Podiatry Review January/February 2010 by The Institute of Chiropodists & Podiatrists

January/February 2010 Vol. 67 No. 1 ISSN 1756-3291

Diabetes News The Primus Metatarsus Supinatus (Rothbarts) foot and the PreClinical Clubfoot Deformity Cellulitis

2010 A.G.M.

The Institute of Chiropodists and Podiatrists Abductor digiti minimi

Cuboid

Metatarsals

Phalanges

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Contacts Editor: Mr. R. H. S. Henry Email: editor@iocp.org.uk Editorial Assistant: Mrs. B. K. Willey Email: bernie@iocp.org.uk Published by: The Institute of Chiropodists and Podiatrists 27 Wright Street, Southport, Merseyside PR9 0TL Telephone: 01704 546141 or 08700 110305 Fax: 01704 500477 Email: secretary@iocp.org.uk Web: www.iocp.org.uk

Contents 1. Editorial 2. Diabetes News 3. HPC News 4. Article - The Primus Metatarsus Supinatus (Rothbarts) foot and the PreClinical Clubfoot Deformity 8. Article - Cellulitis 10. Article - Volunteering and Learning in Mombasa

Dear Reader

Happy New Year, new chapter in life, new beginnings. I hope you like the new colour on the front page. We change the colour every year, so that it stands out, on the bookshelf, if you keep your Reviews to refer to, for Continuous Professional Development. (CPD) What have we of interest and note in this issue? Prof/Dr. Brian A. Rothbart has written a treatise on The Primus Metatarsus Supinatus (Rothbarts) foot and the Preclinical Clubfoot Deformity, on page 8 there is an article on Cellulitis. This can be a debilitating condition. My mother aged 88 gets cellulitis, and I know from personal experience, it can be painful, the leg swells up and warm to the touch. Antibiotics is the treatment preferred, and it takes 2 to3 weeks to clear up. Kathryn Leggate, a first year Podiatry student at Queen Margaret University Edinburgh, was awarded the Cosyfeet Podiatry Award 2009. The £1,000 grant helped to fund her voluntary work in the slums of Mombassa, Kenya. We publish her report commencing on page 10. Up to date information is given about our 2010 A.G.M. and CPD lectures. It will be held at Eastwood Hall, Nottingham on the 7th – 9th May 2010.

January/February 2010

It promises to be educational, informative and fun. Among the speakers will be Professor Wesley Vernon OBE who will be lecturing on Forensic Podiatry. Maureen O’Donnell will be talking about Medical Legal Issues and Expert witness reporting. Maureen is joint editor of, and contributor to, the Podiatry textbook Neales Disorders of the Foot. Dr. Menos Lagopoulos MD PhD (an excellent teacher) will be lecturing on Lower Limb anatomy and pathology of the foot. Finally Judith Barbaro Brown MSc PGDip, BSc(Hons),BA (Hons),PGCE, DPodM, MchS. I understand is our after dinner speaker. Judith needs no introduction to readers of Podiatry Review for she writes many of our CPD centre page pull outs, for which we are very grateful. So plenty to look forward to at our A.G.M., lectures, Trade Show and Dinner Dance. Contact Head Office for tickets. I have included reports of seminars at the North West Area at the University of Central Lancashire (Preston) and Midland area council at the Hilton Hotel Leicester. They were both well attended and successful. Here’s to a healthy and prosperous New Year.

Roger Henry, Editor Podiatry Review

13. 2010 A.G.M. 18. President’s Page 19. Personal Profile 24. Branch News 25. North West Area Seminar 26. Branch News 30. Rambling Roads 34. Diary of Events IBC National Officers Annual Subscription: £25.00 Single Copy: £5.00 Including Postage & Packing ISSN 1756-3291

L-R Colette Johnston (Irish Area Executive Delegate), Malcolm Holmes (North West Area Executive Delegate), Ann Yorke (Scottish Area Executive Delegate), Robert Beattie (Chairman Executive Committee), Stephen Willey (Chairman Board of Ethics), Heather Bailey (President), Roger Henry (Honorary Treasurer), Bill Liggins (Chairman Board of Education), David Elliott (Midland Area Council Delegate), David Crew (Vice-Chairman Executive Committee), Mary Newnham (Southern Area Executive Delegate), Judith Kelly (acting Yorkshire Area Executive Delegate) © 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.

Diabetes News

Islet cell transplantation in Scotland The Scottish National Blood Transfusion Service has opened a new laboratory in Edinburgh to offer around 12 people a year islet cell transplant therapy.

Islet cell transplant therapy is a pioneering treatment for diabetes that was part-funded by Diabetes UK in its research stages.

About islets Islets are groups of cells in the pancreas that contain the insulin-producing beta cells. In people with Type 1 diabetes, the beta cells are destroyed so they must take insulin by injection to remain healthy. This means having to estimate how much insulin they will need and for some people it is very difficult to achieve stable blood glucose levels. Islet cell transplantation A small number of people with Type 1 diabetes can benefit from islet transplantation, a procedure in which an individual’s destroyed islet cells are replaced using cells harvested from donor pancreases.

Who is eligible for a transplant? Because the drugs required to prevent rejection of the transplant can have serious side effects, the procedure is currently only suitable for those people who have extreme problems controlling their diabetes, experience innumerable hypos with little or no warning, which can be life threatening, and as a consequence have drastically reduced quality of life. Diabetes UK-funded research helps diabetes management “It is fantastic to see Diabetes UK-funded research helping people to manage their diabetes more effectively,” said Dr. Iain Frame, Research Director at Diabetes UK.

Life-changing “Islet cell transplantation can be life-changing for a small number of people with Type 1 diabetes and getting it to this stage would not have been possible without the collaborative efforts of all the dedicated researchers and doctors involved.” Groundbreaking Scotland’s Minister for Public Health, Shona Robinson, said: “I’m delighted to be launching this groundbreaking programme, which will be of great benefit to some groups of people living with Type 1 diabetes.”

HPC Audits 2010 - Guide to CPD – HPC Audits for our profession are back this year! In 2008 almost 90% of the 5% audited registrants complied with HPC regulations regarding CPD. As a result, the HPC have confirmed that a random 2.5% will be selected for audit in 2010. Members who deferred last time will automatically be selected. We would ask that Members notify us if they are selected for audit as we are not automatically notified by HPC. Although majority of you will be prepared for audit, a small minority may need help. Please ask if you are still unsure.

Standard

Standard not met

Standard partly met

Standard met

A registrant must maintain a continuous, up-to-date and accurate record of their CPD activities.

The registrant has not provided evidence that they have kept a record Assessment criteria of their CPD.

There is some evidence that the registrant has kept a record of their CPD. For example, they have described keeping a record.

There is evidence that the registrant has maintained a record of their CPD activities, and as part of their supporting evidence they have sent in a brief summary of all the CPD activities they have undertaken.

A registrant must seek to ensure that their CPD has contributed to the quality of their practice and service delivery.

There is no evidence that the registrant’s CPD activities have improved the quality of their work, or that they have aimed for their CPD to improve the quality of their work.

There is some suggestion that the registrant’s CPD has improved their work – improvement is hinted at in the information they have provided but they have not given any evidence to support this.

A registrant must demonstrate that their CPD activities are a mixture of learning activities relevant to current or future practice.

The registrant has not undertaken any CPD activities. Or The registrant’s CPD consists of only one type of CPD activity. Or The registrant’s CPD is not relevant to their current or future practice, as described in the ‘summary of practice’.

The registrant has undertaken two types of CPD activity, but they have not explained why they have concentrated just on those. Or There is some evidence that the registrant’s CPD is relevant to current or future work, but this is not made clear.

A registrant must seek to ensure that their CPD benefits the service user.

The registrant has not provided any information which explains any benefit to service users.

There is limited information about how the registrant’s CPD activities have benefited service users. Or The registrant has stated a benefit to service users but not given any evidence or explanation to support this.

A registrant must present a written profile containing evidence of their CPD upon request.

The registrant did not return their profile by the deadline.

A registrant must seek to ensure that their CPD has contributed to the quality of their practice and service delivery.

There is no evidence that the registrant’s CPD activities have improved the quality of their work, or that they have aimed for their CPD to improve the quality of their work.

The registrant has provided a profile by the deadline but it was incomplete (for example, they said that evidence was to follow).

A registrant must seek to ensure that their CPD benefits the service user.

The registrant has not provided any information which explains any benefit to service users.

A registrant must present a written profile containing evidence of their CPD upon request.

The registrant did not return their profile by the deadline.

The registrant has provided a profile by the deadline but it was incomplete (for example, they said that evidence was to follow).

There is some suggestion that the registrant’s CPD has improved their work – improvement is hinted at in the information they have provided but they have not given any evidence to support this.

The registrant’s CPD includes three or more types of CPD activity. Or The registrant’s CPD includes two types of CPD activity and their CPD profile has explained why they have chosen to concentrate only on those types of activity. And There is evidence that the registrant’s CPD activities are relevant to their current or future practice and the link is clear in the personal statement.

The registrant has shown (through evidence provided or an explanation given) how their CPD activities have benefited service users, either directly or indirectly. Or The registrant has shown how they believed their CPD would benefit service users, but this has not been the case. (The profile must show that they have considered why this has happened and what you will do next to make sure their CPD will benefit service users in the future.) The registrant must send in their profile by the deadline.

The registrant’s personal statement shows that their CPD activities have improved the quality of their work and this is backed up with evidence. Or The registrant has shown how they believed that their CPD might improve the quality of their work, and had planned for this, but this had not been the case. The registrant’s statement must show that they have considered why this has happened, and what they will do next to make sure their CPD will improve the quality of their work in the future.) The registrant has shown (through evidence provided or an explanation given) how their CPD activities have benefited service users, either directly or indirectly. Or The registrant has shown how they believed their CPD would benefit service users, but this has not been the case. (The profile must show that they have considered why this has happened and what you will do next to make sure their CPD will benefit service users in the future.) The registrant must send in their profile by the deadline.

The Primus Metatarsus Supinatus (Rothbarts) foot and the PreClinical Clubfoot Deformity A Brief Introduction

By Prof/Dr. Brian A. Rothbart

n the Journal Bodyworks and Movement Therapy (Rothbart, 2002), two previously unrecognized embryological foot types were reported: the Primus Metatarsus Supinatus foot (PMS), also known as Rothbarts Foot, and the PreClinical Clubfoot deformity (PCD). This paper will discuss: l l

the etiology of each of these two foot structures an innovative test (the Knee Bend Test) to help determine which of the two foot structures the patient might have (e.g., differential diagnosis)

the impact these foot structures have on the patient’s overall health that drugs can not resolve

When weight is applied to this foot, no abnormal foot twist (pronation) is observed.

Abnormal Ontogenetic Development of the Talar Head (Talar Supinatus; resulting in PMS.

The talar head does not complete its normal ontogenetic (torsional) development. When the foot is placed in its anatomical neutral position, the big toe is elevated off the ground This foot structure is termed Primus Metatarsus Supinatus (Rothbarts Foot). (See Figure 2). Figure 2 – Talar head remains in supinatus (twisted inward), and with it, the 1st metatarsal and hallux Fig 2

Etiology of the Primus Metatarsus Supinatus Foot (PMS)

Normal Ontogenetic Development of the Talar Head

The talar head completes its ontogenetic (torsional) development during the 1st trimester of its embryological development. When the foot is placed in its anatomical neutral position, the big toe is plantar grade, that is, rests on the ground (See Figure 1). Figure 1 – Normal Ontogenetic (torsional) Development of the Talar Head Fig 1

Talar Supinatus - Talar head has not fully unwound (red arrow)

When weight is applied to the PMS foot, at mid-stance gravity forces the foot to twist (abnormally pronate) in order to place the first metatarsal and hallux (down) Fig 3 on the ground.

Etiology of the PreClinical Clubfoot Deformity (PCD) Fully Unwound Talar Head (red arrow)

Plantargrade foot

Primus Metatarsus Supinatus (Rothbarts Foot)

Normal Ontogenetic Development of the Calcaneus (heel bone)

The calcaneus completes its normal ontogenetic (torsional) development during the 1st trimester of its embryological development. When this foot is placed in its anatomical neutral position, the bottom surface of the calcaneus is perpendicular to the longitudinal bisection of the tibia (See Figure 3).

Figure 3 – Posterior bisection of the tibia is perpendicular to the plantar surface of the heel bone

Figure 5 – Knee Bend Test, knees straight. The Knee Bend Test is used with other tests to determine which of the two embryological foot structures the patient has.

When the body’s weight is over the heel bones (e.g., the knees are straight), foot twist (pronation) is observed in the Preclinical Clubfoot Deformity (See Figure 5 opposite), and rarely in Rothbarts Foot.

Abnormal Ontogenetic Development of the Calcaneus; resulting in the PCD

The calcaneus does not complete its normal ontogenetic (torsional) development. When this foot is placed in its anatomical neutral position, the bottom surface of the calcaneus is inverted (turned inward) relative to the longitudinal bisection of the tibia (See Figure 4). Figure 4 – the calcaneus remains in supinatus (structurally twisted inward). This foot structure is termed the PreClinical Clubfoot Deformity.

Fig 4

Fig 6

Figure 6 – Knee Bend Test, knees bent. The Knee Bend Test is used with other tests to determine which of the two embryological foot structures the patient has. When the body’s weight is over the front part of the foot (e.g., the knees are bent), foot twist (pronation) is observed in both the PreClinical Clubfoot Deformity and Rothbarts Foot (See Figure 6 above). Fig 7

When weight is applied to this foot, at heel contact gravity forces the PCD foot to twist (abnormally pronate) in order to bring the entire bottom surface of the heel bone down to the ground. The Knee Bend Test (a clinical test I invented) is used to: l

help determine which embryological foot structure is present in the patient (i.e., the Rothbarts Foot or the PreClinical Clubfoot Deformity)

Figure 7 – Primus Metatarsus Supinatus (Rothbarts) foot structure. Left - as a infant. Note the presence of an inner arch. Right - as a teenager. Note the absence of foot twist (pronation) when the body’s weight is over the heel bones.

help determine the postural distortional pattern (e.g., Ascending, Mixed etc.)

Interpretation of Findings

Interpreting Knee Bend Test findings is taught in the Level III certification course, at the International Academy of Rothbart Proprioceptive Therapy (http://IARPT.com).

The photos and associated descriptions are only intended to give the reader a general overview of the Knee Bend Test. It is not intended to be used for self-diagnosis.

Fig 5

Fig 8

Figure 8 – PreClinical Clubfoot Deformity. Left - as a infant. Note the presence of an inner arch. Right - as a teenager. Note the foot twist (pronation) when the body’s weight is over the heel bones. Figure 9 – Clubfoot Deformity. Note the position of the right foot compared to the normal left foot.

Fig 9

Drugs are Not the Answer to Resolve Chronic Musculoskeletal (muscle and joint) pain

Chronic neck, hip, knee and back pain are a problem of pandemic proportions affecting more American than diabetes, heart disease and cancer combined. Statistics reveal that people continue to spend billions on treatments to free themselves from their chronic pain with little to no relief. Drugs are used by millions of chronic pain sufferers across the globe. They are spending billions just to manage their pain. In America alone, billions of dollars are spent each year for over-the-counter pain medication. In 2005, 20 billion dollars were spent on prescription medication for chronic back pain. Opioid therapy has become a common method of treatment for severe chronic pain. Well-known side effects include dependence or addiction, aberrant drug behavior and respiratory depression (which can lead to death). Over one million Americans are currently addicted to opioids.

The American Pain Society has recently issued a new Guideline for Prescribing Opioid Pain Drugs. For patients at “higher risk for misuse of opioids, this guideline advises giving patients clear written rules,” such as: Filling prescriptions at one pharmacy only l Taking random drug tests l Making regular physician visits l Locking their medications at home l

Clearly, this tells us that the time has come to look for alternative and effective non-drug solutions to treat chronic pain. Unfortunately, the problem with many current treatments for chronic musculoskeletal pain is that they do not address the source of the pain. As with anything in life, without addressing the source of a problem, it is impossible to find a real and permanent solution. Without finding and addressing the source of the pain – one must continually manage it. A very common source of chronic muscle and joint pain is in your feet. There exists a neural-mechanical pathway which connects the bottom of your feet to your brain. Signals are sent from the feet to the brain and they tell the brain the position of the body relative to its surroundings. The brain uses this information to adjust the body’s posture.

There are two inherited foot structures (Rothbarts Foot and the Preclinical Clubfoot Deformity) which cause the foot to twist when you stand or walk. This foot twist creates distorted signals being sent to the brain. The brain responds by creating a distortion in the posture. Bad posture then leads to increased stress and strain on the joints and

Correction In the article Flatfoot by Professor Brian A. Rothbart (page 4 November/December issue) photograph C was incorrect. The following photo shows flexible flatfoot on weight bearing (i.e. when weight is placed on the foot). We apologise for this error.

muscles. The end result is inflammation and pain. If the source of the bad posture (the inherited foot structure) is not addressed and handled, the pain becomes chronic. There are many current therapies that address bad posture, such as chiropractic or physiotherapy. But because these treatments only adjust the body’s position temporarily – at some point after, the body returns to its original bad posture and inevitably the pain returns.

Hence, the key to returning to wellness is to correct the distorted signals generated from a twisting foot. This is accomplished by placing specific stimulation underneath the feet, which sends corrected signals to the brain (referred to as proprioceptive therapy). The brain responds by automatically adjusting the posture into a more correct alignment. This is done automatically, like breathing, requiring no conscious effort from the patient to maintain this improved posture. The net result of the improved posture is that the stress and strain on the muscles is considerably reduced. Though it may take time for the body to completely heal, the results are permanent. That is, proprioceptive therapy results in the elimination of musculoskeletal pain (as opposed to pain management that is geared towards treating symptoms and not the cause of the pain). For more in depth description of Rothbart’s Proprioceptive therapy, read Prof/Dr. Rothbart’s book, Forever Free From Chronic Pain, available at http://ForeverFreeFromChronicPain.com.

Unique Garment-Based Kneehab® Electrotherapy System

Available in the UK from Mobilis Rolyan is an innovative and clinically proven, new garment-based EMS (electrical muscle stimulation) system, the Kneehab®, which is designed to treat thigh muscle wastage, or quadriceps atrophy. Designed to accelerate rehabilitation for those recovering from serious knee conditions, including anterior cruciate ligament reconstruction, knee replacement surgery, ligament damage, arthritis and general muscle weakness, the Kneehab works by re-educating and strengthening the quadriceps muscle through programmable cycles of contraction and relaxation. The system’s unique neoprene thigh wrap, dual-channel controller and anatomically-shaped electrodes were designed by the market leader in home-based electrotherapy technology, Neurotech, in association with the University College of Dublin’s School of Physiotherapy. Kneehab is now available for direct purchase or monthly hire by physiotherapists, orthopaedic consultants, sports clubs and patients from Mobilis Rolyan, formed by the recent merger of Mobilis Healthcare into the Homecraft Rolyan business, through its customer services desk, trade catalogue and online shopping arm. The velcro-attached thigh wrap is supplied for either the right or left leg and reutilisation for other patients and injuries is facilitated by replacement garments and gelbased electrodes, whilst retaining the main digital EMS controller, rechargeable batteries and charger. Unlike small, hand-held EMS units, which make it difficult for patients to locate the electrodes accurately and stimulate the large thigh muscle properly, the Kneehab comprises a pad-carrier garment with electrode positioning indicators for exact pad placement, ensuring optimum performance, maximum compliance and error-free home therapy. Large, anatomically-shaped electrode pads help to stimulate the thigh muscles effectively, ensuring even load dispersion, with one pad dedicated to the knee-stabilising VMO muscle and the remaining three to the bulk quadriceps. Kneehab’s patented Multipath technology, developed by Neurotech, enables it to deliver highly focused and accurately coordinated contractions to the VMO and bulk quadriceps, allowing an optimal muscle fibre recruitment sequence and delivering stronger, yet comfortable contractions. The easy-to-operate control unit, with LCD display, gives access to three different programs, for a choice of rehabilitation parameters; while at the touch of a button, the clinician is able to monitor compliance between visits. Kneehab also monitors the quality of the electrical circuit and automatically pauses the unit, if contact with the skin is impaired. The efficacy of the system has been verified in a series of clinical tests. In one study of its effectiveness after ACL reconstruction, it was found that the Kneehab group demonstrated a clear advantage at the 6 week post-operative follow up, compared with the standard rehabilitation groups. In another analysis of patients undergoing total knee arthroplasty, Kneehab users recorded significant improvements in pre-operative functional ability and quadriceps strength within 8 weeks, coupled with a 99.5% patient compliance rate. User testimonials come from Blackburn Rovers and former Manchester United chartered physiotherapist, David Fevre, who regards Kneehab as a valuable tool for keeping players’ ‘injury time out’ to a minimum; from Preston North End and ex-Liverpool FC professional footballer, Neil Mellor, who says he benefited greatly from using Kneehab as an aid to returning to full fitness, after several knee operations; and Irish Olympic athlete, Eileen O’Keefe, who sustained a serious knee injury and recommends Kneehab for accelerated postoperative rehabilitation. Utilised both pre - and post-operatively to limit muscle wastage and speed recovery, Kneehab is typically used for two 20-minute sessions per day, for around 8-12 weeks, and is also recommended for younger arthritis sufferers, to keep them mobile and maintain muscle function. On sale at £350 ex VAT or for monthly hire, Kneehab is available from Mobilis Rolyan, Nunn Brook Road, Huthwaite, Nottinghamshire NG17 2HU, Telephone 08448 730 035. Email mobilisrolyan.sales@patterson-medical.com or online at www.mobilishealthcare.com

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Cellulitis

ellulitis is a severe bacterial infection of the skin tissues which spreads rapidly. It is not connected to cellulite which is a cosmetic condition producing dimpling of the skin.

Generally starting as a small area of redness which may be tender and swollen, cellulitis can be mistaken for impetigo. Impetigo is highly contagious but superficial skin infection, whereas cellulitis infection is non contagious and penetrates the dermis and subcutaneous tissue. As in impetigo, the main bacteria which cause cellulitis are streptococcus and staphylococcus.

Impetigo Methicillin resistant staphylococcus aureus (MRSA) can also cause cellulitis. These bacterias are not the only causes of cellulitis, other bacteria such as Pneumococcus, Hemophilus influenzae and Aeromonas hydrophilia may all contribute. As the area enlarges it can cause fever and swollen lymph nodes near the affected area.

Cellulitis is not confined to any particular part of the body although the leg is the most common site especially the tibia, shinbone and foot, nor is it confined to areas of previously broken skin for example insect bites, surgical wounds, tattoos etc. Certainly it can and does occur following trauma to the skin in this way but can also develop where there has been no break in the skin at all. Cellulitis in the lower leg can look like a clot occurring in

Cellulitis

the veins such as complaints of warmth, pain and swelling. Both need urgent clinical diagnosis. DVT can be diagnosed with a compression leg ultrasound. Cellulitis is treatable by anti-biotics but is more difficult to confirm, the concentration of bacteria can be low and cultures can fail to demonstrate the causative organism. Doctors will choose a treatment based upon several factors such as history, location and extent of the infection.

Diabetics are more prone to cellulitis in the feet because of impaired blood circulation in the legs which can lead to foot ulcers. Because of the poor control of blood glucose levels bacteria grows more rapidly in the affected tissue and facilitates rapid progression if the infection enters the bloodstream. Often diabetics cannot feel warning pain in their feet which increases the risk of the infection spreading without awareness.

Cancer and aids sufferers, people with weakened immune systems because of immunosuppressive drugs are extremely vulnerable. However other illnesses such as chickenpox and shingles need to be monitored also as the characteristic blisters break open providing a gap in the skin through which bacteria can enter. Pregnancy and severe obesity also increase the risk of developing cellulitis.

Orbital Cellulitis Children are generally more prone to Periorbital cellulitis which starts out with a sinusitis or a â&#x20AC;&#x153;pink eyeâ&#x20AC;?. Periorbital cellulitis is an infection of the soft tissues around the eye generally caused by bacteria such as Haemophilus influenzae This should not be confused with orbital cellulitis which is an infection of the soft tissues in the eye socket and presents as proptosis (bulging eye), opthalmolplegia (limited movement in eye), pain and loss of vision and is far more serious requiring hospital admission with IV antibiotics. In the case of orbital cellulitis, besides the possible damage to the eye there is a danger that infection may spread along the nerves and blood vessels to the brain producing meningitis.

Necrotizing cellulitis (or necrotizing fasciitis), a rare but severe form of cellulitis, is the dreaded "flesh-eating disease" that occasionally hits the media headlines. There are two types. The first is due to a very aggressive strain of Group A streptococcus and can start anywhere on the skin. The second is due to a polymicrobial infection of different bacteria that often starts just forward of the anus following surgery or rectal abscesses. Necrotizing cellulitis starts as an extremely painful, red swelling that soon turns purple and then black as the skin and flesh die. However, the risk of getting necrotizing cellulitis is extremely small. The risk is a bit higher for people who are already sick or have a compromised immune system Another cause of periorbital cellulitis is common eye make up. If eye make up is not removed, microscopic pieces of make-up can remain undetected in the eyelid for days, causing infection. Types of Bacteria that can cause cellulitis

Streptococcus (Groupâ&#x20AC;&#x2122;s A and B) Staphylococcus aureus Hemophilus influenzae (Generally children under 6) Pasteurella multocida (Animal Bites or scratches) Aeromonas hydrophilia and Vibrio vulnificus (Exposure to seawater) Pseudomonas aeruginosa (Puncture wound)

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Cellulitis Cellulitis has varying incubation periods ranging from twenty-four hours to several days. With appropriate antibiotic therapy the duration can be relatively short, however, untreated cellulitis can prove fatal or at least result in severe disability. Oral antibiotics are sufficient in most cases but in severe cases intravenous therapy may be required.

To reduce the risk of cellulitis, preventory measures such as cleaning and dressing wounds correctly, changing bandages regularly and not allowing dressing to become wet or dirty are strongly recommended.

Mobilis Rolyan Nunn Brook Road ,Huthwaite,Nottinghamshire NG17 2HU Tel: 0161 678 0233 Fax: 0161 627 4401 Email: homecraft.sales@patterson-medical.com Website: www.mobilishealthcare.com or www.homecraft-rolyan.com

Volunteering and Learning in Mombasa A

rriving in Mombasa after an eight hour flight, my feelings of anxiety, excitement and curiosity had begun to settle. I was ready for my adventure. The project I had volunteered for was targeted at individuals with some medical training. As a first year Podiatry student, it provided me with an opportunity to volunteer my skills in a developing country and increase my own knowledge along the way.

I was greeted at the airport by the volunteer co-ordinator, John. He escorted me to my accommodation and introduced me to my Kenyan host family. I was to share Mahaad and Zahra Hassans’ home for a month.

Mahaad worked at Bomu Hospital as chief pharmacist. On the Monday morning, after a restful weekend, I received my induction to Bomu Hospital and met lots of people from various departments. It was a daunting prospect to have so many new names and faces to remember. Everyone gave me a warm welcome and made me feel part of the team instantly. Thankfully, the majority of staff members could speak English as my Swahili was far from perfect. Bomu hospital aims to provide quality care in family planning, general medical care, antenatal care, and since 2004 provides HIV care to the poor living in urban Mombasa. It is the largest non-profit healthcare facility serving the shanty towns of Mombasa.

I was lucky enough to spend time in each area of the hospital assisting the doctors and nurses. Although my main interest is of course Podiatry, there is no Podiatric department within the hospital. Podiatry in general is not a well developed area of medicine in Africa. As a result, I had spread the word that if anything came through the door of a Podiatric nature, I would be delighted to be informed. This opened many windows of opportunity for me as the helpful, friendly work place ethic at Bomu Hospital revealed itself. The phone never stopped ringing and I was extremely pleased to become a regular assistant in the Diabetic clinic. Patients came to their appointments with various problems, wounds being the most interesting to me. Patients often presented with diabetic foot ulcers and funigating wounds, their tissues broken down, forming a route of entry for bacteria.

One particular case encapsulated for me much of the endemic difficulties facing diabetic patients in Kenya. The patient, named Justice, was a 48 year –old male. He came

Kathryn Leggate, a first year Podiatry student at Queen Margaret University, Edinburgh, was awarded the Cosyfeet Podiatry Award 2009. The £1,000 grant helped to fund her voluntary work in the slums of Mombasa, Kenya. Her report is published here.

to the Diabetic Clinic at Bomu after being diagnosed as a noninsulin dependent diabetic by a private doctor in Mombasa. He worked in the docks as a baggage handler and often found himself feeling very tired, thirsty and suffering from increasing hunger. Justice had been prescribed Metformin but was not given the correct information about how to take his medication. His diabetes was therefore poorly controlled and was having a damaging effect on his body: the result of him having very high blood sugar for long periods of time. Justice was under the impression that if he took all the medication prescribed to him and finished the course then he would be cured. When he came to clinic we had to educate him about diabetes and explain to him that the medications are not a cure and that he would need to take them for life. He was an intelligent man and once properly informed he understood the risks of his condition and the importance of controlling his blood sugar. Justice felt let down by his previous doctor and had lost trust in medics. Only after a lengthy discussion was he willing and prepared to follow his prescribed regime. Justice’s experience of the medical profession is not uncommon in Kenya. Doctors sometimes tailor treatment so that the patient will keep returning with problems requiring further consultation and treatments, all at additional cost to the patient.

I explained to Justice the importance of keeping blood sugars at an appropriate level and educated him on dietary choices and the importance of good foot health. I also encouraged him to check his feet regularly for changes in sensation, colour and

circulation and proceeded to examine him. His diabetes had been poorly controlled for a relatively short time and no visible damage had been done to his feet. Justice had good colour, sensation, movement, pulses and proprioception. His feet did have severe fissures, however, which I explained were potential routes of infection into already vulnerable feet. I encouraged him to keep them clean, use emollients regularly, and to increase his fluid intake to help rehydrated his skin. Whilst working in Mombasa I struggled on a daily basis with the fact that people would save against the odds to get medical help only to find they could not afford the ongoing cost of treatment. The sheer numbers affected were daunting.

In the Diabetic clinic I became quite skilled at dressing foot ulcers with the limited supplies that were available. We had only Betadine-soaked gauze and bandages to work with. Broad strain antibiotics were available to use when necessary. They were prescribed if patients presented with signs of infection, for example if the skin was hot to touch, red, swollen, itchy or if yellow exudate was present. If the patient presented with a temperature and potential systemic infection, they would be brought in for intravenous antibiotic therapy and observation to prevent it from worsening and becoming life threatening. Once a wound was identified it was important to discuss its appropriate care with the patient. This became complex at times. Patients with very little money were unlikely to spend it on medications for foot care in favour of feeding themselves or their family. Even more so if their foot problem was currently manageable. As a result, great emphasis was placed on teaching the patient how to deal with wounds at home, so reducing the need for hospital visits. We taught the importance of boiling water to sterilise it, waiting for it to cool and then using it to cleanse the wound. Even these very basic measures were, however, very difficult for many patients to carry out at home. Much of the population lives in unsanitary slum conditions, frequently sharing a home with livestock. In the rainy season it is common for rubbish to be swept through peopleâ&#x20AC;&#x2122;s dwellings. The force of water running down the hills can even destroy peopleâ&#x20AC;&#x2122;s homes altogether. The aftermath of the rains is a warm, moist environment which is a breeding ground for bacteria. Around 20% of patients are immuno-suppressed. So what starts as a small graze, nick or cut can easily break down, becoming gangrenous within weeks. The saving grace for

Bomu patients suffering from HIV is that all their healthcare cost are covered by the assistance of programme partners, donors and USAID sponsored organisations like Family Health International (FHI), Pathfinders International and the International Centre of Reproductive Health (ICRH).

A large number of patients attended the Diabetic clinic for wound care treatment. Working within the clinic gave me an insight into what to expect when I am a qualified Podiatrist. I gained a great deal of hands-on experience at cleaning, irrigating, debriding and dressing wounds. I learned to asses each patient as an individual, taking into consideration their social and home back ground, and whether they were likely or able to comply with instructions. Individual care plans were created for each patient so the best possible results were obtained for them. The whole experience was extremely rewarding for me.

At the clinic I would see patients with many interesting conditions. Some I had prior knowledge of, but many others were new to me. I got accustomed to the sight of onychomycosis within the toe nails and fingernails. This was evident by the thickening of the nail plate and yellow discolouration. People often came wondering what this was and why it had occurred rather than complaining of pain or discomfort. Some patients presented with fevers from septic wounds. They frequently had pain and discomfort from lacerations caused by standing on sharp objects, jagged rocks or shells in the sea. Such injuries are more common in countries where the population cannot readily afford shoes. Patients were treated and sent home, with antibiotics if necessary, and with instructions on how to take their analgesia. Other patients presented with problems caused by ill fitting shoes. Many wore shoes donated from the Western World and

could not afford the luxury of properly fitting footwear. This encouraged onychauxis - thickening of the nail due to ill fitting shoes and toes becoming cramped and crowded as a result. Toe deformities such as claw toes or hammer toes, and blisters caused by friction, were also apparent among the patients I treated.

Even on our days off the work experience never stopped. John and Sammy, the volunteer co-ordinators, often gave up their Saturdays to help those who could not make it to hospitals or medical centres due to illness, poverty or the distance they were expected to travel. Through Sammy’s church community, parishioners and local people would volunteer their skills to help others. I was fortunate to be a part of this on many occasions and travelled with them. We often drove for more than four hours on dirt track roads (if we were lucky enough to have roads at all) to reach our destination.

We would set up See and Treat clinics in slum areas, treating patients with basic supplies donated by local business people, or bought with funds raised by the Church. Doctors and nurses listened to those requiring medical attention, made diagnoses accordingly and provided on-the-spot treatment. For those patients requiring further investigations, appointments would be made at local hospitals. HIV testing camps were frequently run alongside the See and Treat clinics. These tested people for HIV within slums and in schools and orphanages as part of the outreach programme.

Whilst working away at one of the See and Treat clinics I encountered a seven year old boy from the slums named Malambe Mwena. Malambe had been identified with walking problems from the age of 1 year when he was not achieving his usual milestones of growth and development. When all the other children his age were starting to walk, Malambe shuffled along on his bottom. Unable to weightbear, he mobilised and got around in a sort of ‘bum shuffling’ and dragging motion. Malambe’s parents saved and took him to a local doctor and his legs were bound up in plaster splints for two weeks. His family could not cope with the demand on their limited finances to assist him further, however. Medical treatment fell by the way side and Malambe did not receive the care he needed to improve his condition. He was left with severe mobility problems. Malambe could move around a tiny enclosure of 10m² with the assistance of a makeshift scooter that a local carpenter had made for him to use like a zimmer frame. This enabled Malambe to support his own weight and steady his balance. Due to the slum being at the bottom of a hill, and the surrounding terrain being unsafe for him, Malambe was restricted to this tiny area in which to live. Here he ate, slept, washed and looked after himself when his mother was working.

On examination and gait analysis, Malambe presented with his head cocked to the left when mobilising, his shoulders uneven, the left lower than the right. His arm swing was impossible to assess as he was holding onto his frame for stability. His

hips were uneven and he appeared to be hip hiking. Malambe’s bilateral knees were internally/medially rotated. His right foot had a considerable amount of foot drop at times and did not always clear the ground during the swing phase of the gait cycle. His stronger, left leg, although weak and deformed, was the one he used to weightbear. The sole of his left foot appeared supinated, adducted, plantar flexed and inverted. Malambe’s mother, Mambe Mwena, aged 20, had to leave her son alone from 8am to midday each day in search of work in order to buy food. His father, who was HIV positive and an alcoholic, was away from home from 8am to 8pm daily looking for work, and spent much of his earnings on alcohol. He frequently arrived home drunk and argumentative, with disputes that needed to be settled by the village chief as mediator. Mambe expressed a desire to leave her husband and become self sufficient. With the small amount of money that Mambe made from washing clothes, her diet and Malambe’s consisted mainly of maize, peas, beans and wheat. Malambe’s mother described him as a very intelligent, bright boy. She wished that he was able to walk, go to school, play with other children, and not be isolated.

Of all my experiences in Kenya, Malambe’s case touched me the most. Staff at Bomu are aware of his condition and will do all they can to equip him for his life ahead. Until I am qualified and can offer further help myself to Malambe and others like him, I intend to donate to Bomu regularly. Bomu relies on supporters like myself to reach out to those in desperate need.

I really enjoyed and appreciated my time in Kenya and feel I learnt a great deal on a professional and personal level that I will carry with me for a lifetime. At times, though, due to not yet being a fully qualified Podiatrist, I did feel I was not as helpful as I might otherwise have been. I do intend to go back once qualified, to offer further help to people who cannot afford treatment, and to assist them to achieve a better quality of life. If you have questions for Kathryn, or would like more information about donating to Bomu Hospital, email: kml94@aol.com

2 0 1 0 A. G. M.

Happy and Prosperous New Year is wished to all members by Nottingham Branch and also by your hosts of the 2010 Annual General Meeting, David Elliott and Stephen Gardiner, who are working to arrange a most enjoyable social and professional weekend.

For this year's annual conference and exhibition we will be in Nottingham in the heart of the East Midlands from the 7th – 9th May. Once again we have invited a faculty comprising esteemed speakers from the UK to provide introductory and plenary sessions for each day. A wide range of sessions are also planned for the three days and new for this year are workshops from invited Trade Houses. Members, who are attending the Conference for the first time, we are delighted and hope it surpasses your expectations and that you never before realised what a great educational event it actually is. So if any of you reading this have not been before, do get your booking in next year, as the Conference is an ideal place to enhance your knowledge and meet your colleagues.

In the November/December issue of the 'Podiatry Review' we gave a light-hearted approach to the Friday evening social events that have been arranged, and which we hope that you will wish to join, along with some details of the attractions of visiting Nottingham and Nottinghamshire. Most will realise that, in using a dedicated conference centre some twelve miles from the City centre, and although set in 26 acres of beautiful parkland, there was the need to provide on-site social activities as delegates who may have travelled some distance would not necessarily wish to travel further on that day and the Conference Centre Organiser has been most helpful in advising what has previously worked well for other professional bodies. This social evening will, of course, be open to our Trade Exhibitors whom we know are always sociable people and we hear that our President is considering awarding a prize to the most proficient archery team! In the next issue of Podiatry Review we will be profiling the lecturers and guest speakers.

We also viewed that you would like to read the professional profiles and experience of the lecturers and guest speaker that we have booked and these are set out opposite and overleaf:

Friday Afternoon

Professor Wesley Vernon, OBE BSc(hons), CHMS, DPodM, PhD, MSSF, MChS, FCPodM, FCPod Med, FFSSoc.

Professor Wesley Vernon OBE qualified as a podiatrist in 1980 and after a number of additional academic pursuits, gained a PhD for research in forensic podiatry. He is Head of Podiatry Services and Research Lead for Sheffield PCT and a visiting Professor at Staffordshire University. He has chaired and been a member of a number of national and international committees relevant to forensic practice, footwear, podiatry and research. In the forensic world, he currently chairs the committee for forensic podiatry within the International Association for Identification (IAI) and has previously been a Board Member of the Council for the Registration of Forensic Practitioners. He holds Fellowships of the Forensic Science Society and the separate Faculties of Management and Podiatric Medicine within the Society of Chiropodists and Podiatrists (SCP). He is a recipient of the Meritorious Award of the SCP and the Distinguished Membership Award of the IAI and in 2009 was the first person ever to achieve a 100% pass rate in the Society of Shoefitters entrance examination. He has published and presented his research work on forensic podiatry and on workforce and developmental aspects of podiatry nationally and internationally. He was awarded an OBE for services to medicine and healthcare in the Queens’ Birthday Honours list in June 2009. Prof Vernon’s lecture will focus on the possibility of forensic podiatry practice has been discussed for almost 90 years in podiatric literature, however it is only in the last 15 years that the speciality has finally become formally established. In 2006, forensic podiatry was formally recognised as a new forensic discipline in the UK by the Council for the Registration of Forensic Practitioners (CRFP) – a regulatory body aimed at promoting confidence in the practice of forensic science. Although the CRFP has now been superseded by new regulatory arrangements, this recognition paved the way for further recognition, particularly within the International Association for Identification (IAI) - the largest professional association in the world for those involved in human identification. Within the IAI, an international committee for forensic podiatry has been established and the role and scope of practice of the discipline has been tightly defined.

Forensic podiatry covers a number of areas of practice including identification from podiatry records, bare footprint identification, footwear identification and forensic gait analysis. A brief history and overview forensic podiatry work will be provided and illustrated by several real-life case studies in which forensic podiatry has played a role in criminal investigations.

Saturday Afternoon Maureen O’Donnell,

BSc(Hons) DPodM FChS FPodMed

Maureen has been involved in teaching undergraduate students and the delivery of postgraduate CPD courses to podiatrists since 1975. She was Programme Leader, Senior Lecturer of the BSc (Hons) Podiatry programme at Glasgow Caledonian University until September 2007. Her main areas of professional interest and expertise are clinical podiatry, medicine and dermatology. Through her work at Caledonian University she carried out Quality Assurance Surveys in podiatric practice for Health Boards and this and her knowledge of specialist subjects led to employment as an Expert Witness for individual Solicitors and the Scottish Legal Office. She is joint editor of, and contributor to, the Podiatry textbook Neale’s Disorders of the Foot.

Maureen recently left full time teaching and returned on a part time basis to work in Private Practice which is where she started her Podiatry career in 1967. Maureen’s lecture will focus on Medical Legal Issues and Expert witness reporting and will consider the cost of litigation to the National Health Service and to individual Podiatrists working in all areas of podiatric practice. The extent of the role of an expert witness and the sources from which information is obtained will give the practitioner an insight into the detail which is required to be reported by an expert witness. The main reasons for successful litigation against podiatrists and the procedures which should be adopted in practice, which will reduce the likelihood of successful litigation against the practitioner, will be highlighted. Individual case reports from litigation cases will be given. Dr. Menos Lagopoulos, MD PhD Comes to us from Hull York Medical School from the department of anatomy and developmental biology. He has been voted ‘best teacher' by students during audits on more than one occasion. His work has focused increasingly on improving and updating teaching methods, designing courses which reflect the move towards more active learning and thought processes in medical education.

Menos has written a range of study workbooks, in particular on the thorax, head and neck, and numerous clinical case scenarios which complement the teaching of anatomy. He has also designed and directed courses on understanding sports injuries. His research areas are peptic ulcer disease, sports injuries and trauma.

His lecture will be on the anatomy of the lower limb including the gluteal region, this will cover major muscle groups, their nerves and actions. 1. Major joints 2. Arteries and veins 3. Points of clinical importance like common fractures and dislocations, compartment syndrome, varicose veins.

After Dinner Guest Speaker Judith Barbaro-Brown,

MSc, PGDip, BSc(Hons), BA (Hons), PGCE, DPodM, MChS

Judith has been involved in the conception, design, and delivery of CPD courses to Podiatrists since 1999.

Her achievements include involvement with the Department of Health on the delivery of a bridging Programme aimed at grand-parented podiatrists, and the design and successful validation of the first standalone, HPC-approved, Local Analgesia Course. She has been a guest speaker and presenter at numerous Conferences and national events, and continues to present to professional groups, branches, and NHS Podiatry groups when invited. She also acts as a professional and educational advisor to a number of training providers throughout the UK. Judith recently took up a full-time position as Teaching Fellow at the University of Durham.

Sunday Morning

There will be an extra lecture for those who have asked for more CPD at the A.G.M.’s – Watch this space!

We do hope that in our first two articles carried in the 'Podiatry Review we have more fully informed of plans made, addressed slightly new departures from previous A.G.M.’s, and hope that you will wish to visit Nottingham and Nottinghamshire and to meet up with friends and colleagues once again at your Annual General Meeting and Conference.

In the March/April issue of the ‘Podiatry Review’ we will give the latest updates prior to the Conference. David Elliott and Stephen Gardiner

Institute of Chiropodists and Podiatrists 2010 Annual Conference & AGM th

Friday, 7 May 2010 12.00pm

Trade Exhibition Opens - Chatterley Suite

From 2.00pm

Arrival of Delegates

2.00pm

Refreshments in Trade Exhibition - Chatterley Suite

3.30pm

Lecture - Professor Wesley Vernon OBE - AForensic Podiatry@ - Lawrence Suite

4.30pm

Lecture - to be arranged

6.30pm

Drinks Reception in Trade Exhibition - Chatterley Suite

7.30pm

Barbeque & Medieval Evening with Games and Archery (Medieval Fancy Dress Optional) th

Saturday, 8 May 2010 9.00am

Trade Exhibition Opens - Chatterley Suite

9.30am

Opening of Conference - Lawrence Suite

9.45am

Concurrent Sessions Annual General Meeting Lawrence Suite

11.00am

Workshop 1

Workshop 2

Workshop 3

Refreshments in Trade Exhibition - Chatterley Suite

11.30am

Concurrent Sessions Annual General Meeting Lawrence Suite

Workshop 1

Workshop 2

Workshop 3

12.30pm

Lunch and Trade Exhibition - Restaurant

2.30pm

Lecture - Maureen O=Donnell - AExpert Witness and Medical legal@ Lawrence Suite

3.30pm

Refreshments in Trade Exhibition - Chatterley Suite

4.00pm

Lecture - Dr Menos Lagopoulos - ALower Limb anatomy and pathology of the foot@ Lawrence Suite

6.30pm

President=s Reception - Lawrence Suite

7.30pm

Annual Dinner and Dance - Lawrence Suite

Sunday, 9th May 2010 9.30am

Lecture - Dr Andrew Franklyn-Miller Royal Navy - AReducing Lower limb injury@ - Lawrence Suite

10.30am

Annual General Meeting - Lawrence Suite

11.00am

Refreshments - Chatterley Suite

10.15am

Annual General Meeting - Lawrence Suite

12.30pm

Lunch - Restaurant

2010 Conference

Includes:

Total Conference Rate

No. required

Cost

Tick

All lectures Friday, Saturday & Sunday, 2 nights’ accommodation in 4* Hotel, Lunch Sat & Sun, all refreshments, BBQ Friday night, Dinner dance Saturday night

£240

Friday Night Conference Rate

All lectures Friday & Saturday - 1 nights’ accommodation in 4* Hotel, Lunch Saturday, all refreshments, and BBQ Friday night

£125

Saturday Night Conference Rate

All lectures Saturday & Sunday - 1 nights’ accommodation in 4* Hotel, Lunch Saturday or Sunday, all refreshments, and Dinner Dance Saturday night

£125

Total Conference Day Delegate Rate

All lectures, Lunch Saturday and refreshments

£130

Day Rate Friday

All lectures and refreshments

£35

Day Rate Saturday

All lectures, Lunch and refreshments

£65

Day Rate Sunday

All lectures and refreshments

£35

! ! ! !

Friday Dinner

Barbeque Ticket

£15

Saturday Dinner

Dinner Dance Ticket

£30

! !

Total Conference Payment

£2.79 (per tube) + VAT RETAIL

£4.99

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Decontamination Standards

Warning to all Members… Publishing and Marketing Scams

Following enquiries from members regarding decontamination standards we would advise you that The Institute of Chiropodists and Podiatrists recommends decontamination by ultrasonic bath or washer disinfector and sterilising at 134 degrees centigrade using an autoclave. It is also recommended that a log of decontamination and sterilisation be kept.

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The majority of publishers are reputable and provide valuable services, however, a small minority will resort to dishonesty for illicit gains. Rogue ‘publishers’ can make huge sums of money by inducing large numbers of victims to pay for adverts in publications that either do not exist or are not what people are led to believe.

Rogue ‘publishers’ operate in grey areas of the law. They act in various ways with the same intent, to extract money from unsuspecting persons and can be quite convincing, sometimes claiming to be connected to a charity or other such worthy cause. Once a victim has received an invoice it is almost certain he/she will be pursued RELENTLESSLY for the money. Some victims pay up either because they get confused or because they are bombarded constantly and want to ‘get rid’. However, paying, only identifies the victim as an ‘easy target’ and it is likely (almost guaranteed) that they will be targeted again by the same ‘company’ operating under a different guise. If you find you are targeted please do not panic but do please telephone Head Office for advice. On no account pay for anything you have not asked for or cannot remember ordering. It may be wise to ask ALL telephone sales people to ‘put it in writing’ and then hang up the telephone. Do not get into lengthy, confusing conversations with sales people unless you have invited them to phone you.

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Continued ProfessionalDevelopment

Continuing Professional Development The Institute of Chiropodists and Podiatrists

Deep Vein Thrombosis

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

By Judith Barbaro-Brown, MSc BSc(Hons) PGCE, DPodM, MChS Thrombosis is the formation of a blood clot (thrombus) inside a blood vessel, obstructing the flow of blood. When there is damage to the endothelial lining of the vessel, the injury exposes collagen, which begins the process of platelet aggregation. During this process (and in subsequent events) fibrin becomes involved in the ‘plug’, and a clot is formed as the first step in repairing the damaged vessel (haemostasis) to prevent loss of blood. This is a normal, physiological process. However, if that mechanism causes excessive production of the clot, then that process becomes pathological.

When a thrombus occupies more than 75% of surface area of the lumen of the artery, blood flow is reduced enough to cause hypoxic symptoms and the accumulation of metabolic products. More than 90% of obstruction can result in anoxia, the complete deprivation of oxygen, and infarction, a mode of cell death. Thromboembolism is the term used to describe both thrombosis and its main complication, which is embolisation. Certain conditions within a blood vessel are necessary for the beginning of thrombus development. These are: 1. a change to the surface over which blood flows, i.e. the endothelium 2. a change in the dynamics of flow 3. a change in the constituency of the blood, it becomes hypercoaguable. Together, these three factors have become known as Virchow’s triad.

The first factor, changes to the endothelium, includes damage to the veins arising from shearing stress, or hypertension. The second factor, alterations in normal blood flow, refers to several situations. These include turbulence, stasis, mitral stenosis, and varicose veins.

The last category, alterations in the constitution of blood, has numerous possible risk factors such as hyperviscosity, deficiency of antithrombin III, nephrotic syndrome, changes after severe trauma or burns, disseminated cancer, late pregnancy and delivery, race, age, whether the patient is a smoker, and obesity. All of these risk factors cause a situation called hypercoaguability.

What is interesting about this model is that Rudolf Virchow himself did not actually propose it, and neither did he suggest the link in the pathogenesis of thrombosis. In reality it was some time following Virchow’s death before a consensus was reached proposing that thrombosis is the result of alterations in blood flow, vascular endothelial injury, or alterations in the constitution of the blood. Moreover, the eponym “Virchow’s triad” did not emerge in the literature until almost 150 years after his original work.

Deep vein thrombosis (DVT) is the formation of a thrombus in a deep vein, and has an annual incidence in developed countries of 1 in 1,0001. They almost all present in the leg or lower limb as there is a greater tendency to stasis in the lower limb veins.

The following are all risk factors for DVT: 1. surgery – particularly major abdominal or pelvic surgery, hip or knee replacement, and post-op intensive care 2. obstetrics – delayed pregnancy, caesarean section 3. lower limb fractures 4. malignancy – especially abdominal or pelvic disease 5. reduced mobility or stasis – hospitalisation, institutional care 6. sepsis

January/February10CPD

Continued ProfessionalDevelopment

7. dehydration

8. CV disease – congenital, congestive cardiac failure, hypertension 9. oestrogens – oral contraceptive pill, HRT

10. miscellaneous – previous history of DVT, COPD, neurological disability, thrombolytic disorders, long distance travel, obesity.

The main symptoms of DVT are swelling and pain in the limb, with discomfort on palpation and mobilisation. However, it’s worth noting that 25%-50% of DVT may have no symptoms (clinically silent). The main signs are an increase in skin temperature, erythema, and occasionally engorgement of superficial veins, with a mild fever. Unilateral lower limb swelling with a 1cm or greater increase in circumference compared to the opposite limb is observable. Previously, Homan’s sign (pain on passive dorsiflexion) was noted, but this test is to be discouraged due to the risk of precipitating a pulmonary embolism by dislodging the thrombosis2.

There are a number of differential diagnoses for lower limb DVT:

1. venous disorders – superficial thrombophlebitis, post-thrombotic syndrome, chronic venous insufficiency, venous obstruction 2. cellulitis – there may be infection present

January/February10CPD

3. Ruptured baker’s cyst – swelling and effusion behind the knee, with a history of recent trauma 4. Achilles tendon and calf muscle injury – recent history of injury 5. haematoma

6. lymphoedema.

It is possible to determine the risk of developing a DVT in patients with appropriate clinical signs and symptoms using a modified ‘Well’s Score’3. Wells score or criteria:

1. Active cancer (treatment within last 6 months or palliative)

2. Calf swelling greater than 3cm compared to other calf (measured 10cm below tibial tuberosity) 3. Swelling of collateral superficial veins (nonvaricose)

4. Pitting oedema (confined to symptomatic leg) 5. Swelling of entire leg

6. Localized pain along distribution of deep venous system

7. Paralysis, paresis, or recent cast immobilization of lower extremities

8. Recently bedridden for more than 3 days, or major surgery more than 2 months ago 9. Previous DVT or PE.

Continued ProfessionalDevelopment A positive response to 3 or more criteria suggest a high probability (75%) of DVT, 1-2 suggested a moderate probability (17%), and 0 suggests a low probability (3%).

Depending on the situation of the patient, further blood tests could be performed. Often these would include full blood count to check platelet count, urea and electrolytes to check renal function, and a clotting screen. A further test would be check D-dimer blood levels - this is a cross-linked fibrin degradation product and indicates thrombosis is occurring, and that the blood clot is being dissolved by plasmin. A low Ddimer level should prompt other possible diagnoses. Other investigations may include: Venography – this is seen as the gold standard investigation in this situation, but it is not used routinely due to its invasive nature – some patients are sensitive to the contrast agent, which can also be harmful to the kidneys. Venous ultrasound – this is considered the best noninvasive diagnostic test, with good sensitivity and specificity (97%) for femoral veins, although less so for tibial vessels. Impedance plethysmography – changes in electrical resistance are measured which indicate changes to blood volume, although it is not helpful in vessels below the knee.

Management Low molecular weight heparins – patients with a first episode of DVT should be anti-coagulated for 6 months, aiming for an international normalised ration (INR) of 2.54. LMW heparin is preferred to unfractioned heparin as it is considered to be as effective in preventing recurrent DVT and also in reducing both major haemorrhage during treatment and patient mortality. In the UK LMW heparin is the preferred anticoagulant during pregnancy or in patients who have contraindications to oral anticoagulants.

Warfarin – the common mode of treatment for a single episode of DVT below the knee is to give warfarin for 3 months, although this is reduced to 6 weeks if the patient is post-operative. Above the knee, warfarin for 6 months is preferred. For a recurrent DVT warfarin will usually be lifelong, and if a further DVT occurs during therapy, the dose is titrated to achieve an INR of 3.5 for at least 6 months.

Compression therapy – wearing graduated compression hosiery has been shown to reduce the risk of DVT, but they should be fitted and used correctly. Once a patient has been stabilised on warfarin within the appropriate INR, then the GP remains responsible for regular review. The patient should be aware of the many drugs which interact with warfarin, and the potential teratogenic effects during pregnancy in those of child-bearing age. Prophylaxis

The THRIFT5 guidelines classify prophylaxis according to the risk of the patient, and combine the use of anticoagulation with compression therapy. High risk

1. graduated elastic anti-embolism stockings

2. unfractioned heparin before any surgery, or LMW heparin, or adjusted doses warfarin – aiming for an INR 2-3 3. may require intermittent pneumatic compression. Moderate risk

1. graduated elastic anti-embolism stockings

2. unfractioned heparin before any surgery, or LMW heparin. Low risk

1. appropriate mobilisation.

References

1. Carter CJ (1996) Epidemiology of venous thromboembolism (in) Hullb ED, Pineo Gf (eds) Disorders of Thrombosis. Saunders. 159-174. 2. Tovey C (2003) Diagnosis, investigation, and management of deep vein thrombosis. BMJ. 326 1180-1184.

3. Scarvelis D, Wells P (2006). Diagnosis and treatment of deep-vein thrombosis. CMAJ 175 (9) 1087–92. http://www.cmaj.ca/cgi/content/full/175/9/1087 Free Full Text.

4. Haemostasis and Thrombosis task force (1998). Guidelines on oral anticoagulation. British Journal of Haematology. 101 374-387.

5. THRIFT (1992) BMJ 305 567-574.

January/February10CPD

The Institute of Chiropodists and Podiatrists Continued ProfessionalDevelopment

Training School, Sheffield

Membership of The Institute of Chiropodists and Podiatrists is open to chiropodists/podiatrists registered with the Health Professions Council Contact Head Office for details:

The Institute of Chiropodists and Podiatrists 27 Wright Street, Southport, Merseyside. PR9 0TL Telephone: 01704 546141 Email: secretary@iocp.org.uk

January/February10CPD

Personal Profile

Susan Charles, MInstCh.P, LCh

y career as a chiropodist started twelve years ago. Chiropody was the answer to ‘what shall I do now’. After working for eleven years in a hospital for the criminally insane I decided I didn’t want to do it anymore. Deciding to get as far away from the head as possible, I retrained as a chiropodist and I can honestly say it has been one of my better life decisions!

I qualified from the Scholl chiropody course in 1998, with the words of our tutor Jill ‘Don’t stop learning’ ringing in my ears and joined the Institute of Chiropodists and Podiatrists.

I have built up a busy domiciliary business, whilst also fitting in surgery work in different locations. I was a ‘Saturday girl’ for another very busy chiropodist for a few years. That gave me valuable experience which I was grateful for when I started as the resident chiropodist at Johnson’s the Cleaners. They were offering a service for all their employees and the retired staff that could access the site in Liverpool. It was a very busy and popular practise and I was sad to leave when the company relocated to three different sites which made it impossible to continue the service. Throughout this time I had heeded the advice from Jill and attended many CPD courses run through the Institute. I bit the bullet and embarked on the Diploma in Chiropodial Medicine (DChM) course worrying that home life and work commitments would drain me physically and mentally. I need not have worried as the modules were so well set out that they encouraged success. I achieved my licentiate in 2005 but by then the diploma was on hold until the HPC decided which way the qualifications needed to be a chiropodist, would go. Still wanting some more relevant knowledge based training I listened to the feedback from others that had taken the degree course offered by New College Durham and felt that I would give it a try. The first time I tried to enrol I hadn’t considered my work commitments as a lot of my patients want a certain time on a particular day and will book months in advance. Two I can think of will book for the coming year in January!!

Thus my diary was already full when I received the dates for my attendance in Durham. I contacted the college and deferred till the following year and blocked the week out in advance. Attending that week was a bit daunting. Any new environment plus not really knowing what was expected of you can worry the most confident of people. The tutors

though were very helpful and had obviously structured the course to make it easier. We had been given workbooks to study over the summer to prepare us for the quantitative statistical modules.

I will not lie it was very complicated but the help in that induction week allowed everything to fall into place. The hardest part for me was choosing three of the offered six modules to focus on for my qualification. I wanted to do five of the six modules! There is the opportunity to study them separately after completing the course if finances and time allow. I chose to push myself and get as many assignments done before Christmas when my motivation and commitment were strongest. I’m pleased as that worked for me. We have our main holiday in January so completing most of the work before Christmas was hard but allowed me to focus on the remaining assignments without panicking. February to June is not as long as you think when faced with deadlines, work and family. In retrospect the induction week was great fun, being part of an academic group was helpful, I found kicking ideas around with friends that I made on the course very helpful. Being part of an academic atmosphere helps with the process of getting back to studying and the remote access support system that the college employs are effective. Emailing your tutor gets a response faster than trying to arrange a mutually convenient time to meet and discuss an issue.

I feel that the degree course allows us as practitioners to expand our knowledge base into areas that we may not encounter on a daily basis and has given me the confidence to challenge myself and approach other areas of learning and study with renewed vigour. The second year is not mandatory and the college allows five years for students to complete. I have not made a decision one way or the other yet.

Very well Done Susan from all at the Institute.

Algeos Launches UK’s First Private Podiatrist Loyalty Program

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Algeos has developed this new to the UK in-house loyalty scheme – Arthurs Club - as a way to reward customer loyalty. As a thank you for choosing Algeos as your Podiatry supplier – customers will be rewarded each time they spend over £100 exclusive of VAT. Simply accrue Arthurs Club points and then redeem them for recognised high street and online vouchers. If you are not already an existing Algeos customer, simply start placing orders and add value to your purchases.

The scheme coincides with the launch of the brand new complete and comprehensive Algeos Podiatry Catalogue. The new easy-to-use Podiatry catalogue

details the extended podiatry range featuring essential new additions such as premium consumables, diagnostic devices and clinic equipment. The catalogue documents a commitment in seeking innovation and sourcing new products to offer more of a complete collection of high quality podiatry products for customers.

Products are listed and categorised into colour coded sections making product identification and selection simple. Each product is listed against its price to provide cost clarity for our customers. Algeos aim is to supply customers with innovative products from trusted brands at competitive prices. Please contact Algeos today for your free Podiatry Catalogue and see how they can make buying your podiatry goods that much more rewarding!

A Belated ank You for a Great Welcome in Glasgow

pon reading the first issue of Podiatry Review published after the Glasgow A.G.M. this year (July/August), I wondered why you hadn’t published a letter from me, thanking you for inviting me there and complimenting all concerned upon what probably was the most enjoyable A.G.M. yet! I was, as usual, warmly welcomed but my grandson, Richard, was absolutely spoilt (showered with sweets, 100 lollies, toys, a flag, pens, a cap, a badge and even money but best of all loads of cuddles) by your staff, delegates, visitors, committee members and also fellow exhibitors. I remember arriving home, lying in bed and mentally composing the letter but couldn’t remember actually typing or posting it. It crossed my mind that as there were so many complimentary letters from delegates and visitors in the Review perhaps my letter had been relegated to a later issue or hadn’t been chosen for publication, quite understandably as I’d been lucky enough to have my views published about 6 or 7 times before and you had published a photograph of Richard and myself with a prize he’d won. It wasn’t until the next issue of the Review arrived that I again wondered about that letter. I couldn’t remember exactly what I’d written to you so I

looked through my correspondence file, only to find that there was no copy there!

The penny was beginning to drop. I wondered if I had actually sent anything at all? Then my wife, who always reads my letters before I send them, not so kindly broached the subject of senility as she informed me that I hadn’t even written one, never mind sent it! So with much embarrassment, I would like, if allowed, to belatedly offer well deserved thanks and congratulations especially to the local members, but also of course to all the others concerned who made our visit so enjoyable. I really did intend to write earlier to compliment Alisdair, Jacquie and the rest of the organisers, especially the ladies who were so kind and hospitable to me and exceptionally so to my grandson, Richard Currie, who thoroughly enjoyed himself. Thank you very very much Des Currie Currie International Printing Co Durham 01207 505191

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SOUTHERN AREA COUNCIL The Institute of Chiropodists and Podiatrists

Spring 2010 Seminar Saturday 6th March 2010 10:00am-4:00pm at

Best Western Calcot Hotel, Reading, Berkshire

Day to Day Conservative Management of the patient with foot problems Our speaker for the day

Miss Emma Supple FCPodS, DPodM, PGDip (Pod)

This seminar is about going back to the basics of day-to-day foot care in general private practice, improving your skills and having a better clinical understanding of the conditions your patients present with Emma Supple is a highly respected Podiatrist and Podiatric Surgeon â&#x20AC;&#x201C; HPC Registered. Here are just some of her career highlights: l

l l l l

Graduated from Durham and went on to work full time for the NHS for many years:- Harlow, Westminster and Enfield. Gained Fellowship in Podiatric Surgery with Professor Tagoe at West Middlesex Hospital. Completed a threemonth Residency in Chicago with Dr Lowell Weil. Studied for a Post Graduate Certificate in Podiatry from Brighton.

Member of Council for three years and in that time organised two annual conferences. Awarded Fellowship of the College of Podiatric Medicine.

Currently in private practice in Enfield with an appointment to Chase Farm Hospital as Podiatric Surgeon within Orthopaedics. Sits on Health Profession Council Panel Hearings as a Podiatry Partner, Visitor and CPD Assessor

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

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

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

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

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

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

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

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

Please make cheques payable to IOCP Southern Area Council and send with booking form to: Ms G. Webster (SAC Education Officer) The Woodlands Clinic, 7d The Triangle, Clevedon North Somerset BS21 6NB For further information Tel 01275 342655 or email gillianwebster@backtofeet.co.uk

Are your nippers letting you down? You may not even realise it until you try the best! We are told the 2 key factors in a good nipper are: 1. Sharpness 2. Reliability We say: Both of these relate to quality of steel and quality of finish in manufacturing. Don͛t be deceived by some claims that ͚Made in Solingen͛ means both steel and instruments are made in Solingen. The house of Clauberg is a small family business in Solingen producing hand finished, quality instruments from Solingen steel. If you value quality instruments you will not be disappointed. If treated properly and professionally it is an investment that will last you for years. Until you try them you won͛t realise what you are missing.

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From sturdy general purpose nippers, finest ingrowing nippers, specialist diabetic nippers (Onychosoft) to robust cantilevers helping those with weaker wrists or hands. A small but exclusive range! Also available from the h Lau L fwunder range: SALq q ʹ gentle nail & skin softener - speeds up treatment time; Mykored ʹ nail & skin antifungal (pipette, spray, cream & oil); the Laufwunder range of creams ʹ moisturising, warming, cooling and the new Callus Reduction Cream.

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Devon and Cornwall Branch n 11th October 2009 Devon and Cornwall branch held their Lecture Day at Exeter Golf and Country Club. Gareth Hicks Managing Director Bailey Instruments Limited kindly “popped down” to see us to deliver two talks. The first was regarding Decontamination of instruments and equipment; something we all need to do on a daily basis , but a reminder on the techniques is always beneficial, e.g. all instruments should go through the process of cleaning and disinfection before sterilisation, de-ionised water should always be used in autoclaves. Gareth recommends the use of Endozine instead of Instol. There was mention of autoclave legislation, where we were made aware that there are no new regulations but merely recommendations.

The second talk was a presentation on Digital Splinting, the products that are on the market and their use, e.g. Digital silicone putty and how much hardener should be used. We had a “socks off and hands on” practice. The talks were interesting easy to follow and fun.

Thanks were expressed to Gareth Hicks for coming down all the way from Wales to Exeter to give his talk and to Maria Reay our secretary for organising it all. The afternoon was taken up with our branch meeting. Roger Henry, Devon and Cornwall Branch

Microbiology & Sterilisation Seminar Lecturer Mr John Patterson, MInstChP, BSc(Hons), MSc, DChM,

Expand your knowledge of bacteriology, virology and mycology and update your sterilisation skills.

Includes hands-on-session, micro-organism types, types of virus, social behaviour, the organisms, classification of bacteria, Diagnostic techniques, identify fungal infection, defensive organs of the body, how things get into cells, every infection is a race. Microbiology is the study of microscopic organisms, which are generally invisible to the naked eye, and their effects on the environment and mankind

There is now incontrovertible evidence that the only safe method of sterilising instruments and equipment is autoclaving.

The Institute of Chiropodists & Podiatrists Training Centre Sheffield On Saturday, 30th January 2010 Full Day Seminar - £85 Members and £105 Non Members Book early to reserve your place on 01704 546141

North West Area Council 12th Annual Seminar

he 12th Annual Seminar took place at a new venue this year – The University of Central Lancashire, Preston. The seminar was opened, as usual, by Mr. B. Massey, who also welcomed our guest Mr. S. Willey, Chairman of the Board of Ethics. Despite some technical difficulties resulting in a last minute room change the first lecture started only a few minutes late. Mrs. C. Fielding (a pharmacist), was introduced by the Chairman of the NWAC, Mr. B. Carter. Her lecture concerned drugs which have a direct effect on the feet, or particular relevance to podiatrists. After a short coffee break, Mr. S. Kelly spoke on the biomechanical changes resulting from diabetes, and the methods which can be used to relieve the resulting pressure areas. This was followed by a lunch break, where we were served an excellent two course lunch, after which there was time to visit the trade stands. At 1.30 pm we were back in the lecture room for Mr. N. Emms’ lecture on orthopaedic surgery and its possible Michelle Allison with fourth problems. The final lecture of the day was presented by speaker Mr. P. Bowsfield a returning speaker, Mr. P. Bowsfield, a Consultant Gynaecologist. His subject on this occasion was the development of the lower limbs. The prize draw this year was for £100, and was won by Philomena Grieve, of Western branch. We try hard to present an informative seminar in good surroundings, and hopefully with good food. Judging by the content of this year’s feedback slips, we have come very close to pleasing ‘all of the people’ on all those criteria. I thought that I had travelled a fair distance to attend the seminar, but there were some who had travelled much further. One of our members, Miss Nicole Nanton, had travelled from Trinidad and Tobago, to attend. Fortunately having come so far she was overjoyed with the whole experience, not just the lectures, but the chance to speak to other Institute Members, as well as the traders on the trade stands. For those who didn’t attend, you missed an excellent day and significant CPD, at our usual reasonable cost.

Left: Michelle Allison with 1st speaker Mrs. C. Fielding Below: Barry Carter with second speaker Mr. S. kelley

North West Council Members

Left: Trade Stand Right: Mrs. Nicola Manton, member from Trinidad and Tobago

Malcolm Holmes, Western Branch Dear Editor, I attended the North West Area Council’s Annual Seminar yesterday at the new venue of Preston. Although it was a little further than Salford for me to travel I have to say what an excellent choice it was! The accommodation and the lunch were of a very high standard and the lectures were excellent. Mrs. Fielding’s presentation on Pharmacy was very informative and was displayed in a way that we could all understand. The handouts

Top: Trade Stand

supplied were excellent. We had blood thirsty slides of diabetic ulcers, presented by Mr. Kelly, to put us off our lunch! Again a very interesting lecture. The afternoon session consisted of fantastic lectures by consultant Mr. Emms, where we hammered and glued our way through hip replacements, finishing with recently retired consultant, Mr. Bousfield, imagining our body as a meat paste sandwich in the first fourteen days after conception… BRILLIANT!!!!

Having organised the first four of these seminars years ago, with my old friend, Bryan Massey, I do realise how much work goes into such events, so I really do appreciate the vast amount of work and planning that takes place and would like to thank the North West Area Council for all their efforts and congratulate them on an excellent, informative seminar. Helen Lloyd, Western Branch

Midland Area Council Seminar The MAC seminar on dermatology was held on 10th October at the Hilton Hotel, Leicester. The meeting was opened by Bill Liggins, Chairman of the Board of Education. Also present was our President, Heather Bailey, plus members from across the UK. The day was conducted by Judith Barbaro-Brown in her inimitable style which involved an interesting mix of lectures and practical sessions – including a dermatological “bingo”. As well as being fun it was very informative and I am sure all present enjoyed it immensely as well as learning from it. Our thanks to Judith David Elliott, HonF.Inst.Ch.P

Nottingham Branch

Up Up and Away A

fter some 12 months of waiting, my wife Melanie was finally able to take to the air in a hot air balloon on 30 August 2009.

This was her choice of an award for long service which was presented to her at a formal dinner that we attended at Burton Albion’s new luxurious Pirelli Stadium! This stadium was built thanks to the ‘Albion’ playing Manchester United to a draw at home and having a replay at Old Trafford, the gate money from which, has helped to secure the future of our local team. Although I am not a football fan – I detest the game actually - I have to give credit where it is due and wish them well.

Any way back to the plot… After helping to lay out and inflate the balloon, Melanie and her sister in law finally took to the sky from Bakewell with 14 other people at about 8 am into a lovely clear sky. The Balloon took off more rapidly than I expected and soon vanished into the distance, through some low cloud, which they passed above, but when they came through there were many sights to behold. They flew low over Chatsworth and the surrounding area and arrived back at the take off point by coach about 2 hours later. Melanie’s brother and I stayed firmly on the ground, in fact we went for breakfast after they had gone, and a little shopping at the local boot market.

David Elliott, HonF.Inst.Ch.P, Nottingham Branch

The Institute of Chiropodists and Podiatrists

Leeds and Bradford Branch Seminar Saturday 6th March 2010

University of Huddersfield Cost £70.00

to include FOUR CPD Lectures Lunch, Tea/Coffee and biscuits

PROGRAMME

9:00 a.m.

Registration

9:30

Lecture: “Bi-Lateral Oedema, DVT, Phlebitis” Miss Liza Dunkley Senior Lecturer/Huddersfield

9:25

10:30 11:00

12:00 noon 1:30 p.m. 2:30 3:00 4:00

Introduction

Coffee trade stands

Lecture: “Pharmacology” Martin Harvey PGCert BSc(Hons) MInstChP - Podiatrist Prescriber Buffet Lunch and Trade Show

Lecture: Rheumatology and the Foot Judith Barbaro -Brown MSc BSc(Hons) PGCE, DpodM, MChS Tea/Coffee Break

Lecture: Nail Avulsion and Bunion Surgery Mr. Jim Pickard. Consultant Podiatrist Finish and collection of CPD Certificates

If you wish to attend, please complete the booking form below as soon as possible, enclosing a cheque for £70 (this includes coffee and lunch) to IOCP Leeds Branch, and send to Mr. T. M. Hogarth, 3 St. Peters Crescent, Norton, Malton, N. Yorkshire, YO17 9AN.

The seminar is open to Chiropodists from all organisations, all will be made very welcome. If you require more details call, Martin Hogarth on 01653 697389. Booking Form: Name (BLOCK CAPITALS)

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

Branch ........................................................................................................................................................................................... Telephone No..........................................................................................

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

Continuing Professional Development 2010

Continuing Professional Development BOOKING FOR M

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

Name: ..................................................................................................................................................................................... Address:...................................................................................................................................................................................... ............................................................................................................................................... Tel No: .............................................................................. Seminar

Branch/Organisation: Date

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

............................................................ Venue

Cost

Microbiology & Sterilisation

Saturday, 30th January 2010

Sheffield

LCN Wilde-Pedique Seminar

Wednesday, 10th February 2010

Sheffield

Podiatric Dermatology

Saturday, 27th February 2010

Sheffield

Vascular & Neurological Assessment

Saturday, 20th March 2010

Sheffield

Laser Therapy

Saturday, 17th April 2010

Sheffield

Verrucae Treatments

Saturday, 29th May 2010

Sheffield

Skeletal & Muscular Systems

Saturday, 19th June 2010

Sheffield

TOTAL

PAYMENT BY CREDIT CARD Please debit my VISA / MASTER CARD (Delete as applicable) with £............................................ as payment for the above. Card Number: Expiry Date of Card:

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

Security Number:

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

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

Cardholder’s Name:

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

Cardholder’s Signature:

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

Cardholder’s Address:

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

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

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

Assistive Technologies Issue 60, It is intended that this new column by Achilles Hele, will August/September 2009, notes that a become a regular feature of Podiatry Review. Whilst Achilles former Olympic swimming champion Marc Woods has retired from competitive does indeed have a habit of wandering through a multitude sport and has turned his attention to of journals, any additional material is always welcome and mountain climbing instead. His should be sent to Institute H.Q. for the attention of Mrs. current plans include an attempt on Everest in 2012. He is Bet Willey. Achilles is, and will remain, anonymous. lecturing in schools about sports and climbing in It is reported in Clinical Discovery. Vol 4.5 October 2009 that a Scottish trial has particular and hopes to give found that although the effect of antiplatelet drugs such as aspirin is well proven 3 young people the opportunity in individuals suffering from a history of arterial disease, the results of use to climb on Everest with him. healthy individuals are equivocal. Professor Gerry Fowkes from the Wolfson Very laudable you may say, but Unit for Prevention of Peripheral Vascular Diseases in Edinburgh, used not particularly remarkable. Well, Ankle/Brachial pressure screening to arrive at 3,350 relatively high risk it is, because Marc lost his left leg subjects from a total of 28,980. The participants were randomly allocated to when he was 17 years old. He is either once daily 100mg aspirin or placebo groups. Follow-up was a mean currently working with Bob Watts 8.2 years. There was no statistically significant difference between the at Dorset Orthopaedics and they groups at the end of the trial. The British Heart Foundation advise that have devised a foot which offers people who do not suffer from symptomatic arterial or cardiac disease flexion and extension at the ankle should not take aspirin because the risks of bleeding may outweigh the potential benefits. joint. He still has problems with the socket of his prosthesis because the silicone lining is not breathable and becomes hot. Any ideas? Achilles is avowedly non-political but was amused to note in a leader in The Economist that some politicians in the U.S.A. who oppose President Obama’s intent to introduce a type of free-at-point-of-delivery healthcare in the United States have resorted to “…a diet of ludicrous untruths”. A trial by Paul, Ahmad, Lee, Ariff, Amongst these ‘untruths’ is that of the astrophysicist Stephen Hawking Saranum, Naicker and Osman would have been abandoned to die of his motor neurone disease had he reported in the International Wound been unfortunate enough to live in Britain. He does, of course, he is Journal, Volume 6.1 of February 2009 British, is a Professor at Cambridge University and on receiving the looked at the effect of larval therapy Congressional Medal of Honour stated that were it not for the NHS he using the larvae of Lucilia caprinaor the would have been dead! tropical blow fly maggot rather than Lucilia sericata or it's temperate cousin. The research compared conventional New Scientist 22nd August 2009 reports that The drug company (surgical) debridement against the effects of Vaxinnate, are investigating the possibility of producing a the maggot therapy over a group of 29 universal 'flu vaccine. The difficulty is that current vaccines patients. There was no significant difference target the haemagglutinin protein which is located on the noted in the results of wound healing. prominences on the outer portion of the 'shell' of the virus. However, the authors' make the point that the These proteins are able to rapidly mutate, with the result treatment would be a feasible alternative to that our immunological 'memory' will not protect us surgical debridement where this might be from the new evolving strains. If a vaccine can impossible or undesirable. be discovered which acts on the M2 ion channels located lower down on the shell it may well protect The naked mole rat, is to our eyes, not the most beautiful against mutations as the creature in the world. However, it possesses the remarkable M2 channels change ability to never to succumb to cancer. Research carried out by little. Seluanov and Gorbunova at Rochester University in New York Achilles Hele reported in New Scientist 19th September 2009 has found that skin cells did start to proliferate but stopped at a relatively low intensity. This was controlled by two genes, p16 and p27, whilst in humans it is controlled by p27 only. If this check to tumour progression can be duplicated in humans, it could halt the growth of cancerous tumours.

MBLIN

A DS

The same journal carries the unexpectedly good news that many people may carry unexpected immunity to swine ’flu. A seasonal virus of the same ‘family’ as H1N1 has been circulating since 1977 but it had been thought that it did not provide immunity to swine ’flu. The expert virologists therefore believed that two doses of vaccine would have to be provided to each person. However, Novartis and CSL, both of whom have produced a an experimental vaccine have reported that early trial results indicate that nearly 300 adults developed antibodies after just one dose. This suggests that seasonal 'flu vaccine may boost the antibodies. A good reason to get yours this year!

For those members intending to embark on research projects, the UK Research Integrity Office - an independent advisory body hosted by Universities UK and supported by the major health regulators and funders of biomedical research - has issued an online code of practice. It is reported in Clinical Discovery. Vol 4.5 October 2009 that this can be found in pdf format at http://www.ukrio.org.uk

CPD for Podiatrists

and Chiropodists BOOK ONLINE: WWW.MKUPDATE.CO.UK or call: 01768 773030 Diabetic Foot Health

Blood Tests for Podiatrists

1 day – 8 hours £131.10 per place Manchester: 29 March 2010

1 day – 8 hours £131.10 per place London: 25 March 2010, Manchester: 25 June 2010

Aims/outcomes To identify the causes, prevention and treatment of Diabetic Foot Disease

Aims/outcomes Routine full blood count and biochemistry results Clinical implications of results Course content: Overview of: haematology & biochemistry Full blood count (FBC); low, normal, high Hb, thrombosis and haemorrhage Differential white count Systemic infection and its effect on blood results Musculo-skeletal disorders and inflammatory Response Calcium and bone, autoimmune disease Practical aspects of interpreting results

Course content: Understanding the pathophysiology and anatomy Neurovascular complications and assessment techniques Diagnostic therapies Management of infection and ulceration The Charcot Foot Painful diabetic neuropathy Legal and professional considerations

Foot X-ray Interpretation for Podiatrists

IRMER Theory Training 1/2 day – 6 hours £78.20 per place London: 19 May 2010, Manchester: 26 May 2010

1 day – 8 hours £131.10 per place Manchester: 10 February 2010, London: 28 April 2010 Aims/outcomes To provide theoretical underpinning for a range of commonly encountered conditions and injuries To strengthen consultation skills and X-ray interpretation

Aims/outcomes The IRMER regulations state no practitioner or operator shall carry out a medical exposure or any practical aspect without having been adequately trained. The regulations define adequate training as that training which satisfies the syllabus set out in Schedule 2 of IRMER. A certificate of theoretical training is provided.

Course content: Normal and abnormal appearances of bone, soft tissues and joints on X-rays Assessment and indications for x-ray X-ray referral and IRMER regulations Common X-ray requests including: osteomyelitis, calcified blood vessels, charcot joint Podiatry weight bearing views: including: true lateral of the hallux, axial for sesamoids Lower limb injuries X-ray interpretation workshop Legal and professional responsibility

Course content: IRMER regulations Biological effects of radiation, risks and benefits Patient management, dose and its’ measurement Responsibilities of key personnel in the context of the regulations Duties and responsibilities of the employer, operator Practitioner and medical physics expert in the context of the regulations Justification, authorisation and optimisation of X-ray exposures Requirements of quality assurance systems Medico-legal considerations, accurate record keeping and clinical audit

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A Guide to Research for Podiatrists ISBN: 978-1-905539-41-3 Professor Jackie Campbell, School of Health, University of Northampton M&K Publishing / October 2007 120pp / Illustrated £21.00

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

Chiropody Supplies

BUSINESS CARDS printed 1 side: 1,000 = £40, 10,000 = £96. Appointment Cards printed two sides: 10,000 = £99. Record Cards, Continuations, Sleeves all 8” x 5” x 1,000 = £59. Small Receipts: 2,000 = £48, 4,000 = £68. Des Currie: 01207 505191. BERGMAN UK – For all your Orthotic Requirements 28 High Street Northallerton, North Yorks DL7 8EE. Telephone: 01609 781397 or 07877 986605.

Systagenix Announces Formation of New Global Medical Advisory Board to Support Future Clinical Advances in Wound Care

Systagenix Wound Management has announced the formation of a new global Medical Advisory Board, consisting of a group of multidisciplinary and highly respected wound care clinicians and practitioners from North America and Europe, which will be led by Systagenix’s newly appointed Medical Director, Dr Robert Snyder. Representing major specialist organisations and thought leaders in the wound care field, the Systagenix Medical Advisory Board will meet at specific intervals to provide feedback, input and guidance on company clinical and commercial strategies and their implementation. The group represents a broad section of the wound care clinical community with multi-disciplinary backgrounds, including academic and health economic experts, practicing surgeons, and nurse specialists. As well as advising Systagenix regarding their existing portfolio, they will focus on new and emerging technologies as well as future clinical trends within wound care. They will also advise on other critical issues, such as health economics and reimbursement in order to help Systagenix meet the changing needs of the global wound care market. In addition to clinical and new product development, working with Dr Snyder, the Systagenix Medical Advisory Board will also focus on education, including new pathways to help reach and communicate with fellow healthcare professionals on the best and most up-to-date wound care practices. Systagenix was formed by a management buyout of the Johnson & Johnson Professional Wound Care business which had a 75 year heritage. Systagenix has very clear objectives to become the world’s strongest and most admired wound care company. The new Medical Advisory Board is designed to help the company meet those objectives by better understanding the needs of the clinician and their patients. Systagenix’s CEO, Steve Atkinson comments: “Education, innovation and forward thinking are crucial in the constantly changing and evolving wound care field. We are delighted to welcome such a prestigious panel of experts under the renowned guidance of Dr Snyder, all of whom will help us define and refine our thinking for future clinical, educational and technological developments.” Dr Snyder adds: “With such a varied and experienced panel of experts, we are bound to create new and exciting opportunities to forge ahead with innovation which is specifically aimed at meeting clinician and patient needs around the world. I am delighted that the Systagenix Medical Advisory Board has been formed and I look forward to working with the group as we seek to pioneer new ideas and techniques in wound care across a number of key areas”. For more information on SILVERCEL*Non-Adherent dressing please contact your local Systagenix Wound Management representative or visit www.systagenix.com

AMBER CHIROPODY SUPPLIES

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

* Domiciliary * Sterilization * Diagnostics * Retail Products

To view our website/online store please visit:

Classified Advertisements www.ambersupplies.co.uk

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

Trade Classified Advertisements Eighth page (minimum) £85.00 + VAT.

The closing date for receipt of Classified Advertisements is the 1st day of the month preceding publication i.e. Jan-Feb issue - 1st Dec.

All Classified Advertisements must be prepaid and sent to:-

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

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Diary of Events January 2010

Southport Study Group

Birmingham Branch A.G.M. 14th January at 7.30 p.m. The Red Cross Centre, Avon Street, Evesham Tel: 01905 454116

Bradford Branch A.G.M. Sunday 10th January 23 Haworth Road, Bradford BD9 5PB Tel: 01274 546424

Cheshire North Wales A.G.M. 17th January at 10.00 a.m. Dene Hotel, Chester – Presentation: To be arranged Autoclave Servicing will be available Tel: 0151 327 6113

Hants and Dorset Branch A.G.M. 25th January at 7.45 p.m. Crossfield Hall, Broadwater Road, Rosmsey Tel: 01202 425568

Leeds Branch A.G.M. Sunday 10th January at 10.00 a.m. Anne Kingsmith’s House (Please phone for details) Tel: 01653 697389

Leicester and Northants Branch A.G.M. 10th January at 9.45 Lutterworth Cricket Club

Tel: 01530 469816

London Branch A.G.M. 20th January at 7.30 p.m. Victory Services Club, 63-67 Seymour St. Marble Arch Tel: 01895 252361

Midland Area Council A.G.M. Sunday 31st January 10.00 a.m. Kilsby Village Hall Tel: 01865 434756

Meeting 31st January at The Royal Clifton Hotel, Southport PR8 1RB. There will be a CPD lecture and trade support from Mobilis-Rolyan

Surrey and Berkshire Branch 10.00 a.m. Emergency Aid in Workplace A.G.M. 9th January at 1.30 p.m. Greyfriars Centre, Reading Tel: 01252 514273

Sussex Branch 9th January at 9.00 a.m. A.G.M. Buffet lunch and lectures - Would Care by Barbara Wall, The Bent Arms, High Street Lindfield, RH16 2HP Tel: 01730 812377

Teeside Branch A.G.M. Sunday 31st January at 2.00 p.m. The Meeting Room, Dolphin Centre, Darlington

West of Scotland Branch Scottish Area A.G.M. 24th January at 10.30 a.m. Followed by the West of Scotland Branch A.G.M. Express by Holiday Inn, Springkerse Business Park, Stirling, FK7 7XH Tel: 01796 473705

West Middlesex Branch A.G.M. Wednesday 13th 8.00 p.m. - 10.00 p.m. Kenton Methodist Church, Woodgrange Avenue, HA3 0XF Tel: 0208 903 6544

Western Branch A.G.M. 10th January 12.15 p.m. - 3.00 p.m. Lecture Room, Liverpool Women’s Hospital, Crown Street, Liverpool Tel: 01745 331827

Wolverhampton Branch A.G.M. 10th January at 10.000 a.m. 4 Selmans Parade, Selmans Hill, Bloxwich, Walsall Tel: 01902 332847

February 2010

Nottingham Branch A.G.M.

Head Office

Sunday 17th January 10.00 a.m. The Red Cross Centre, Nottingham Tel: 0115 932 8832

Executive Committee Meeting 13th/14th February 27 Wright Street, Southport Tel: 01704 546141

Sheffield Branch

Leeds/Bradford Branches

Meeting and A.G.M. 21st January 7.30 p.m. Lecture: “Hands on” Diabetic testing by Philip Walker SWK Sports and Social Club, Sheffield Tel: 01623 452711

Southern Area Council Meeting and A.G.M. 23rd January at 1.00 p.m. The Victory Services Club, 63-69 Seymour Street, London W2 2HF Tel: 01992 589063

7th February at 10.00 a.m. The Oakwell Motel, Birstall, York Nr. Leeds, WF17 9HD Tel: 01274 546424 or 01653697389

March 2010 Leeds/Bradford Branches 6th March Full Day Seminar – Huddersfield University HD1 3DH Tel: 01274 546424 or 01653697389

Devon and Cornwall Branch

Nottingham Branch Meeting

A.G.M. plus Lecture on Diabetes - 24th January Tel: 01805 603297

Wednesday 24th March The Red Cross Centre, Nottingham Tel: 0115 932 8832

28 SEPTEMBER 2009

SOLE WINS BEST FOOTWEAR AWARD AT THE FIRST EVER OTS NOVEL INNOVATIONS AWARDS A pioneer of technologically advanced and stylish orthopaedic footwear, SOLE is proud to announce that their Platinum Sport Flip has won the Novel Innovations Award for Footwear, at the Outdoor Trade Show (OTS). The OTS Novel Innovations Awards recognise outstanding product innovation and technology and are judged by some of the most recognized journalists, retailers and outdoor personalities in the industry. Judging criteria included: innovation, functionality, workmanship, ergonomics, choice of materials, utility value, environmental friendliness and safety. “We are thrilled that SOLE has won the Novel Award for footwear innovation. It’s an honour that outdoor industry leaders have recognised the performance enhancing benefits, and distinctive shape, that makes the SOLE Platinum Flips so uniquely effective.” Kris Harley, SOLE UK General Manager and Sales Director

Launched in Canada eight years ago, SOLE specialises in creating custom-moldable footbeds designed to bridge the gap between a massproduced shoe and an individual’s unique foot shape, for superior fit, comfort and performance.

Recognising that flip-flops are a popular choice of footwear for many individuals, yet notoriously bad for you, SOLE set about creating a new design of flip-flop that incorporated the advanced Custom Footbed technology and created the Platinum Sport Flip. Supporting the foot in a neutral position, the SOLE Sport Flip top layer moulds to Press Release Crocs™ Medical Rx: Healthy footwear for diabetic and arthritis patients Crocs™ Medical Rx is the new range of healthy comfort footwear, from the popular brand Crocs™, which has been specifically designed for the diabetic and arthritic foot and will be sold exclusively via medical distribution channels like pharmacies, foot specialists and podiatrists. In a similar style to the bestselling Cayman, the Crocs™ Medical Rx range helps to ease painful foot complaints which often affect sufferers of diabetics and arthritis. The Crocs™ Medical Rx range are made using the unique Croslite Ag+™ material which includes a concentration of silver crystals that is naturally antibacterial, effectively killing harmful strains of bacteria and fungi which are routinely at issue with foot infections. The American Podiatric Medical Association (APMA) has awarded Crocs™ Rx its Seal of Acceptance with many doctors recommending the footwear to their patients. Medical reasons to have them: F Wide sole increases the stability of each step F Proven to resist mildew and various fungi including athlete’s foot fungus F Roomy forefront and soft toe box, reducing pinch injuries and bunions F Passive retaining heel strap reduces load and fatigue while walking F Ventilation holes reduce temperature in shoe and keep feet cool. Alternatively they can be worn with socks to keep feet warm Effective immediately, the Crocs Medical Rx™ product range will be more widely distributed throughout the UK. Leading podiatric distribution company DLT Chiropody Ltd, now too trades the medical division of Crocs called Crocs™ Medical Rx.

give each foot a perfect, custom fit, thus encouraging neutral alignment and balance to promote the wearer’s natural gait and shock absorbing ability. Podiatrist approved, the award winning Platinum Sport Flip combines performance-enhancing features and design to offer orthopaedic support with the right blend of cushioning, flexibility and comfort. “Sport Flips are great not only for preventative foot care, but for actively healing such ailments as plantar fasciitis, due to the supportive shape of the top layer and midsole,” explains SOLE’s resident designer, Rob Nathan. “I’ve personally worn them for 12 hours straight, standing on cement floors, and had no foot pain.” Already worn by a growing legion of loyal customers, from worldclass athletes and professional teams to the military and boardroom professionals, all of whom testify to the performance enhancing benefits of these remarkable footbeds and sandals, SOLE is trusted by medical professionals and their products have been awarded the APMA Seal of Acceptance. To find out more about SOLE UK or to place an order, please contact Kris Harley on 0845 644 3742 or email sales@yoursole.co.uk For further press information contact Entice Communications on 0208 959 3656 or email charlotte.a@enticecommunications.com As DLT Chiropody Ltd, has a long standing reputation for producing and distributing quality equipment, and supplies for the podiatry professional, the Crocs Medical Rx™ product range is an ideal product line extension for the company. The Crocs™ Medical Rx range consists of the “Relief”, “Silver Fox”, “Silver Cloud II” and the “Custom Cloud” which are a fashionable yet a comfortable alternative for suffering feet. Besides footwear Crocs™ Rx also offers “Orthocloud Socks” with a double cushion and compression band and “Silver Soft Insoles”. The most recent addition to the range is the Custom Cloud, SRP £67,95, which is impregnated with silver and offers foot professionals a customisable platform to suit differing foot forms and the needs of the wearer. Suitable for use as a semi-orthopaedic shoe for people with a variety of foot problems as well as for diabetics with mild neuropathy, the Custom Cloud provides extra depth and has front and back straps for extra support. The shoe features closed side vents and comes complete with a sliver insole. Alternatively the Custom Cloud is available as a kit that includes one pair of silver insoles and three heat mouldable inserts by Orthofeet, SRP £95,95. When heated, with either a heat gun or an oven, the Thermofit insoles can be easily moulded directly to the foot, and will maintain the shape to create a full contact foot bed. Also, the Orthofeet insoles can Custom Cloud be further adapted and customized by a specialist for extra support. The Croslite Ag+™ is utilised throughout the whole construction of the Custom Cloud making it fully antibacterial and odour resistant. The silver particles offer a protection against harmful bacteria and fungi which are common in foot infections. Laboratory tests show a 90+% kill rate on harmful bacteria and fungi. The Custom Cloud is approved by the APMA, AAPPM and US ergonomics. The Crocs™ Medical Rx range will be on display for chiropodists & podiatrists at the Crocs™ Medical Rx booth 1, November 19-21 at the Harrogate International Centre.

Silver Fox

Relief

Silver Soft Insoles

For more information on the Crocs™ Rx range and you can visit www.crocsrx.eu

ELSEVIER ELSE VIER presents pr esents

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01704 546 141

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National Officers

Branch Secretaries

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

Birmingham

Mrs. J. Cowley

01905 454116

Bradford

Mrs. S. Keighley

01274 546424

Cheshire North Wales

Mrs. D. Willis

01510327 6113

Devon & Cornwall

Mrs. M. Reay

01805 603297

East Anglia

Mrs. S. Bennett

01223 881170

Essex

Mrs. B. Wright

01702460890

Hants and Dorset

Mrs. J. Doble

01202 425568

Kent

Mrs. C. Hughes

01303 269186

Leeds

Mr. M. Hogarth

01653 697389

Leicester & Northants

Mrs. R. Rose

01582 668586

London

Mrs. L. Towson-Rodriguez 01895 252361

North East

Mrs. E. Barwick

0191 490 1234

North of Scotland

Mrs. S. Gray

01382 532247

North West

Mrs. C. Hughes

0161 748 7569

Northern Ireland

Mrs. C. Johnston

02893 340589

Nottingham

Mr. S. Gardiner

0115 932 8832

Oxford

Mrs. V. Howells

01865 248139

Republic of Ireland

Mr. R. Sullivan

00353 5856 059

Sheffield

Mrs. D. Straw

01623 452711

Chairman Executive Committee Mr. R. Beattie Hon. F.Inst.Ch.P Vice-Chairman Executive Committee Mr. D. A. Crew OstJ, F.Inst.Ch.P., DCh.M Chairman Board of Ethics Mr. S. Willey M.Inst.Ch.P., L.Ch. Chairman Board of Education Mr. W. J. Liggins F.Inst.Ch.P., F.Pod.A., B.Sc(Hons) Vice-Chairman Board of Education Mr. J. W. Patterson B.Sc(Hons)., M.Sc., M.Inst.Ch.P Honorary Treasurer Mr. R. H. Henry F.Inst.Ch.P., D.Ch.M

Standing Orders Committee Mr. C. B. Goldman M.Inst.Ch.P., D.Ch.M Mrs. L. Pearson M.Inst.Ch.P

Secretary Miss A. J. Burnett-Hurst

Area Council Executive Delegates Irish Area Council Mrs. C. A. E. Johnston M.Inst.Ch.P Midland Area Council Mr. D. Elliott Hon.F.Inst.Ch.P North West Area Council Mr. M. J. Holmes M.Inst.ChP., D.Ch.M, B.Sc.Pod Scottish Area Council Mrs. A. Yorke M.Inst.Ch.P Southern Area Council Mrs. M. Newnham. M.Inst.Ch.P Yorkshire Area Council Mr. N. Hodge M.Inst.Ch.P., L.Ch., H.Ch.D

Sth Wales & Monmouth Mrs. J. Nute

02920 331 927

Surrey and Berkshire

Mrs. J. Hornby

01252 514273

Sussex

Mrs. C. Page

01730 812377

Teesside

Mr. J. Olivier

01287 639042

Western

Mrs. L. Pearson

01745 331827

West Middlesex

Mrs. H. Tyrrell

0208 903 6544

West of Scotland

Mrs. J. Drane

01796 473705

Wolverhampton

Mrs. V. Davies

01902 332847

Yorkshire Library

Mrs. J. Flatt

01909 774989

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The new Canonbury Footcare Supplies & Surgery Equipment 2010 Catalogue is here. Our largest ever catalogue combines Consumable and Surgery Equipment ranges to provide you with a one-stop-shop for all your practice requirements. If you havenâ&#x20AC;&#x2122;t received a copy you can request one at www.canonbury.com or by calling 01280 706661.