOMINATIONS

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

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

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

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

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

The professional solution for effective Verruca and Wart removal

www.cuxsongerrard.com

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