Podiatry Review
ISSN 1756-3291
Volume 70 No.3. Published by the Institute of Chiropodists and Podiatrists as a Peer Review Journal May/June2013
INSTITUTE OF CHIROPODISTS AND PODIATRISTS
NATIONAL OFFICERS
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M AY/J U N E 2013 V O L 70 N o.3
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PODIATRY REVIEW
The Institute of Chiropodists and Podiatrists
Contents
Editorial .............................................................................2 Human Prion Disease Christine Carrington M.Inst.Ch.P., and Michelle Taylor BSc., M.Inst.Ch.P ..........................................4 The effect of patients’ preference on outcome in the EverT Cryotherapy versus salicylic acid for the treatment of plantar warts (verruca) trial Cockayne, Hicks, Kangombe, Hewitt, Concannon, Thomas, Hashmi, McIntosh, Brierley, Torgerson, Watt..................................................6 Lymphoedema Michelle Taylor BSc., M.Inst.Ch.P ........................................12 Scarlet Fever Article ........................................................14 So what is the point of CPD and its continued emphasis on Podiatrists, Chiropodists and Foot Health Practitioners Beverley Wright M.Inst.Ch.P. FHEA, BSc(Hons) MSc .................16
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Diary of Events ................................................................18 Dementia Awareness ......................................................20 Cosyfeet Press Release ....................................................21 Branch News ...................................................................22 Algeos Press Release .......................................................26 NWAC Seminar Booking Form.........................................27 Diabetes Information Diabetes UK.....................................................................28 NHS Choices Information ................................................30 Orthotic Construction Paul Mountford M.Inst.Ch.P., BSc (Hons)...............................34 Diary of Events ................................................................36
page | 01
EDITORIAL Welcome to this May issue of Podiatry Review.
Our conference is rapidly approaching. We don’t have a booking form included in this issue but if you wish to come along to meet with the traders, you do not need to book. They are on hand to happily answer any questions you may have and generally have a lot of bargains if not freebie samples on offer! If you wish to attend any of the CPD lectures, please contact Julie Aspinwall on 01704 546141. CPD is compulsory for chiropodists and an essential element to all foot health professionals to enhance their expertise and skills. If you wish to have a further understanding of CPD, please turn to page 16. Beverley Wright has put her unique interpretation on why it is so important to carry out CPD.
types. Now that Michelle has taken the plunge in writing for Podiatry Review, she is getting into her stride and has also sent in a treatise on Lymphodema. Thank you Michelle. Anybody else want to take her lead? You will be surprised to find how much you enjoy it and don’t forget… writing articles counts towards CPD profiles also.
We hope you enjoy this issue and look forward to seeing many of you in Southport in June.
Bernadette Hawthorn, Editor
Dear Bernie, My family and I would like to thank head office for the comforting words they sent us during the tough times when I lost my husband. I would also like to thank individual members who sent me cards and flowers. Also thanks to branches and area councils. God bless you all.
Western branch members Christine Carrington and Michelle Taylor have written an article on Human Prion Disease (pages 4 and 5). For many years the prion diseases were thought to be caused by viruses but it has now been recognised that they can be sporadic or inherited. Christine and Michelle explain the different
Kind regards, Flavia Tenywa London Branch
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page | 03
TECHNICAL ARTICLE
Human Prion Disease
By Christine Carrington M.Inst.Ch.P and Michelle Taylor BSc. M.Inst.Ch.P
Human prion disease falls within the transmissible spongiform encephalopathy (TSEs) category of diseases (Concise Medical Dictionary 2002), which are all closely related and are currently fatal neurodegenerative disorders. These rare degenerative brain disorders are characterized by tiny holes within the brain which give it a “spongy” appearance. These holes can be seen when brain tissue is viewed under a microscope [National Institute of Neurological Disorders and Stroke]. Due to the long incubation period – usually years – it makes the disease difficult to identify until the symptoms begin to manifest. Where upon death is usually a matter of months away with no remission and there is no cure (Hughes, J.T 1993).
• Gerstmann – straussler – scheinker (GSS) syndrome • Fatal familial insomnia (FFI).
Prions (proteinaceous infectious particle) are tiny protein based infectious agents which are similar to viruses. As prions do not contain nucleic acids this makes them difficult to destroy (Weller. B.J 2005). Prions are produced by mutations within the gene code for PrP (a constituent protein of the cells within the brain). These are stable gene codes which are not removed by the normal cellular process of degradation and are resistant to radiation. These abnormal mutations interact with the normal PrP in such a way to convert them into abnormal forms accumulating within the brain. Depending on the mutation of the PrP gene one of the following diseases occurs: • Creutzfeldt – Jakob disease (CJD) • Variant CJD (vCJD) • Koru
Disease
Pathogenesis
Cause
Clinical Disease
Eating brain contaminated beef from cattle with “mad cow disease”
Younger, longer course psychiatric and sensory disturbances prominent.
Creutzfeldt – Jakob disease (CJD)
Infectious/transmissible Sporadic. Genetic.
Variant CJD (vCJD)
Infectious/transmissible
Kuru.
Infectious/transmissible
Eating or handling brain from infected people.
Gerstmann – straussler – scheinker (GSS) syndrome.
Genetic.
Germ cell mutations in prion protein gene.
Genetic.
Germ cell mutations in prion protein gene.
Fatal familial insomnia (FFI)
(Spicer, W.J. 2008)
04 | page
Iatrogenic (instruments, grafts, growth hormone). Commonest. cause unknown -?mutation Germ cell mutation.
Myoclonic jerks, ataxia, speech and visual loss, parses and dementia.
Ataxia, tremors but not dementia.
Spastic paraparesis and cerebellar ataxia. Insomnia, autonomic dysfunction, dementi
TECHNICAL ARTICLE Prion diseases include a number of different conditions with different aetiologies. The major types being;
Creutzfeldt – Jakob disease (CJD) is extremely rare, but there is a high degree of uncertainty about its aetiology, diagnosis and clinical course. The incubation period varies before symptoms appear. In the acquired form it can take several decades before symptoms appear. Once the symptoms do appear disease progression is rapid, with70 – 80% of patients dying within 12 months of symptoms appearing. CJD causes brain damage, profound cognitive and behaviour changes, dementia, movement abnormalities, and neurological symptoms – seizures and visual problems (Ryan. R et al 2011). CJD usually presents in patients between the ages of 50 and 70. While death usually occurs between 6 – 12 months of onset of symptoms appearing, towards the end the patient is rendered mute, motionless and incontinent (Spicer. J.W. 2008).
Variant CJD (vCJD) has been confirmed as being caused by the same prion strain as bovine spongiform encephalopathy (BSE) found in cattle. The risk of new dietary expose to BSE in the UK is remote. There is still a risk of non-systematic carriers transmitting vCJD prion infection and disease via blood transfusions or blood products, other medical treatments include cross contamination from contaminated surgical instruments (Wadsworth. J.D.F et al 2001). This variant form of vCJD differs from CJD due to the infectious prion proteins that are found more distributed throughout the bodily tissues such as the spleen and lymphoid tissue (Ryan, R. et al 2011).
Kuru disease is only seen in the eastern highlands of papa New Guinea. This is transmitted via ritual cannibalism (Hughes, J.T. 1993). Kuru had prevalence as high as 2% in some tribes, but due to changes in culture is now rarely found. There is no evidence that it is spread by any other means other than cannibalism [WHO. International accessed 3.2.13].
Gerstmann – straussler – scheinker (GSS) syndrome disease is a slower progressive disease. The pathological features being confined to the central nervous system, other systems include neuronal loss, astrocytes gliosis and spongiform changes (Hughes. J.T. 1993).
Fatal familial insomnia (FFI) pathological features present with progressive insomnia, disturbances within the autonomic nervous system and eventually dementia (Concise Medical Dictionary 2002).
Sporadic – this accounts for approximately 80 – 85% of cases of TSE or 1 case per million of the population per year (Ryan, R. et al 2011). Symptoms include myoclonus jerks – spasmodic contractions of the muscles. Ataxia – failure of muscle co – ordination leading to unsteadiness in standing and walking, speech and visual loss parses(partial paralysis) and dementia (Spicer, W.J. 2008).
Acquired prion disease is due to exposure to the infectious prion proteins. It is transmitted from infected tissue via the human growth hormone, pituitary glands, corneal and dura matter grafts, brain electrodes or contaminated neurosurgical instruments (Spicer, W.J. 2008). These include Kuru and iatrogenic (medically – acquired) CJD and Variant CJD (vCJD) (Ryan, R. et al 2011).
Genetic – inherited - prion disease which is extremely rare and includes fatal familial insomnia (FFI) and Gerstmann – straussler – scheinker (GSS) syndrome. There are now known to be a number of specific genetic mutations within the prion protein which determines both the length of the disease and which conditions are prominent. Genetic screening and predicative pre – natal tests are available for familial CJD (Ryan, R. et al 2011).
As prions cause no inflammatory or immune response, there are currently no tests available to detect prion disease. Diagnosis is general made by ruling out other conditions, with a firm diagnosis made after death. Control and prevention of transmission depends on the disease. The spread of CJD is blocked by excluding those possibly infected from donating blood or tissue. VCJD can be blocked by excluding possible infected sheep organs from entering the food chain via cattle food. Hereditary forma of CJD, GSS, and FFI may be prevented where possible by carrier detection and genetic counselling (Spicer, J.W 2008).
Detailed surveillance by the National Surveillance Unit, in conjunction with research by the Medical Research Council Prion Unit, has begun to throw light on the possible mechanics of human prion disease. This on-going research and surveillance is essential to developing effective treatments, management and diagnostic tools to manage this group of diseases [The Lancet Infectious Diseases 2012]. References Concise Medical Dictionary.3rd Ed Oxford University Press. http://www.who.int/zoones/diseases/prion_diseases/en/ [accessed 3.2.13]. Hughes, J.T. (1993) Prion diseases. Depend on transmissible and sometimes hereditable agents. BMJ vol. 306. National Institute of Neurological Disorders and Stroke. http://www.ninds.nih.gov/disorders/tse/tse.htm [accessed 3.2.2013] Ryan, R. Hill, S. Lowe, D. Allen, K. Taylor, M. Mead, C. (2011). Notification and support for people exposed to the risk of Creutzfeldt – Jakob disease (CJD) (or other prion diseases) through medical treatment (iatrogenically) The Cochrane Collaboration. Spicer, W.J. (2008) Clinical Microbiology and Infectious Diseases. An illustrated colour text. 2nd ed. Churchill Livingstone Elsevier. The Lancet Infectious Diseases 2012 http://www.thelancet.com/journals/laninf/article/PIIS1473-3099%2812%2970302X/fulltext?elsca1=ETOC-TLID&elsca3=HTDJ35F [accessed 3.2.13] Wadsworth, J.D.F. Dalmao – Mensa, I. Joiner, S. Linehan, J.M. O`Malley, C. Powell, C. Brander, S. Asante, E,A. Ironside, J.W. Hilton, D.A. Collinge, J. (2001) Effect of fixation on brain and lymphoretic vCJD prions and bioassay of key positive specimens from a retrospective vCJD study. Journal of Pathology: iss. 223 pg. 511 – 518). Weller. B.J. (2005). Bailliere`s Nurses` Dictionary. For nurses and healthcare workers 2nd ed. Elsevier. World Health Organisation http://www.who.int/zoonoses/diseases/prion_diseases/en/
page | 05
TECHNICAL ARTICLE
The effect of patients’ preference on outcome in the EVerT cryotherapy versus salicylic acid for the treatment of plantar warts (verruca) trial
Sarah Cockayne1, Kate Hicks1, Arthur R. Kangombe1, Catherine Hewitt1, Michael Concannon2, Kim Thomas3*, Farina Hashmi4, Caroline McIntosh5, Gwen Brierley1, David Torgerson1, Ian Watt1,6 and on behalf of the EVerT team • *Corresponding author: Kim Thomas
Abstract Background Randomised controlled trials are widely accepted as the gold standard method to evaluate medical interventions, but they are still open to bias. One such bias is the effect of patient’s preference on outcome measures. The aims of this study were to examine whether patients’ treatment preference affected clearance of plantar warts and explore whether there were any associations between patients’ treatment preference and baseline variables in the EverT trial.
Methods Two hundred and forty patients were recruited from University podiatry schools, NHS podiatry clinics and primary care. Patients were aged 12 years and over and had at least one plantar wart which was suitable for treatment with salicylic acid and cryotherapy. Patients were asked their treatment preference prior to randomisation. The KruskalWallis test was performed to test the association between preference group and continuous baseline variables. The Fisher’s exact test was performed to test the association between preference group and categorical baseline variables. A logistic regression analysis was undertaken with verruca clearance (yes or no) as the dependent variable and treatment, age, type of verruca, previous treatment, treatment preference as independent variables. Two analyses were undertaken, one using the health professional reported outcome and one using the patient’s self reported outcomes. Data on whether the patient found it necessary to stop the treatment to which they had been allocated and whether they started another treatment were summarised by treatment group.
Results Pre-randomisation preferences were: 10% for salicylic acid; 42% for cryotherapy and 48% no treatment preference. There was no evidence of an association between treatment preference group and either patient (p=0.95) or healthcare professional (p=0.46) reported verruca clearance rates. There was no evidence of an association between preference group and any of the baseline variables except gender, with more females expressing a preference for salicylic acid (p=0.004). There was no evidence that the number of times salicylic acid was applied was different between the preference groups at one week (p=0.89) or at three weeks (p=0.24). Similarly, for the number of clinic visits for cryotherapy (p=0.71) 06 | page
Conclusions This secondary analysis showed no evidence to suggest that patients’ baseline preferences affected verruca clearance rates or adherence with the treatment.
Background The Randomised Controlled Trial (RCT) is widely accepted as being the ‘gold standard’ design for evaluating the effectiveness of a medical intervention[1]. In an RCT patients are randomly allocated to a study group so that, on average, the groups formed are equivalent in all known and unknown characteristics that may affect outcome. This process should eliminate selection bias, however, it is possible for other types of bias to be introduced after the randomisation process[2-4].
One potential form of bias is that of patients’ preference, which may adversely affect both the external and internal validity of the trial. The external validity of a trial may be affected if large numbers of patients, who have a strong preference for a particular treatment, refuse to take part in the study as they are not guaranteed to receive their treatment of choice[5]. In this case, the generalisability of the study’s findings may be limited. The internal validity of a study can also be affected depending on whether or not patients who agree to be randomised receive their preferred treatment. Patients who receive their preferred treatment may be more motivated and comply better with the treatment and report better outcomes compared to those who do not receive their preferred treatment. Furthermore, those patients who do not receive their preferred treatment may experience resentful demoralisation and may be more likely to drop out of the study, resulting in differential loss to follow-up[6]. Whilst the randomisation process will ensure that patients with different treatment preferences are allocated equally between the groups, it is unable to deal with the effect the patients’ treatment preference may have on the outcome measures after randomisation. In order to make comparisons between patients with and without a treatment preference, some trialists have used the patient preference design[7,8]. In this design patients who have a strong preference for one treatment are allocated to their preferred treatment and only patients who are indifferent to which treatment they receive are randomised conventionally. Such a design allows for the examination of patient characteristics associated with preference to be explored. There are however, several limitations to this design. First, it is likely that selection bias
TECHNICAL ARTICLE will be introduced into the preference arms of the study as they have not been formed by randomisation. Second, it is not known for certain that patients’ preference will affect outcomes, so using this design might mean patients are lost from randomisation needlessly. Finally the design may increase the size and cost of the trial.
An alternative trial design is that of a fully randomised preference trial[6]. In this design all patients who give their consent to participate in the trial are randomised, but their treatment preference is recorded prior to randomisation. This then makes it possible to take treatment preference into account during the analysis of the trial. Several trials have been undertaken using this approach to assess the effect of patients’ preference on outcome[9,10].
A systematic review and individual patient data metaanalysis in musculoskeletal trials demonstrated that treatment preferences among patients can modify treatment outcomes[11]. To date, the effect of patients’ preference for type of plantar wart treatment on the outcome of the intervention has not been explored. We undertook a randomised controlled trial to assess the clinical and cost effectiveness of cryotherapy using liquid nitrogen and salicylic acid to treat plantar warts in which the patients’ treatment preference was recorded prior to randomisation[12]. The results of the effect of patients’ treatment preference on the outcome of the intervention are reported here. Methods This was a multicentre, two arm randomised controlled open trial. The study was approved by Trent Multicentre Research Ethics Committee (MREC reference 04/mre04/59), Galway Research Ethics Committee and local research ethics committees, Medicines and Healthcare products Regulatory Agency, Irish Medicines Board and local Research and Development Trusts. All patients provided written informed consent prior to being enrolled in the study.
Detailed methods[13] and the main trial results have been published elsewhere[12,14]. In brief, 13 sites within the UK and one in the Republic of Ireland recruited 240 patients from University podiatry schools, NHS podiatry clinics and primary care. Patients were eligible for the study if they were aged 12 years and over and had at least one plantar wart, which in the opinion of the healthcare professional was suitable for treatment with both salicylic acid and cryotherapy. Once written informed consent had been obtained from the patient, baseline data were collected prior to the patient being randomised. This included the treating healthcare professional asking patients whether they had a treatment preference and if so, which treatment did they prefer; salicylic acid, cryotherapy or no treatment preference. Patients were then randomly allocated equally to receive either cryotherapy using liquid nitrogen, for a maximum of four sessions, two to three weeks apart, or daily self-treatment with an over the counter 50% salicylic acid treatment for up to eight weeks. Simple randomisation was used with the allocation sequence generated by a computer which was provided by the York Trials Unit using a remote, secure telephone or on-line randomisation programme. Patients were then followed up at
one, three, twelve and twenty-four weeks after entering into the study. The primary outcome was complete clearance of all plantar warts at 12 weeks after randomisation as observed on digital photos by blinded healthcare professionals and by a healthcare professional assessment performed at the recruiting centres. Secondary outcomes for the study included patient self-reported clearance of verruca(e) at 12 and 24 weeks and patient self-reported time to clearance of verruca(e).
All analyses were conducted on an intention to treat basis, including all patients in the groups to which they were randomised. All analyses were conducted in SAS version 9.2 (SAS Institute, NC, USA) and SPSS version 17.0.2 (SPSS) using two-tailed significance tests at the 5% significance level.
The baseline data were summarised descriptively by treatment preference group. The Kruskal-Wallis test was performed to test the association between continuous baseline variables and treatment preference group and to test the association between measures of compliance (number of times salicylic acid applied and attendance at clinic visits for cryotherapy) and preference group. The Kruskal-Wallis test was used as the data did not meet the assumptions for parametric tests. The Fisher’s exact test was performed to test the association between categorical baseline variables and treatment preference group and to test the association between drop out and treatment preference group. The Fisher’s exact test was used as some of the comparisons had less than 80% of expected frequencies greater than 5 and/or at least one expected frequency less than 1. We fitted a logistic regression model with verruca clearance (yes/no) as the primary outcome and treatment, age, type of verruca, previous treatment, treatment preference and the interaction term between randomised treatment and treatment preference as covariates. Two analyses were undertaken, one using the health professional reported outcome at 12 weeks and one using patient’s self reported outcomes at 12 weeks.
Data on whether the patient found it necessary to stop the treatment to which they had been allocated and whether they started another treatment were summarised by treatment group.
Results In total 240 eligible patients were recruited to the study between November 2006 and January 2010. One hundred and seventeen patients were allocated to the cryotherapy group and 123 to the salicylic acid group. Two hundred and eighteen patients responded to the question about pre-randomisation treatment preference. One hundred and fourteen (47.5%) patients expressed a treatment preference at baseline; of those 114 patients, twenty-eight (12.8%) expressed a preference for salicylic acid and 86 (39.5%) patients expressed a preference for cryotherapy. One hundred and four (47.7%) patients did not have a treatment preference at baseline. Twenty two (9.2%) patients did not respond to this question. The number of patients allocated to each group along with their treatment preference is summarised in Table 1. The groups were balanced at baseline for treatment preference. page | 07
TECHNICAL ARTICLE Table 1
Number (percent) of patients in each treatment group with their treatment preference Treatment preference
Treatment randomised
Cryotherapy
Salicylic acid
Salicylic acid
10 (9.7)
18 (15.7)
Cryotherapy
43 (41.8)
43 (37.4)
Total
103
115
No preference
Overall
50 (48.5)
28 (12.8)
86 (39.5)
54 (47.0)
104 (47.7) 218*
*22 randomised participants had missing preference data. Cockayne et al. Journal of Foot and Ankle Research 2012 5:28 doi:10.1186/1757-1146-5-28 Tables 2 and 3 present the descriptive statistics for the baseline characteristics of patients and their presenting plantar warts between the three treatment preference groups along with the tests of association. The results from the Kruskal-Wallis test demonstrate that there was no evidence of an association between treatment preference and age (p=0.76), number of verrucae at baseline (p=0.5) and duration of the current verruca (p=0.43). The results from the Fisher’s
exact test demonstrate that there was no evidence of an association between treatment preference and type of verruca (p=0.73), previous treatment of verruca (p=0.78), reasons for seeking treatment and type of previous treatment. However, there was evidence of an association between treatment preference and gender (p=0.004), with more females expressing a preference for salicylic acid.
Table 2
Baseline characteristics of patients with plantar warts according to treatment preference Characteristic Age (years)
Salicylic acid(N=28)
Treatment preference
Cryotherapy(N=86)*
No preference(N=104)
P value
Median (interquartile range)
24.8 (16.6, 52.4)
24.2 (17.4, 41.9)
22.9 (18.6, 38.4)
0.76*
Male
3 (10.7)
37 (44.1)
33 (31.7)
0.004
0.05
Gender Female
25 (89.3)
47 (56.0)
71 (68.3)
Painful
11 (39.9)
46 (54.8)
67 (64.4)
Reasons for seeking treatment** Unable to go swimming
Unable to participate in other sports Other
8 (28.6)
7 (25.0)
16 (57.1)
21 (25.0)
17 (20.2)
39 (46.4)
Values are n (%) unless otherwise stated.
*2 participants had missing characteristics data.
**Patients may have more than one reason for seeking treatment.
Cockayne et al. Journal of Foot and Ankle Research 2012 5:28 doi:10.1186/1757-1146-5-28
08 | page
32 (30.8)
20 (19.2)
40 (38.5)
0.69
0.82
0.18
TECHNICAL ARTICLE Table 3
Baseline characteristics of plantar warts according to treatment preference Characteristic
Cryotherapy
No preference
Non-mosaic
5/28 (17.9)
23/28 (82.1)
16/86 (18.6)
24/104 (23.1)
N
26
80
100
Type of verruca
Mosaic
Duration of verruca (months) Mean(sd)
Salicylic acid
Treatment preference
30.7 (27.5)
70/86 (81.4)
22.9 (19.6)
80/104 (76.9)
26.6 (27.3)
Median (interquartile range)
24.0 (12.0, 39.0)
18.0 (9.5, 29.0)
16.8 (8.5, 36.0)
N
28
86
101
Number of verrucae at baseline Mean (sd)
4.3 (4.5)
3.8 (6.6)
P value
0.73
0.43
3.3 (3.3)
0.50
Median (interquartile range)
3.0 (1.0, 5.5)
2.0 (1.0, 4.0)
2.0 (1.0, 4.0)
Yes
23/28 (82.1)
66/84 (78.6)
79/104 (76.0)
0.78
Self-treatment
21/23 (91.3)
53/66 (80.3)
73/80 (91.3)
0.15
GP
10/23 (43.5)
30/66 (45.5)
27/80 (33.8)
0.32
Other
3/23 (13.0)
Previous treatment for current verruca No
Type of previous treatment* Podiatrist/chiropodist Trial investigating verruca treatments
5/28 (17.9)
5/23 (21.7) 0/23 (0.0)
18/84 (21.4)
23/66 (34.9) 2/66 (3.0)
6/66 (9.1)
Values are n/N (%) unless otherwise stated. * Patients may have more than one previous verruca treatment. Cockayne et al. Journal of Foot and Ankle Research 2012 5:28 doi:10.1186/1757-1146-5-28 When we included an interaction term between randomised treatment and preferred treatment we found no evidence to suggest that patients’ preferences at baseline influenced health professional reported primary outcome (p=0.46) or the patient reported outcome (p=0.95). Overall few patients reported stopping their original treatment (n=21, 11.5%). Of those that did, 16 patients were in the salicylic acid group and five in the cryotherapy group. Only three of the 21 patients started a different treatment (2 in the salicylic acid group and 1 in the cryotherapy group). Primary outcome data were reported for 229 (95.4%) patients at 12 weeks with 206 (90.0%) having a blinded outcome assessment. Primary outcome data were unavailable for the remaining 11 participants (4 in the salicylic acid group and 7 in
25/104 (24.0)
20/79 (25.3) 0/79 (0.0)
5/79 (6.3)
0.34
0.41
0.50
the cryotherapy group) due to the patients dropping out of the study. Of these 11, two had their preferred treatment, three did not have their preferred treatment, one did not have a preference and five participants did not express their treatment preferences. There was no evidence of an association between missing data for the primary outcome and whether a participant received their preferred treatment or not (p=0.17).
Table 4 reports the treatment adherence for patients allocated to receive salicylic acid and cryotherapy. There was no evidence that the number of times salicylic acid was applied was different between the preference groups at one week (p=0.89) or at three weeks (p=0.24). There was also no evidence that the number of clinic visits for cryotherapy was different between the preference groups (p=0.71). page | 09
TECHNICAL ARTICLE Table 4
Treatment compliance (number of times salicylic acid applied or number of clinic visits for cryotherapy) Mean(sd)
Median(min,max)
p-value
Preferred cryotherapy
3.58 (0.73)
4 (1, 4)
0.71
No preference
3.68 (0.79)
4 (1, 5)
Randomised to cryotherapy Preferred salicylic acid Randomised to salicylic acid Week 1
3.60 (0.52)
4 (3, 4)
Preferred salicylic acid
6.44 (1.03)
7 (4, 7)
No preference
6.23 (1.63)
7 (0, 7)
Preferred cryotherapy Week 3
6.53 (1.06)
7 (2, 7)
Preferred salicylic acid
6.27 (2.52)
7 (0, 12)
No preference
5.04 (2.23)
6 (0, 7)
Preferred cryotherapy
5.79 (3.55)
6 (0, 22)
0.89
0.24
Cockayne et al. Journal of Foot and Ankle Research 2012 5:28 doi:10.1186/1757-1146-5-28 The results from this secondary analysis found no evidence to suggest that patients’ baseline treatment preference affected outcome and so receiving the preferred treatment did not confer any additional benefits in those who expressed a preference. The findings of this analysis are not totally unexpected since the primary outcome measure in this study i.e. clearance of verruca(e) was undertaken by independent blinded healthcare professionals. Such reported measures are unlikely to be influenced by the patients’ preference compared to patient self-reported outcomes other than indirectly through differences in levels of adherence. In order to investigate this further, we explored whether there was an association between (a) healthcare professional reported outcomes and patient treatment preference and (b) patient reported outcomes and treatment preference. In both cases there was no evidence of an association between outcome and treatment preference.
In this study only 114 (52%) patients expressed a treatment preference at baseline. Of these 114 patients, more preferred cryotherapy (n=86) than salicylic acid (n=28) with just over a half of these patients receiving their preferred treatment. Among those with no baseline preference, similar numbers were randomised to the two treatment groups. The difference in treatment preference could be due to several reasons. First, many of the patients who took part in the trial were identified from referrals to cryotherapy clinics. These patients had already decided that cryotherapy was a suitable form of treatment for them and expected this treatment. Secondly whilst we did not collect data on what informed patients’ treatment preference Thomas et al.[15] have reported these findings from a survey of patients within primary care. They reported the most common reason (35%) for patients seeking 10 | page
treatment was to get rid of plantar warts quickly. So patients could have believed that cryotherapy was the more effective form of treatment. Finally, results from the same survey reported the second most common reason for seeking treatment (21%) was due to patients preferring a ‘professional person’ to treat their plantar wart. The fact that both treatments were frequently used within normal practice and were not considered to be novel or new treatments may have contributed towards almost half of the patients (48%) not having a treatment preference. We anticipated that the majority of patients in this study would have received some form of previous treatment prior to taking part in the study and that the efficacy and experiences of these treatment regimens, would inform future treatment preferences. The majority of patients (n = 168, 78%) reported having received some form of previous treatment. Of those 168 patients, 147 (87%) had used some form of self-treatment (salicylic acid or a freezing agent) whilst 48 (29%) and 66 (39%) patients had received treatment from a podiatrist or their GP respectively. There was no evidence of an association between treatment preference and age, duration of verruca, type of verruca and previous treatment of verruca. However, there was evidence of an association between treatment preference and gender, with more females expressing a preference for salicylic acid. As we did not collect data on what informed treatment preference we are unable to report why patients expressed this preference and this could be a chance finding. However, it has been reported that male gender is a predictor for wishing to have a passive role in clinical decision making (i.e., to receive information with a view of following the doctor's advice)[16] and this may tentatively be extrapolated to receiving a clinician delivered treatment.
TECHNICAL ARTICLE External validity During the course of the study we attempted to collect data on patients who were screened for the study but not enrolled. Two hundred and eighty-four potential patients were approached to take part in the study, 44 of whom were excluded. Approximately half of these (23) were excluded as they were unable to be treated with the trial treatments and only six patients were not interested in taking part in the study. It is possible that data from patients with a strong treatment preference were not collected. For example patients who were approached to take part in the trial whilst requesting treatment at their local GP cryotherapy clinic, may not have been included in the screening data, since sites, understandably concentrated their efforts on collecting data from patients participating in the study. Or patients with strong treatment preferences could have accessed both treatments outside of the study. The participants in this study had longstanding plantar warts, most of which had been self treated, which is typical of patients presenting to healthcare professionals. These patients were recruited from 14 centres across England, Scotland and Ireland from podiatry clinics, general practice and from the community. We can therefore be confident that the results of this study are broadly generalisable and that the study has external validity across the UK and Ireland. Internal validity There was a low incidence of patients stopping their original treatment and of seeking alternative treatments. Only 21 patients reported stopping their treatment. Since only three (15%) of these 21 patients reported starting another treatment it is unlikely that dilution bias has been introduced. In addition patients who did not receive their preferred treatment did not have higher attrition rates than those who did receive their preferred treatment. We found no evidence to suggest that patients who expressed a treatment and received their preferred treatment adhered to their treatment better than those who did not receive their preferred treatment. Comparison with other studies The proportion of patients who expressed a treatment preference in this study is similar to the median preference rate of 56% reported in a systematic review of patients’ preferences within randomised trials[11]. Unlike our study which found no evidence to suggest that patients’ treatment preference affected outcome, this review concluded that patients’ preferences for treatment may influence outcome[10,11]. However, the review differed from our study in two ways. First the therapeutic area of the review, which focused mainly on musculoskeletal trials, was different to that reported here. Secondly, the review only included trials reporting self-reported outcomes as the primary outcome, whereas the primary outcome for this trial was healthcare professional reported clearance of verrucae. Trials using self-reported outcomes may be expected to be more influenced by patients’ preference as opposed to outcomes reported by blinded independent clinicians, or clearance of disease as used in the EverT trial. Strengths and limitations As far as we are aware, this is the first randomised controlled trial assessing the effect of patients’ preference on the clearance of verrucae. Our study does have some potential limitations. First this study was not powered to detect a difference in preference-treatment interaction and so there may have been insufficient patients in the study to detect a
difference, if one existed. Nevertheless, the results of this study could be included with other studies in a meta-analysis to assess the effect of preferences on outcome. Second, the patient’s treatment preference was elicited by the treating healthcare professional, so there was the possibility that their views, (either knowingly or unknowingly) could influence the patients. Care had to be taken when eliciting a response about preference that patients understood and agreed to being randomly assigned to either group. Expressing a particular preference for a treatment would not necessarily result in them receiving the treatment. In order to minimise the possibility of this occurring, clinicians were made aware of this potential limitation during the trial training. Conclusions This trial showed no evidence that treatment preference affected outcomes in the EverT trial. The method employed in this study to explore the effect of patients’ treatment preference on outcome could be used in other trials, and may be a more straightforward alternative to the more complex ‘patient preference’ trial design. Results of this and other trials could then be combined in further work to assess the treatment effects of patients’ preferences in different clinical conditions. References 1. Sibbald M, Roland M: Understanding controlled trials: Why are randomised controlled trials important? BMJ 1998, 316:201. 2. Juni P, Altman DG, Egger M, Schulz : Assessing the quality of controlled clinical trials. BMJ 2001, 323:42. 3. Schulz KF, Chalmers I, Hayes RJ, Altman DG: Empirical evidence of bias: dimensions of methodological quality associated with estimates of treatment effects in controlled trials. JAMA 1995, 273:408-412. 4. Kjaergard LL, Villumsen J, Gluud C: Reported methodologic quality and discrepancies between large and small randomized trials in meta-analyses. Ann Intern Med 2001, 135(11):982-989 5. King M, Nazareth I, Lampe F, Bower P, Chandler M, Morou M, Sibbald B, Lai R: Impact of participant and physician intervention preferences on randomized trials: a systematic review. JAMA 2005, 293:1089-1099. 6. Torgerson DJ, Klaber-Moffet J, Russell IT: Patient preferences in randomised trials: threat or opportunity? J Health Serv Res Policy 1996, 1:194-197. 7. Brewin CR, Bradley C: Patient preferences and randomised clinical trials. BMJ 1989, 299:313-315. 8. Torgerson DJ, Sibbald B: Understanding controlled trials. What is a patient preference trial? BMJ 1998, 316:360. 9. Thomas E, Croft PR, Paterson SM, Dziedzic K, Hay EM: What influences participants’ treatment preference and can it influence outcome? Results from a primary care-based randomised trial for shoulder pain. Br J Gen Pract 2004, 54:93-96. 10. Klaber Moffett JA, Jackson DA, Richmond S, Hahn S, Coulton S, Farrin A, Manca A, Torgerson DJ: Randomised trial of a brief physiotherapy intervention compared with usual physiotherapy for neck pain patients: outcomes and patients’ preference. BMJ 2005. 11. Preference Collaborative Review Group: Patients’ preferences within randomised trials: systematic review and patient level meta-analysis. BMJ 2008, 337:a1864 12. Cockayne S, Curran M, Denby G, Hashmi F, Hewitt C, Hicks K, Jayakody S, Kang’ombe A, McIntosh C, McLarnon N, Stamuli E, Thomas K, Turner G, Torgerson D, Watt I, EVerT: Cryotherapy versus salicylic acid for the treatment of verrucae: A randomised controlled trial. NIHR Health Technology Assessment Programme Report 2011, 15(No 32):1-170. 13. Cockayne S, EVerT Team: The EVERT (effective verruca treatments) trial protocol: a randomised controlled trial to evaluate cryotherapy versus salicylic acid for the treatment of verrucae. Trials 2010, 11:12. 14. Cockayne S, Hewitt C, Hicks K, Jayakody S, Kang’ombe AR, Stamuli E, Turner G, Thomas K, Curran M, Denby G, Hashmi F, McIntosh C, McLarnon N, Torgerson D, Watt I: Cryotherapy versus salicylic acid for the treatment of plantar warts (verrucae): A randomised controlled trial. BMJ 2011, d3271. 15. Thomas KS, Keogh-Brown MR, Chalmers JR, Fordham RJ, Holland RC, Armstrong SJ, et al.: Effectiveness and cost-effectiveness of salicylic acid and cryotherapy for cutaneous warts. An economic decision model. Health Technol Assess 2006, 10(25):ix-87. 16. Benbassat J, Pilpel D, Tidhar M: Patients’ Preferences for Participation in Clinical Decision Making: A Review of Published Surveys. Behav Med 1998, 24(2):81-88. Complete Article by be red on the Journal of Foot and Ankle Research
Author Affiliations Department of Health Sciences, York Trials Unit, University of York, York, UK Division of Podiatry, University of Huddersfield, The School of Human & Health Sciences, Huddersfield, UK 3 Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK 4 University of Brighton, School of Health Professions, Brighton, UK 5 The National University of Ireland, Galway, Discipline of Podiatry, Galway, Ireland 6 Department of Health Sciences, Hull York Medical School, University of York, York, UK For all author emails, please log on. Journal of Foot and Ankle Research 2012, 5:28 doi:10.1186/1757-1146-5-28 1 2
The electronic version of this article is the complete one and can be found online at: http://www.jfootankleres.com/content/5/1/28 Trial registration Current Controlled Trials ISRCTN18994246 and National Research Register N0484189151 Abbreviation RCT: Randomised controlled trial.
page | 11
TECHNICAL ARTICLE
Lymphoedema
Michelle Taylor BSc., M.Inst.Ch.P
Lymphoedema is a condition in which the intercellular spaces within the tissues contain an abnormal amount of lymph, leading to the obstruction of lymph drainage system (Weller, B.F. 2005). Interstitial fluid is a clear watery, straw coloured fluid similar to blood plasma, which circulates through the porous capillary walls into the interstices or spaces between the cells that form the tissues. A certain amount of this fluid returns back through the capillary walls, with the excess returning back to the blood via the lymphatic system. The term lymph means once the interstitial fluid has entered the lymphatic system. Any fluid not removed by the lymphatic system from the interstitial spaces leads to oedema. This build-up of fluid leads to both pain and a lack of mobility within the patient, with the arms and legs commonly affected by oedema (Watson, R. 2005).
It is thought that up to 90% of interstitial fluid is reabsorbed into the venous capillaries’ via colloid pressure (the pressure exerted by the large molecules in the blood, draining fluid into the bloodstream from the surrounding tissue). While the lymphatic system reabsorbs the remaining 10% of fluid (Waugh, A et al 2001). During a 24 hour period between 2 – 4 litres of interstitial fluid is returned to the circulatory system via the lymphatic system, compared to 8 – 16 litres via the vascular system (Wigg, J. 2010).
The lymphatic system is responsible for the development of both immunity and the resolution of infections (Waugh, A. et al 2001). Lymphoedema may be due to a congenital abnormality of the lymphatic vessels – Milroy`s disease is a congenital lymphoedma of the legs. Or it can be due to an obstruction of the lymphatic vessels by a tumour, parasite, inflammation or injury (Concise Medical Dictionary).
Primary lymphoedema or Milroy’s disease is caused by the failure or the absence of lymphatic vessels in embryotic life. It is either seen in isolation or with other congenital abnormalities i.e. Turners Syndrome. Oedema development is insidious and depending on age at onset will reflect the degree of failure. There are 2 main categories that Milroy’s disease falls into either primary or idiopathic lymphoedema (Menz, H.B. 2008). There are 3 different subtypes; • Congenital lymphoedema – appears at or near birth (Milroy’s disease). • Lymphoedema praecox – typically appears at puberty and before 35 years (Meige disease). • Lymphoedema tarda – appears after the age of 35. thought to be caused by a defect in the lymphatic valves. (Lorimer, D. et al 2006).
Secondary lymphoedema is due to the obstruction of the lymphatic system caused by trauma, surgical intervention, invasive tumours, radiotherapy or filarial infestation (parasitic worms that affect the human connective and lymphatic tissue) (Menz. H.B. 2008).
Clinical presentation and diagnosis is based on patient history, clinical signs and symptoms. Swelling is the most common factor affecting the limbs and other bodily parts. The swelling is generally resistant to compression – non pitting – than venous oedema. Therefore is less commonly associated with ulceration and hyperpigmentation, with advanced cases hardening of the skin and subcutaneous tissue is common (Menz. H.B. 2008). Lymphangiograms is a definitive test to confirm lymphatic obstruction (Lorimer, D. et al 2006).
ISL
Description
ISL stage 0
A subclinical state where swelling is not evident despite impaired lymph transport. This stage may
ISL stage 1
This represents the early onset of the condition where there is accumulation of tissue fluid that
ISL stage 11
Limb elevation alone rarely reduces swelling and pitting is manifest.
ISL late stage 11
There may or may not be pitting, as tissue fibrosis.
ISL stage 111
The tissue is hard (fibrotic) and pitting is absent. Skin changes such as thickening, hyperpigmentation,
(Cooper, G. 2012).
12 | page
exist for months or years before oedema appears.
subsides with elevation. The oedema may be pitting at this stage.
increased skin folds, fat deposits and warty overgrowths develop.
TECHNICAL ARTICLE In primary lymphoedema the age of onset varies, while in secondary lymphoedema it depends on the cause. Both sexes are affected in primary lymphoedema with females making up to 70 – 80% of all cases.
• • • •
10% of cases of oedema are present from birth. 80% of cases present before the age of 35. 10% of cases present in the over 35.
In 80% of primary cases develop in one lower limb. (Lorimer, D. et al 2006).
Initially, the oedema is of the pitting type, elevation of the limb leads to a reduction in oedema. Over time the pitting becomes non – pitting and indurated due to fibrous. The epidermis is classically ‘warty and hyperkeratotic in appearance’, leading to opportunistic infections in 20% of cases (Lorimer, D. et al 2006). With 50% of patients complaining of pain or discomfort, usually described as aching or heaviness within the limb (Menz. H.B. 2008). The International Society of Lymphology has identified a 5 point staging for the level of lymphoedema within the patient.
There is no known cure for lymphoedema, except management of the condition. The best treatment option is to reduce congestion. Management includes compression bandaging, exercise and manual lymph drainage along with maintaining the integrity and pliability of the skin. Compression hosiery can be used as a stand-alone treatment once the initial multi-layer bandaging has been removed, as this prevents excess fluid buildup with in the limb (Menz. H.B. 2008).
Skin care has been acknowledged to both maintain and improve skin integrity and suppleness. both during and after treatment (International Lymphoedema Framework 2006). The general principles of skin care include:
References
Concise Medical Dictionary.3rd Ed Oxford University Press.
Cooper, G. (2012) Lymphoedema treatment in palliative care: a case study. British Journal of Nursing, 21 (15), p.897 - 903.
International Lymphoedema Framework. (2006) International Consensus. Best Practice for the Management of Lymphoedema Medical Educational Partnership. Available through: www.woundsinternational.com/pdf/content-175.pdf [Accessed: 7th Dec 2012].
Lorimer, D. French, G. O`Donnell, M. Burrow, J. G. Wall, B. (2006) Neales Disorders of the Foot. 8th ed. Churchill Livingstone Elsevier.
Menz, H.B. (2008) Foot Problems in older People. Assessment and Management. Churchill Livingstone Elsevier. Watson, R. (2005) Anatomy and Physiology for Nurses.12th Ed. Elsevier. Waugh, A. Grant, A. (2001) Ross and Wilson: Anatomy and Physiology in Health and Illness. 9th ed. Churchill Livingstone. London.
Weller, B.F. (2005) Bailliere`s Nurses` Dictionary for Nurses and Health Care Workers. 24th ed.
Wigg, J. (2012) Medical Lymphatic Drainage and Lymphoedema Management. Leduc. Cannock.
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HEALTH ARTICLE
Scarlet Fever - Alert! Scarlet fever, the disease which killed thousands during the 19th century, is making a comeback, public health specialists have warned. Although scarlet fever was thought to have been almost eradicated in modern Britain, the past few years have seen an increase in reported cases. Availability of antibiotics has made the disease much easier to treat, and it is a lot less serious than it once was. Patients generally make a full recovery without problems. However, swift medical diagnosis and immediate commencement of a course of antibiotics is recommended as if it is left untreated it can turn into rheumatic fever which can then lead to rheumatic heart disease and serious heart problems in later life.
What is scarlet fever? Scarlet fever is due to a throat infection caused by a bacterium (germ) called streptococcus. There are various strains of streptococcus. They cause different infections and a strain called group A streptococcus causes scarlet fever. The scarlet fever rash occurs when the streptococcal bacteria release toxins that make the skin go red. The toxins get into the blood from the infected throat. However, not all people with streptococcal infections develop the rash, as some people are not sensitive to the toxin. A mild form of scarlet fever may occur; which is commonly called scarletina.
What to look for Scarlet fever presents as a red, bumpy rash. It has a very sand papery feel and usually starts on the torso and spreads to the arms and legs. Often the cheeks will look very flushed. The tongue can develop a thick white coating leaving a swelling and then develop a strawberry-like appearance.
Complications due to the spread of the infection can occur early in the infection and may include following: · · · · ·
Ear infection (otitis media) Throat infection and abscess Sinus infection Pneumonia Meningitis and brain abscess
Later complications can rarely occur a few weeks after the infection has cleared. These occur as a result of immune reactions in the tissues. These may include: · ·
Rheumatic fever (which can damage the heart) Kidney damage (glomerulonephritis)
Other symptoms include sore throat, headache, fever, fatigue and body aches.
Deaths from scarlet fever are now extremely rare.
Who does it affect
Is scarlet fever infectious?
Scarlet fever can affect anyone but most commonly affects children between four and eight years of age. The sore throat and fever last a few days, and then usually eases. The rash lasts about six days, and then usually fades away. As the rash fades, some of the skin may peel, mainly on the hands and feet.
Yes. Coughing, sneezing and breathing out the bacteria can pass it on to others. Scarlet fever can even be passed on by sharing towels, baths, clothes or bedlinen with a person who has been infected.
What are the possible complications of scarlet fever? Treatment with antibiotics reduces the chance of complications. Complications now very rarely occur. However, if they do occur, they can be serious.
14 | page
It takes 2-4 days to develop symptoms after being infected. An infected person is not considered infectious 48 hours after commencement of antibiotics. Once a person has had scarlet fever, they are very unlikely to get it again. References: patient.co.uk; nhs choices; nhsdirect
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INFORMATION ARTICLE
So what is the Point of Continuing Professional Development (CPD) and its Continued Emphasis on Podiatrists, Chiropodists and Foot Health Practitioners? Beverley Wright, M.Inst.Ch.P, FHEA, BSc (Hons), MSc. Most everyone would agree that in order to enhance their expertise and skills in whatever their speciality or chosen field it is important to consider undertaking some form of Continuing Professional Development (CPD). More importantly it is an essential element in the pursuance of personal and professional development, particularly across many Professional Body or Regulatory Associations/Organisations, which includes the field of Podiatry. In fact it does appear that like some other professions, Podiatrists, Chiropodists and Foot Health Practitioners (FHP) have an ambivalent relationship with CPD.
So what is the point of CPD? First let us look at CPD, which has the capacity of being able to cover a vast range of life-long learning activities. This can be in a chosen professional field or other area that is likely to contribute to the development of an individual’s learning, knowledge and skill for a current or evolving role; or just for personal growth. This hopefully will ensure that from the time a health professional/practitioner first qualifies and practices they should be able to continue practicing safely, effectively and legally (Potter, 2008).
Primarily CPD for health professionals/practitioners will enable them to improve their abilities for the sake of their patients/clients. It will certainly help to improve their professional skills and practice, by gaining or extending their range of knowledge and understanding.
Many Professional Associations and Organisations now require proof of CPD to be eligible for the renewal of annual membership applications. This is not an uncommon practice for doctors, nurses and other medical personnel who are required to undertake a minimum of CPD hours in order to keep their licence to practice. If the CPD requirements are not met there are harsh penalties brought against professionals who choose to ignore these standards and regulations, as
16 | page
set by their respective Professional or Regulatory Body Associations/Organisations. This is especially pertinent when life and death issues to patients/clients may be at stake. Of course this does not affect every individual working in the field of Podiatry as a Podiatrist, Chiropodist, or FHP working for the NHS or in private practice, but it could potentially affect their patient/client care. The Health Care Professions Council (HCPC) who regulates Podiatrists and Chiropodists expect a registrant of the HCPC to undertake CPD. These are set out in the HCPC guidelines as a proviso of continuing on their professional register.
Although there are many instances where some individuals may choose to ignore providing proof of their CPD attendance, in the hopes that it will be overlooked when renewing their membership. Particularly as many Professional Body Associations/Organisations have in the past been more lenient about CPD involvement and may have even turned a blind eye, for fear of losing members. This is certainly not the case now when Professional Bodies and Regulators expect their members to be following their standards and guidelines. For example even for the Institute of Chiropodists and Podiatrists (IOCP) Associate members (non HCPC registered members) amongst the IOCP membership, there is still an expectation of CPD to keep health professionals/practitioner’s skills up to date.
CPD has become one of the many reasons for relinquishing membership to many Association or Organisation, because some individuals think they will no longer have to do CPD. Many individuals are happy with the qualifications they have and do not feel that CPD will benefit the effectiveness of their practices, or to the way in which they work with their existing clientele. Some individuals even consider CPD to be of little value or, worse, irrelevant.
INFORMATION ARTICLE The Financial consequence of doing CPD continues to add to the issues surrounding CPD, such as loss of earnings and the time taken from work to attend courses. This may be particularly relevant to many individuals who are self-employed and/or in private practice during the current economic climate. For others it might be the distance and the time it takes in which they have to travel to attend CPD courses that can contribute to the rising costs and other issues overall in undertaking CPD.
The list of problems with having to do CPD may be long and getting longer, but not so by individuals who have trained and practiced abroad where they highlight the difference in attitude to CPD, as being completely different. Health professionals from other countries view the problems we have in doing CPD as almost unique to the UK. In many countries health practitioners/professionals are passionate about CPD and will even travel abroad to other countries around the world to attend CPD courses to improve their knowledge, skills and practice. This is evident in many countries where education is viewed as a luxury afforded only by the rich, or by others not so well off, as being an important factor in life in order to get a job, or a better status in life and/or society.
I have always been interested in learning and passionate about education, because I can see the value and its many benefits, especially by filling in the gaps of my own knowledge and understanding. So, in order to keep up the standards of my work and practice, I try to attend as many CPD courses as I can, even if the subjects are sometimes obscure and not always related to work. But, it is also nice to do a course in something completely different, interesting and enjoyable. Surprisingly, in whatever guise the course may be packaged it can be considered CPD, because there is a level of learning involved.
There are hundreds of CPD courses available and some that offer good quality CPD, but there are also those that don’t. Fortunately, there are many organisations that offer good CPD courses to the general population of health professionals/ practitioners, but there are often those that are biased or closed to even those in their own discipline. Some courses can be hugely expensive and beneficial, others even very limited in value, which can often make it difficult to make comparisons to decide on the right course to do.
Health professionals/practitioners that have attended a great deal of CPD courses should be able to use the appropriate treatment for each case they deal with. In addition they may only need to see the majority of their patients/clients for a one-off treatment, because their acquired knowledge has given them the opportunity for minimum action that produces the greatest effect. This can be of benefit when time is money and the satisfaction and wellbeing of a patient/client is paramount. CPD can be extremely useful for networking, and as many health professionals/practitioners tend to work in isolation it can be quite refreshing to socialise with like-minded people. CPD can have the advantage of giving individuals a personal challenge and a sense of professional pride for being involved with new learning. Particularly as CPD can add weight to their own personal and professional development and confirm the quality of their own professional work practices to their peers and clientele. This may be especially useful in light of being a very effective means of comparing performance with the standards of their peers, who are also their competitors for clientele. Potential clients will also be seeking competent health professionals/practitioners that have up to date skills and knowledge in their professional work practice. So if you are reading the ‘Podiatry Review’ you are doing CPD. If you attend Branch meetings - it is CPD! If you do not attend Branch meetings – go on be brave and attend one it might have a presentation – that is also CPD! There are lots of different ways to obtain CPD and in the process you could have some fun along the way with some interesting people that you will also meet. So, yes there is a point to emphasise CPD, but you have to do it to get it! References:
Health Protection Order (2001)
www.opsi.gov.uk/si/si2002/20020254.htm
www.hpcuk.org/publications/ruleslegislation/index.asp?id=54
www.nmc-uk.org/aFrameDisplay.aspx?DocumentID=5045
Potter, M. 2008. Standards for CPD. Health Professions Council http://www.hpc-uk.org/
page | 17
DIARY
What’s on in your area?
May 2013 3
East Anglia Branch Meeting 10:30 a.m. Barrow Village Hall, Bury St. Edmunds IP29 5DX Tel: 01992 589063
12 Leeds Bradford Branch Meeting 10:00 a.m. Oakwell Motel, Leeds WF17 9HD Tel: 01924 475338 12 Wolverhampton Branch Meeting 9:30 a.m. 4 Selman’s Parade, Selman’s Hill, Bloxwich, Walsall, WV3 3RN Tel: 0121 378 2888
13 West Middlesex Branch Meeting 8:00 p.m. The Harvester, Watford Road, Croxley Green, Rickmansworth WD3 3RX Tel: 0208 903 6544
16 Sheffield Branch Meeting 7:30 p.m. SWD Sports Club, Heeley Bank Road, Sheffield Tel: 01623 660104 19 Cheshire North Wales, Staffs and Shropshire, Branch meeting 10:00 a.m. The Dene Hotel, Hoole Road, Chester Tel: 0151 327 6113
19 South Wales and Monmouth Branch Meeting 2:00 - 4:00 p.m. The Village Hotel, Coryton, Cardiff, CF1 7EF. Preceded by lunch at 12:30 in the restaurant Tel: Esther 01656 740772
June 2013 3
Surrey and Berkshire Branch Meeting 7:30 p.m. Pirbright Village Hall, Pirbright, Surrey Tel: 0208 660 2822
7th - 9th National Podiatry Conference Southport Theatre and Convention Centre, The Promenade, Southport Tel: 01704 546141 for further details
9
North West Branch Seminar Day 10:00 a.m. Biomechanics Training Venue to be advised Tel: 0161 486 9234
11 Birmingham Branch Meeting 8:00 p.m. British Red Cross Centre, Evesham, Worcs. Tel: 01905 454116
15 Southern Area Council Meeting 1:00 p.m. Victory Services Club, 63-79 Seymour Street, London W2 2HF Tel: 01992 589063
19 Hants and Dorset Branch Meeting 7:45 p.m. Crosfield Hall, Broadwater Road, Romsey SO51 8GL Tel: 01202 425568 23 Essex Branch Meeting 2:00 p.m. Southend University Hospital Education Centre, Carlingford Drive, Southend-on-Sea SS0 0RY Tel: 01702 460890 18 | page
23 Western Branch Meeting 12:15 p.m. Blair Bell Education Centre, Liverpool Women’s Hospital, Crown Street, Liverpool. Presentation: TBC plus trade stand and raffle. Further details: 01745 331827
28/ Executive Meeting Head Office 29 150 Lord Street, Southport PR0 0NP
July 2013 1
6 8
Tel: 01704 546141
Wolverhampton Branch Meeting 9:00 a.m. 4 Selman’s Parade, Selman’s Hill, Bloxwich, Walsall, WV3 3RN Tel: 0121 378 2888 Surrey and Berkshire Branch Meeting 1:30 p.m. Greyfriars Centre, Reading Berkshire Tel: 0208 660 2822
West Middlesex Branch Meeting 8:00 p.m. The Harvester, Watford Road, Croxley Green, Rickmansworth WD3 3RX Tel: 0208 903 6544
August 2013
28 London Branch Meeting 7:30 p.m. Ozzie Rizzo, 14 Hay Hill, Mayfair, London W1J 8NR Tel: 0208 586 9542
30 East Anglia Branch Meeting 10:30 a.m. Barrow Village Hall, Bury St. Edmunds IP29 5DX Tel: 01992 589063
September 2013 1
1 9
Western of Scotland Branch Meeting 10:00 a.m. Express by Holiday Inn, Springkerse Business Park, Stirling, FK7 7XE Tel: 0141 632 3283
Scottish Area Council Meeting West Middlesex Branch Meeting 8:00 p.m. The Harvester, Watford Road, Croxley Green, Rickmansworth WD3 3RX Tel: 0208 903 6544
14 Southern Area Council Meeting 1:00 p.m. Victory Services Club, 63-79 Seymour Street, London W2 2HF Tel: 01992 589063
17 North West Branch Meeting 7:00 p.m. Includes CPD Presentation St. Joseph’s Parish Centre, Harpers Lane, Chorley, Lancs. Tel: 0161 486 9234
DIARY 20 Birmingham Branch Meeting 8:00 p.m. British Red Cross Centre, Evesham, Worcs. Tel: 01905 454116 22 Western Branch Meeting 12:15 p.m. Blair Bell Education Centre, Liverpool Women’s Hospital, Crown Street, Liverpool. Presentation: “Tissue viability” Further details: 01745 331827 and trade stand. 27/ Executive Meeting Head Office 28 150 Lord Street, Southport PR0 0NP
Tel: 01704 546141
29 Essex Branch Meeting 2:00 p.m. Southend University Hospital Education Centre, Carlingford Drive, Southend-on-Sea SS0 0RY Tel: 01702 460890 29 Nottingham Branch Meeting Feet and Co. Ltd. West Bridgford, Nottingham NG1 6EN Tel: 0115 931 3492
October 2013 2
6 6 7
Hants and Dorset Branch Meeting 7:45 p.m. Crosfield Hall, Broadwater Road, Romsey SO51 8GL Tel: 01202 425568 Cheshire North Wales, Staffs and Shropshire Branch Meeting 10:00 a.m. The Dene Hotel, Hoole Road, Chester Tel: 0151 327 6113
Leeds Bradford Branch Meeting 10:00 a.m. Oakwell Motel, Leeds WF17 9HD Tel: 01924 475338
Surrey and Berkshire Branch Meeting 7:30 p.m. Pirbright Village Hall, Pirbright, Surrey Tel: 0208 660 2822
18 Sheffield Branch Meeting 7:30 p.m. SWD Sports Club, Heeley Bank Road, Sheffield S2 3GL Tel: 01623 452711 27 Northern Ireland Branch Meeting Lagan Valley Hospital
Tel: 028 9446 2423
27 Wolverhampton Branch Meeting 9:30 a.m. 4 Selman’s Parade, Selman’s Hill, Bloxwich, Walsall, WV3 3RN Tel: 0121 378 2888
November 2013 3
3
3
3
Leeds Bradford Branch Meeting 10:00 a.m. Oakwell Motel, Leeds WF17 9HD Tel: 01924 475338
Scottish Area Council Meeting
South Wales and Monmouth Branch Meeting 2:00 - 4:00 p.m. Venue to be arranged. Tel: Esther 01656 740772
Western of Scotland Branch meeting 10:00 a.m. Express by Holiday Inn, Springkerse Business Park, Stirling, FK7 7XE Tel: 0141 632 3283 11 West Middlesex Branch Meeting 8:00 p.m. The Harvester, Watford Road, Croxley Green, Rickmansworth WD3 3RX Tel: 0208 903 6544
13 London Branch Meeting 7:30 p.m. Ozzie Rizzo, 14 Hay Hill, Mayfair, London W1J 8NR Tel: 0208 586 9542
24 Essex Branch Meeting 2:00 p.m. Southend University Hospital Education Centre Carlingford Drive, Southend-on-Sea SS0 0RY Tel: 01702 460890
December 2013 1
6
Leeds Bradford Branch Meeting 10:00 a.m. Oakwell Motel, Leeds WF17 9HD Tel: 01924 475338
Hants and Dorset Branch Christmas Social Meeting 7:45 p.m. Crosfield Hall, Broadwater Road, Romsey SO51 8GL Tel: 01202 425568
January 2014 5
Leeds Bradford Branch A.G.M. 10:00 a.m. Oakwell Motel, Leeds WF17 9HD Tel: 01924 475338
11 Surrey and Berkshire Branch A.G.M. 1:30 p.m. Greyfriars Centre, Reading Berkshire Tel: 0208 660 2822
12 Western Branch A.G.M. 12:15 p.m. Blair Bell Education Centre, Liverpool Women’s Hospital, Crown Street, Liverpool Further details: 01745 331827
14 North West Branch A.G.M. 7:00 p.m. St. Joseph’s Parish Centre, Harpers Lane, Chorley, Lancs. Tel: 0161 486 9234
15 Hants and Dorset Branch A.G.M. 7:45 p.m. Crosfield Hall, Broadwater Road, Romsey SO51 8GL Tel: 01202 425568 17 Sheffield Branch A.G.M. 7:30 p.m. SWD Sports Club, Heeley Bank Road, Sheffield S2 3GL Tel: 01623 452711 28 London Branch A.G.M. 7:30 p.m. Ozzie Rizzo, 14 Hay Hill, Mayfair, London W1J 8NR Tel: 0208 586 9542 16 Birmingham Branch A.G.M. 8:00 p.m. British red Cross Centre Evesham, Worcs. Tel: 01905 454116 17 East Anglia Branch A.G.M. 10:30 a.m. Barrow Village Hall, Bury St. Edmunds IP29 5DX Tel: 01992 589063 19 Essex Branch A.G.M. 2:00 p.m. Southend University Hospital Education Centre Carlingford Drive, Southend-on-Sea SS0 0RY Tel: 01702 460890
19 Western of Scotland Branch A.G.M. 11:00 a.m. Express by Holiday Inn, Springkerse Business Park, Stirling, FK7 7XE Tel: 0141 632 3283
25 Southern Area Council A.G.M. 1:00 p.m. Victory Services Club, 63-79 Seymour Street, London W2 2HF Tel: 01992 589063
page | 19
AWARENESS WEEK
The week that makes sure you don't get forgotten about Dementia Dementia Awareness Week — 20th - 26th May 2013
Dementia is a serious and progressive disease that leads to memory loss and communication problems that can make life confusing. So to help sufferers and their families the Alzheimer’s Society is hosting Dementia Awareness Week. Plenty of celebrity supporters have also been on board - like Dame Judi Dench and X Factor’s Danyl Johnson who used to visit care homes and perform for the residents. It has been proven that music is therapeutic for sufferers and can make communicating easier for them. Pretty amazing eh? Living with dementia isn’t easy to imagine if you haven’t been put in that situation. Reading stories from people who have might help your understanding. Some people have a great support network and others live alone. There is plenty of help available to assist people living alone and help them remain independent as long as possible. 92-year old Rose does tai-chi every day and gets help with carers to plan out her days. She fills them up with going to memory groups, drawing and other activities that help keep her mind active. And this May you can raise dementia awareness to give people like Rose a more improved standard
20 | page
of life. The theme for 2012 was ‘Remember the Person’. Are you a sufferer? Could you help people think differently about dementia? If you think you can help the Alzheimer’s Society wants you to download their ‘Remember the Person’ poster templates and make your own poster of either yourself or of someone you know with dementia. You can include a photograph or a hand drawn picture and write a few words about the person and their interests. Next the Alzheimer’s Society wants us to get as many posters as possible displayed in public places to raise awareness of dementia. There are many other ways that you could participate, for example, take part in a memory walk, go parachuting or… come up with your very own idea for an event! Organise a benefit performance, hold books and cake sales or do a collection. To find out more, visit the Dementia Awareness Week website and see how you can do your bit to help raise awareness. Whatever you decide to do, you know you'll feel great about helping other people. Good luck! Further Information can be obtained at http://www.alzheimers.org.uk/remembertheperson
INFORMATION
Like a Trainer but Smarter
For more information call Cosyfeet on 01458 447275 or see www.cosyfeet.com/heaven. Cosyfeet was the first British company to make shoes for people with swollen feet. 30 years on they still offer the biggest range of extra roomy shoes on the market.
The super-wide Heaven shoe is designed to be as versatile as a trainer, with the flair of leather casuals. Crafted from hand-finished, supersoft leather, this brand new style has been launched by Cosyfeet to celebrate 30 years of making extra roomy footwear for swollen and wide feet. With a EEEEE+ width as standard, the Heaven has an adjustable, touch-fastening strap for a perfect fit. It also has a deep, seam-free toe area designed to protect vulnerable toes, and a soft, odour-resistant lining to cushion the foot. The streamlined appearance of this comfy yet smart shoe belies its extra roomy fit, and a light, shockabsorbing sole makes it ideal for shopping or strolling outdoors. The Heaven is available in Navy leather, Stone leather or Tan leather and is priced at £59.00, (or £47.20 if you qualify for VAT relief due to a chronic medical condition). It comes in sizes 3 to 9 including half sizes. Strap extensions are also available for especially swollen feet.
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01458 447275 page | 21
BRANCH NEWS
Use Your Branch! By Denise Willis B.Sc. M.Inst.Ch.P
When you became a member of the Institute of Chiropodists and Podiatrists you also became of member of your nearest branch. This gave you the entitlement of joining in with your colleagues in your area. You are asked to meet up four times a year to catch up on the latest news from the Institute and to discuss any problems you may have encountered and to get feedback from colleagues on how they deal with their problems. You are also entitled to make decisions on who you want running the institute on your behalf. So why don’t more members attend their local meetings?
Branch membership is very important to all of us. Private chiropody is a very isolated profession especially if you work for yourself. Who do you speak to about an unusual case, or how do you deal with a difficult patient.
Branch meetings are lively and interesting. You are asked what topics you want to learn more about. Your branch members who run the branch on your behalf – unpaid, go
out of the way to provide CPD for you. They will contact companies, trade houses even contact head office for lists of companies who will come to the branch and provide good courses for you. Often they can negotiate with companies to attend the meetings free of charge. Most branches will do this for a minimal charge and are such good value. When you consider some CPD can be on your doorstep it makes sense to use your branch.
So again I ask why don’t more members attend their local meetings?
As a profession, we are audited on a regular basis. If you have not attended a branch meeting or a training course, what have you got in your CPD portfolio? When did you learn a new skill? What new equipment or products are on the market now since you qualified? Branch members are very knowledgeable.
They are a great source of information and are willing to help on any aspect of chiropody or business. Some branches have regular social gatherings which are great fun. Be involved in your local branch. You gain valuable CPD, make great friends, and have a group of peers to help you through any aspect of your business. Details of branch meetings appear in Podiatry Review and on the IOCP website (www.iocp.org.uk) Please contact your branch secretary for more details. All members are welcome to attend other branch seminars subject to availability of places. 22 | page
BRANCH NEWS
North West Branch
North West Branch held their latest branch meeting on 19th March at St. Joseph’s parish centre in Chorley. The guest speaker was Mark Lawrie of DLT who presented an update on the latest products available and forthcoming. He also explained the benefits to the practitioner of the Podopro range of products available from his company.
The meeting was well attended and all who were there had an informative and enjoyable evening. The next branch meeting will be in September but before that the Branch has organised a training event on “Demystifying Biomechanics”, to be presented by Michelle Weddell of Algeos on 12th May. Members from all branches are welcome to attend and details can be obtained from Bryan Massey, Branch Secretary.
Barry Carter North West Branch
FUNGAL INFECTIONS ARE INCREASING! There are now fewer products on the market that are available and can claim they really do work. If your patients suffer from fungal infections then you may have a solution. .. USE MYKORED The results speak for themselves when treating fungal infections of the SKIN and/or NAILS. MYKORED The one product solution for fungal infection of skin and nails. Low cost, painless and very effective! Successfully used in the UK for over 10 years. Only available through you as foot specialists; thus protecting your market and your income. Mykored is not available over the counter from pharmacies!
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ALSO AVAILABLE FROM
DLT Hilary Supplies, 34A Halstead Road, Mountsorrel. Leics. LE12 7HF Tel: 0116 230 1900 Fax: 0116 230 3363 eMail: soniak@hilarysupplies.co.uk page | 23
BRANCH NEWS
News from the Southern Area Council
The Southern Area Council (SAC) members have been working hard over the past year on behalf of the nine Branches it represents. It has however, had a number of highs and lows, but still continues to strive to come together and listen to each Branch and its member’s issues, good or bad.
In 2012 the SAC had a financially successful spring seminar, which will enable the SAC to support and fund the travel expenses of its Branch Delegates to attend this year’s (2013) Institute of Chiropodist and Podiatrists (IOCP) National Podiatry Conference and A.G.M. in Southport. This will help support the IOCP’s Honourable Treasurer - Jacquie Drane’s aim to offset some of the financial burden associated in organising and providing the IOCP’s annual conference.
In view of the SAC’s large expense of funding Branch Delegate’s A.G.M. expenses and the escalating costs and work-loads in trying to organise the SAC annual spring seminar, the SAC decided, with much regret, to cancel this year’s seminar, but will begin organising a seminar for 2014. The SAC’s decision to cancel this years’ event was not taken lightly, as in recent months the SAC’s efforts had also been marred by the sad news and bereavement of the SAC Honourable Treasurer - Flavia Tenywa’s husband, who died earlier this year following an illness. It was also with great sadness that the SAC learned of the death, late last year, of Derek Bird the Essex Branch Delegate to the SAC. Sadly he had been suffering from ill-health over the last few years. Derek was the much respected Chairman of Essex Branch and member of the SAC. He joined the SAC as the Delegate for Essex Branch in June 2010, but due to ill health he was unable to attend an SAC meeting until the following June, 2011. Although, he was only with the SAC for a short time, he had made a big impact with its members. Derek was a dear friend and gentleman, his friendly banter, intelligence, great knowledge base and sound advice was a great part of the contributions he made, which commanded the respect he gained from the SAC and Essex Branch members, who he had served for many years as their Chairman. Derek had also been a long serving member of the IOCP, and for more than 30 years his dedication and commitment was highly regarded and respected by everyone who knew him. Derek will be sadly missed by both the SAC and Essex Branch members. The SAC member’s thoughts are with both Flavia and Derek’s families at this time.
On a happier note the SAC is proud to see two of its more notable members from the SAC region, nominated to become the next President of the IOCP. Roger Henry represents Devon and Cornwall Branch and David Crew of the Surrey and Berkshire Branch. David is also a serving SAC Officer as the elected Delegate for the Executive Committee. The SAC wishes both of them all the best in their endeavours for securing the future role of President of the IOCP.
24 | page
The SAC continue to meet in London three times a year in an effort to advise and support the members of the various Branches they serve. I can say in all honesty, my fellow SAC colleagues are committed, proactive and supportive of each of the Branches they represent, and continue to encourage their Branches and its members to attend Branch meetings and provide Continued Professional Development (CPD) whether it is at Branch or Area Council levels.
On a final note it continues to be my great pleasure to work alongside the members of the SAC. In addition, I wish to express my grateful thanks for their continued support of the SAC, and although we are together primarily to conduct business on behalf of our Branch members, we do have some fun. This has also resulted in having made some very good friendships along the way and long may this continue.
Kindest regards and best wishes Beverley Wright Chairperson, Southern Area Council
15th NORTH WEST AREA COUNCIL SEMINAR SUNDAY 13th OCTOBER 2013
The North West Area Council will be holding their 15th Annual Seminar at the University of Central Lancashire, Preston on 13th October 2013. The confirmed lectures this year are Podiatric Surgeon: ‘Criteria for the Management of Hallux Valgus’ and’ The Effects of Medicine on Blood Pressure’ by Dr. Emma Allison MBBs. Hons. One more lecture is to be confirmed.
The lecture theatre is superb with comfortable seating and space. The trade stands are putting on a great show this year providing members a good variety of products and consumables. There is a hot two course lunch provided and tea and coffee is available throughout the day. There was no Seminar last year so this year will be one not to miss. At the end of the Seminar there will a Prize Draw and you will gain a valuable CPD Certificate for your portfolio’s. The cost of 3 CPD lectures, and excellent lunch and a chance to grab a few bargains from the trade stands is £65.00 (same price two years ago). Free parking is available. Book your place now on a very worthwhile and enjoyable day. Booking Form on Page 27. Denise Willis
CITY AND GUILDS
Congratulations: Ben Williams, Naomi Best, Emma Gelling, Wendy Johnson and Nicola Strong
Friday 22nd March saw me in Sheffield with the task of assessing our City and Guilds students for their practical aspects of the course. Despite the inclement weather, and despite having numerous cancellations on the day we did get enough patients turn out for the students to treat!
It was to my great pleasure that all five students passed their assessments and after cracking open the celebratory bottle of bubbly, were presented with their certificates. On behalf of the Executive Committee, I would like to congratulate them, welcome them into the Institute of Chiropodists and Podiatrists as Foot Health Practitioners, and wish them all well for what I am sure will be for them, a very rewarding future. I would also like to extend the thanks of the Executive Committee to Mr S Gardener for the sterling work that he has done on behalf of the Institute of Chiropodists and Podiatrists.
Malcolm Holmes BSc, MInstChP Acting Vice-Chairman, Executive Committee
page | 25
PRESS RELEASE
UK based Algeos forays into the Indian Market with Diaped - a comprehensive diabetic foot care clinic at seven locations across Mumbai
Mumbai, Jan 6th: Diaped, a division of the ALG Group of companies which includes Algeo’s, have established and opened a Franchise network of Diabetic Foot Screening Clinics in India with the ambitious goal of operating 100 clinics in 5 years. The clinics were launched in the presence of Maharashtra’s Health Minister Shri Suresh Shetty along with Alan Sheridan, Chairman (A. Algeo U.K.), Mr. Hugh Sheridan, Commercial Director (A. Algeo U.K), and Mr. Bhushan Hemade, CEO (Algeos India Pedorthic Pvt. Ltd.)
Mr. Hugh Sheridan, General Manager of Asia Pacific Middle East and Africa and Commercial Director- (Algeo’s, U.K.) commented, “Mumbai is the Diabetic Capital of India with almost 20% of its 18m population having Diabetes and many more pre-diabetic. I established our operations here because of a highly visible need for awareness and education for this massive population of diabetics. We have been able to put together a foot screening plan for diabetics using our diagnostic technologies. At the same time, depending on their risk classification we are able to offer Indian made footwear, insoles and socks to prevent Foot ulcers and then amputation. It is a simple plan but one which has had great results which have been proven in 2 trial clinics. Education and awareness are the key and this network will help in that.” According to the Ministry of Health-Government of India statistics, approximately 20% of diabetics are admitted in Indian hospitals for foot problems, while as much as 50-70% of all amputations performed are on diabetics.
Speaking at the launch of the Dadar clinic in Central Mumbai, Minister Mr. Suresh Shetty said, “Diaped clinics will provide therapy that will prevent gangrene in diabetic foot patients thereby preventing disability.”
Diaped was launched in India with the objective of preventing diabetic lower limb amputation and providing cost effective services to the patients in the country. Confirming the same, Mr. Hermade said, “Diaped will provide diagnostic services and preventative products at approximately 25% of the cost that the health system incurs in the UK. The company has plans to make a sizeable presence in major cities across Maharashtra in the next 6 months followed by PAN-India presence on a franchise basis. The idea is to provide service accessibility to the masses.”
About Diaped A multidisciplinary Foot Clinic, Diaped will deal with Prevention, Diagnostics, Management & Education and offer services like Diabetic Foot Care & Solutions, Foot Scanning, Foot Sensation Tests, Counseling and Treatments, Footwear & Customization and Foot Rehabilitation. The Foot Clinic will also provide regular foot examination to check for Early symptoms of Neuropathy, Ischemia, Foot Biomechanics, Foot Deformities, Callus and Corns, Infection and Necrosis
Diaped is a division of ALG, which is marketed by Algeos India and supports Franchise set-ups for Diabetic Amputation Prevention. Currently there are 7 Clinics open in Mumbai and Pune with further 6 clinics opening in the next 6 months. There are ambitions of Mr. Bhushan Hemade (CEO of Algeos India) to operate over 100 clinics throughout India over the next 5 years. With assistance from UK, Franchisees are equipped with the latest diagnostic and prevention technologies with continuous training from UK based Podiatrists. Algeos India operates a centralized fabrication facility for customized shoes, sandals and Foot Orthotics.
26 | page
Diaped Clinics have been proven to be a welcome addition in the role of amputation prevention and as part of the Multidisciplinary Diabetic Foot Team which includes Family Doctors, Diabetologists and Vascular Surgeons. Within the clinic, diabetic patients are diagnosed into risk categories, educated about their risk category status and prescribed different management and prevention solutions dependent on that risk category before a Diabetic Foot Ulcer occurs. This Care Pathway with extensive international research has proven to cut the amputation rates in India and Globally. www.diaped.co.uk About Algeos India and ALG
Algeos India is a Member of the ALG Family of companies and was established in 2010 with headquarters in Mumbai.
With Global Headquarters in Liverpool, UK, ALG are viewed as the market leader in: Orthotics & Prosthetics; Podiatry; and Rehabilitation ALG is the holding company of the Distributor Algeos and has offices and distribution centres in Melbourne, Australia; Dubai, UAE; Los Angeles, USA; and Mumbai, India. ALG has over 10,000 products in its portfolio and during 2011 we sold to 10,000 customers in over 50 countries with almost 100 staff globally. Algeos UK was established in 1881 and has been owned by the Sheridan Family since 1990. ALG designs, develops and manufactures products through its own UK Based R&D Department and markets them through 7 branded product ranges where they are sold through ALGs Global Subsidiaries and over 70 Global Distribution Partners.
Aortha – Orthotic & Prosthetic Materials and Components Diaped – Products and Solutions for the Diabetic foot clinic Podotech – Biomechanical solutions for Diagnostics, Comfort and Correction Multicast – Range of Products for the Fracture clinic and Post-Operative clinic Nova – Equipment for the Podiatry Clinic Physioworx – Physiotherapy Clinic Consumables and Muscular Pain Relief Bodytonix – Wearable Orthotic Technology – From Neoprene Bracing to Electronic Pain Relief www.algeos.com www.algeos.in
NORTH WEST AREA COUNCIL
BRANCH NEWS
15th ANNUAL SEMINAR at
The University of Central Lancashire, Preston on
Sunday, 13th October, 2013
PROGRAMME 9:30 a.m.
Registration; tea; coffee and biscuits
11:00 a.m.
Tea, coffee & biscuits
12:30 p.m.
Lunch, tea & coffee and trade stands
3:00 p.m.
Prize Draw & CPD Certificate Issue and Close of Seminar
10:00 a.m.
Lecture: Podiatric Surgeon: Criteria for the Management of Hallux Valgus Lecturer T.B.C.
11:30 a.m.
Lecture: The Effects of Medicine on Blood Pressure Lecturer Dr. Emma Allison MBBs.Hons
2:00 p.m.
Lecture: To be confirmed
If you plan to attend please send your details and a cheque made payable to:
‘IOCP North West Area Council’ for £65.00 (This includes all refreshments and cooked lunch)
Send to: Mr. Bryan Massey, 104, Gillbent Road, Cheadle Hulme, Cheshire, SK8 6NG For more information please contact David Topping (Secretary) 01772 615769
✁ ✁ -----------------------------------------------------------------------------------------------------------------------------------------------Booking Form
NWAC 15th ANNUAL SEMINAR 2013
I enclose a cheque for £65 made payable to the IOCP North West Area Council
Name:.....................................................................................................................................................................
Address: ................................................................................................................................................................. .................................................................................................................Post Code: ............................................
Branch: ................................................................................................................................................................... Tel No.: .......................................................................Email:.................................................................................. Please Return to Mr. B. Massey, 104 Gillbent Road, Cheadle Hulme, Cheshire, SK8 6NG
page | 27
DIABETES NEWS
Having the right care is essential for the wellbeing of all people with diabetes. There is a minimum level of healthcare that every person with diabetes deserves and should expect.
1
15 Healthcare Essentials
Get your blood glucose levels measured at least once a year. An HbA1c blood test will measure your overall blood glucose control and help you and your diabetes healthcare team set your own target.
2
Have your blood pressure measured and recorded at least once a year, and set a personal target that is right for you.
3
Have your blood fats (cholesterol) measured every year. Like blood glucose levels and blood pressure, you should have your own target that is realistic and achievable.
4
Have your eyes screened for signs of retinopathy every year. Using a specialised digital camera, a photo of each eye will be taken and examined by a specialist who will look for any changes to your retina (the seeing part at the back of your eye).
5
Have your feet checked – the skin, circulation and nerve supply of your feet should be examined annually. You should be told if you have any risk of foot problems, how serious they are and if you will be referred to a specialist podiatrist or specialist foot clinic.
6
Have your kidney function monitored annually. You should have two tests for your kidneys: urine test for protein (a sign of possible kidney problems) and a blood test to measure kidney function.
7
Have your weight checked and have your waist measured to see if you need to lose weight.
8
Get support if you are a smoker including advice and support on how to quit. Having diabetes already puts people at increased risk of heart disease and stroke, and smoking further increases this risk.
9
Receive care planning to meet your individual needs – you live with diabetes every day so you should have a say in every aspect of your care. Your yearly care plan should be agreed as a result of a discussion between you and your diabetes healthcare team, where you talk about your individual needs and set targets.*
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10
Attend an education course to help you understand and manage your diabetes. You should be offered and have the opportunity to attend courses in your local area.
11
Receive paediatric care if you are a child or young person. You should receive care from specialist diabetes paediatric healthcare professionals. When the time comes to leave paediatric care, you should know exactly what to expect so you have a smooth change over to adult health services.
12
Receive high quality care if admitted to hospital. If you have to stay in hospital, you should still continue to receive high-quality diabetes care from specialist diabetes healthcare professionals, regardless of whether you have been admitted due to your diabetes or not.
13
Get information and specialist care if you are planning to have a baby as your diabetes control has to be a lot tighter and monitored very closely. You should expect care and support from specialist healthcare professionals at every stage from preconception to post-natal care.
14
See specialist diabetes healthcare professionals to help you manage your diabetes. Diabetes affects different parts of the body and you should have the opportunity to see specialist professionals such as an ophthalmologist, podiatrist or dietitian.
15
Get emotional and psychological support. Being diagnosed with diabetes and living with a long term condition can be difficult. You should be able to talk about your issues and concerns with specialist healthcare professionals. Checks and services for children. Children should receive more frequent HbA1c measurements and regular weight, height and general health checks from their healthcare team. Formal screening for complications generally begin at age 12.
Become a member of Diabetes UK – www.diabetes.org.uk/ membership or call 0845 123 2399 Get involved with the work and help improve services – www.diabetes.org.uk/get-involved For advice and support call the Diabetes UK Careline 0845 120 2960
DIABETES NEWS
Slow treatment “leading to thousands of diabetes-related foot amputations”
Thousands of people a year endure a diabetes-related foot amputation because their foot ulcer is not treated quickly enough, according to a new report. The Diabetes UK report, called Fast Track For A Foot Attack: Reducing Amputations’, warns that too many areas do not have the systems in place to ensure foot ulcers and foot infections in people with diabetes are treated within 24 hours. This is despite the fact that ulcers can deteriorate extremely quickly and a matter of hours can make the difference between keeping a foot and losing it. It has highlighted the lack of these systems at a local level as one of the main reasons the number of foot amputations is increasing – there are already 6,000 diabetes-related amputations a year and this is projected rise to 7,000 by 2015. It is thought that up to 80 per cent of these amputations could be prevented. The report, which Diabetes UK has produced with the Society for Chiropodists and Podiatrists and NHS Diabetes, makes recommendations that could dramatically reduce diabetesrelated amputation rates and bring an end to the current situation where people with the condition are over 20 times more likely to have an amputation than the rest of the population. The recommendations include: • All hospitals should have a multi-disciplinary footcare team (MDT), which brings together different healthcare professionals to ensure good quality care for foot problems in people with diabetes. The National Institute for Health and Clinical Excellence recommends that these teams should be in place, but the most recent figures suggested 40 per cent of hospitals do not have them. • Every hospital should guarantee that people with urgent foot problems can be assessed by an MDT within 24 hours, as it is vital that foot problems are treated quickly.
• Every area should have a system for identifying and regularly reviewing people at high risk of foot ulcers and infections , including annual foot checks and foot protection teams in the community. • People with diabetes who are at high risk of foot problems should know what to look out for and where to go in the event of a foot attack. Barbara Young, Chief Executive of Diabetes UK, said: “It is unacceptable that every single week people with diabetes who have treatable foot problems are having feet or toes amputated because they are not being treated quickly enough. “It is not as if this is a problem we don’t know how to solve. If every hospital had a multi-disciplinary footcare team and ensured access to that team within 24 hours, then that would make a huge difference to the amputation rates. We also need to make sure people with diabetes are getting a thorough annual foot check and then those at high risk of amputation are given the help they need to prevent them. All too often, we hear stories about foot checks that are so fleeting that the person is not even asked to take their shoes off. “This is not something that requires more money. In fact, putting these kind of systems in place can actually save money because the amputations that they prevent are so expensive. But we need leaders across the NHS, the NHS Commissioning Board and local clinical commissioning groups (CCGs), to insist that this happens and hold those areas that do not have these systems in place to account. “We need action now.”
For information about Diabetes UK’s Putting Feet First campaign, visit www.diabetes.org.uk/putting-feet-first. The new report will also be available here.
New implant could aid bone healing process Arthritis Research UK
UK scientists have developed a new implant material that could help to repair broken bones. The degradable rigid material is combined with bone stem cells to encourage the growth of new bone material in the damaged or diseased area. The implant benefits from a honeycomb scaffold structure which is designed to allow blood to flow through it. This enables stem cells from the patient's bone marrow to reach the material, attach to it and grow new bone. Over time, the lightweight plastic that the implant is made from - a blend of three types of plastics - degrades as it is replaced by newly grown bone tissue. The material has already been tested in the laboratory and in animals and clinical trials are now being planned. It is hoped that the advance could form the basis of a new treatment for people with fractures or diseased bone. Professor Mark Bradley, from the University of Edinburgh’s School of Chemistry, revealed: “We were able to make and look
at hundreds of candidate materials and rapidly whittle these down to one which is strong enough to replace bone and is also a suitable surface upon which to grow new bone.” “We are confident that this material could soon be helping to improve the quality of life for patients with severe bone injuries, and will help maintain the health of an ageing population.” Scientists in Edinburgh have been collaborating with researchers at the University of Southampton on the work, which is now published in the journal Advanced Functional Materials. Richard Oreffo, professor of musculoskeletal science at the University of Southampton, said: "Fractures and bone loss due to trauma or disease are a significant clinical and socioeconomic problem. “This collaboration between chemistry and medicine has identified unique candidate materials that support human bone stem cell growth and allow bone formation. Our collaborative strategy offers significant therapeutic implications.” page | 29
INFORMATION
Antidepressant link to heart changes confirmed
Citalopram is a widely prescribed antidepressant in the UK
“Heart risk link to SSRI antidepressants confirmed,” BBC News reports. The BBC goes on to say that “some but not all antidepressant drugs known as SSRIs pose a very small but serious heart risk”. This news, which was reported well by the BBC was based on good quality research into the relationship between the electrical activity of the heart and use of antidepressant medication.
Researchers were particularly interested in potential risks associated with a kind of SSRI antidepressant called citalopram, as it has been the subject of recent warnings by European and US drug regulators. Other SSRI antidepressants were included in the study as well. The researchers were also interested in an older tricyclic antidepressant called amitriptyline, which is also used to treat nerve pain.
The researchers examined the medical records of tens of thousands of patients who had been prescribed an antidepressant and had also had an electrocardiogram (ECG). They found that some of the drugs being studied were associated with a disturbance of the electrical activity of the heart, which increased at higher doses of the medication.
While these changes in the electrical activity of the heart represent a theoretical increase in the risk of serious heart rhythm problems, such events are quite rare. Doctors are already aware that these drugs carry this potential risk. As a result, new recommendations about antidepressant dosage were released in 2011. The news is that there is now more research to support a link between certain antidepressants and heart problems, not that there is a sudden shift in the evidence.
The study was carried out by researchers from Massachusetts General Hospital and Brigham and Women’s Hospital in the US and was funded by the US National Institutes of Health and National Library of Medicine.
The study was published as an open access article in the peer-reviewed British Medical Journal.
The BBC covered this story appropriately, from the headline through to discussion of the risks versus the benefits of antidepressant use. The Daily Telegraph similarly reported on the balance of risks and benefits. However, its headline: “the most widely-used antidepressant in Britain increases the risk of potentially fatal heart rhythm problems”, is not strictly correct. The researchers were not looking at heart rhythm problems – only at changes to the heart’s electrical activity, which could potentially lead to heart rhythm problems.
This was a cross-sectional study that examined the association between doses of antidepressant medication and
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a variation in the electrical activity of the heart, as measured by an electrocardiogram (ECG).
An ECG measures the electrical activity of the heart as it beats. The electrical activity of one heartbeat is traced on the ECG in five segments. These are called the P, Q, R, S and T segments. These segments indicate how the electrical signals flow through the chambers of the heart. The change in electrical activity that this study was interested in was the duration between the Q wave and the T wave – known as the QT interval.
When the QT interval is prolonged, this means that electrical activity is spreading through the heart slightly slower, and this may carry a risk of triggering a rare condition of abnormal electrical activity known as torsade de pointes.
The main risk of torsade de pointes is that this may lead to a serious condition known as ventricular tachycardia, which is a very rapid heart rate that carries the risk of progressing to cardiac arrest (where the heart stops pumping blood around the body).
This study examined the link between antidepressant medication use and prolonged QT interval – the first step in a chain of risk factors. It is important to note that it did not directly assess the link between taking an antidepressant and having or developing a serious heart rhythm problem.
The US Food and Drug Administration (FDA) has previously warned about the use of high doses of citalopram, which is a commonly prescribed SSRI antidepressant medication, because of concerns over its association with prolonged QT intervals.
This prompted the UK’s regulatory body, the Medicines and Healthcare products Regulatory Agency (MHRA) to amend its dosage guidance so that it no longer recommends high doses of SSRIs.
As this was a cross-sectional study, we cannot say for certain whether the medication directly caused the change in electrical activity seen. The presence of a dose-response relationship (where the QT interval is more prolonged at higher medication doses) supports the theory that the medication caused the changes seen. However, other criteria must be met, and this research must be supported with more robust evidence, before we can be absolutely certain of the nature of the relationship.
The researchers accessed the health records of patients who had been prescribed antidepressant medications (including SSRIs and tricyclics), and who underwent an ECG test to trace the heart’s electrical signal after they were prescribed the medication.
INFORMATION The researchers classified each patient according to which drug they were prescribed. They analysed the association between each drug and the length of the QT interval using a variety of statistical models. There are standard categories of QT interval duration associated with higher risk of future heart rhythm problems. The researchers classified the patients into these categories based on their ECG results.
In this analysis, they took into account several variables that may confound the relationship between medication use and QT interval, including: • age • ethnicity • sex • history of major depression • history of cardiovascular disease
What were the basic results? The study included 38,397 patients. Of these, about a quarter were prescribed the SSRI citalopram. Approximately 20% of the study participants were classified as having an abnormal or high QT interval, and this percentage did not vary greatly between the medications.
The researchers found that increasingly large doses of several antidepressants were significantly associated with increased QT interval. These antidepressants included the SSRIs citalopram and escitalopram, and the tricyclic antidepressant amitriptyline.
The drug bupropion (used to treat nicotine dependence and to help people quit smoking) was found to be significantly associated with decreasing QT interval at higher doses. The other medications examined had no significant association with QT interval.
How did the researchers interpret the results? The researchers conclude that there is a modest increase in the QT interval among patients treated with some antidepressants, but that the sizes of these associations were small, and the clinical implication of this increase is not known.
Conclusion This study shows a link between three antidepressants (two SSRIs and one tricyclic) and prolonged QT interval (a risk factor for rare but serious heart rhythm problems). The study did not assess the risk of these heart rhythm problems directly (which is difficult to measure because of their rarity). The researchers point out that the recent FDA warning over the risks of citalopram was based on its association with prolonged QT interval only, and “in spite of the epidemiological data showing no difference in risk for arrhythmia [heart rhythm abnormality]”.
The researchers say that certain SSRIs were not significantly associated with risk of prolonged QT interval, and that these medications may be preferable treatment options for people with other cardiac risk factors.
Although this evidence backs up previous evidence in this area, the study has several limitations that should be considered. First, there is a risk that the manner in which patients were selected for the study may bias its results. This
is because the researchers did not include all patients who were prescribed an antidepressant, but only those who underwent an ECG as well. As ECGs are not routinely conducted for patients treated with antidepressants, this may automatically have excluded patients at lower risk of having a prolonged QT interval, biasing the results towards those patients with prolonged QT intervals.
The authors examined the differences between the participants included in the study (those with an antidepressant prescription and an ECG) and those excluded because they hadn’t had an ECG. When they did this they found that the research group tended to be older, with more comorbidities (illnesses in addition to that being treated with antidepressants), and that they used more healthcare services than the “excluded” group of patients.
Therefore, the associations found in this study should not be assumed to apply to all people taking antidepressants. The authors report that their results are most relevant to older, sicker patients being treated with antidepressants, and not to an “average” (presumably meaning a younger and otherwise healthy) patient.
A second limitation worth noting is that – as the authors point out – the study did not assess a hard clinical outcome, such as torsade de pointes, but rather chose the “proxy outcome” of QT interval. Prolonged QT interval will not necessarily develop into a serious heart rhythm problem. And this study cannot tell us whether individuals taking citalopram, escitalopram and amitriptyline are at increased risk of these problems.
A third limitation to consider (again pointed out by the researchers) is that the patients were not randomly assigned to treatment, and this may confound the results. This is because doctors may make treatment decisions on factors not included in the present analysis.
Overall, this study suggests that some patients being treated with antidepressants may be at increased risk of prolonged QT interval. It isn’t possible to say whether this risk translates into increased risk of serious heart problems, nor is it possible to estimate the size of this risk.
This research provides valuable further information on the association of certain antidepressants with prolonged QT interval – a risk factor already recognised by the medical profession. However, further research is needed to examine any link between antidepressant use and heart rhythm problems.
In conclusion, the results of this study probably won’t affect most people using antidepressants. The potential risk that a prolonged QT interval will cause a serious complication is small and the benefits of antidepressant treatment outweigh the risk in many cases. However, this reinforces that all such risks need to be considered by patients and their doctors when medication is chosen or reviewed.
If you are concerned about the medication you have been prescribed never stop taking it without first speaking to the doctor who is responsible for your treatment and care. page | 31
INFORMATION
Could ‘healthy’ margarine fats be bad for you?
Products such as margarine may contain omega-6 fatty acids
A study published today in the British Medical Journal finds that people who followed health advice and ate certain omega-6 polyunsaturated fats instead of animal fats had higher death rates. This study has prompted media comment as it appears to contradict established health guidance. Polyunsaturated fats are commonly used in "healthy" margarines, spreads and other alternatives to butter.
However, experts say that we should not be unduly alarmed. The Science Media Centre has issued a statement that says that the research, "does not alter our understanding of the possible relationship between diet and cardiovascular risk" and that "the claims in the paper are not new or at odds with existing evidence".
There's a danger of over-interpreting this research. It focused on one, not all, omega-6 polyunsaturated fats, and the results are in a very specific group – middle-aged men who had had heart attacks.
The study suggests that not all polyunsaturated fatty acids are good for the heart. But British consumers should not panic – the safflower oil used as a source of omega-6 in this study is rarely used in this country.
The study was carried out by researchers in the US and Australia. It was funded by the Life Insurance Medical Research Fund of Australia and New Zealand and the Intramural Program of the National Institute on Alcohol Abuse and Alcoholism, US National Institutes of Health. The study was published in the peer-reviewed British Medical Journal.
This was a second analysis of a randomised controlled trial performed in Australia between 1966 and 1973. A randomised controlled trial is the ideal trial design to examine cause and effect. However, the current analysis includes outcomes that were not primary outcomes of the original trial. The original trial investigated whether replacing sources of saturated fats, such as animal fats and butter, with safflower oil (a kind of oil used for cooking and in some manufactured foods) reduced the risk of death from any cause in men with premature coronary heart disease. It only reported the risk of death from all causes and deaths
32 | page
due to cardiovascular disease (CVD) or coronary heart disease (CHD) were not examined.
In this new study, the researchers calculated whether eating more safflower oil affected the risk of death in people with cardiovascular or coronary heart disease (this is called "secondary prevention"). The researchers also wanted to know to what extent an increased intake of polyunsaturated fatty acids or saturated fatty acids was associated with deaths from CVD or CHD. The results of this new analysis were then used to update a meta-analysis of other trials looking at polyunsaturated fatty acids for cardiovascular risk reduction.
Researchers recruited 458 men aged between 30 and 59 who had suffered a heart attack or an episode of coronary insufficiency or angina after admission to hospital. These men were randomised to receive either a dietary intervention or no specific dietary instruction, in addition to standard medical care.
The dietary intervention consisted of instructions to:
• increase polyunsaturated fatty acid intake to about 15% of total energy intake
• reduce saturated fatty acid intake to less than 10% of energy intake • reduce cholesterol to less than 300mg per day
To help achieve these targets, the men were given liquid safflower oil and safflower oil polyunsaturated margarine. They were told to use these items to replace animal fats, butter and margarine, shortenings, cooking oils and salad dressing, as well as taking safflower oil as a supplement. Safflower oil contains 74.6g per 100g of a type of polyunsaturated fat called omega-6 linoleic acid, and no other polyunsaturated fatty acids.
Men returned for clinical assessment every three months for the first year and then every six months for a median of 39 months. Blood samples were taken to measure the levels of cholesterol and triglyceride (fat). The men also filled in a food diary so that their diet could be assessed.
Deaths that occurred during the trial were assigned codes from the International Classification of Diseases (ICD), according to information taken from death certificates of
INFORMATION final hospital admission records. Using survival analysis, the researchers analysed whether the risk of death from any cause or deaths from cardiovascular and coronary heart disease differed between the intervention and the control group. The researchers also examined whether nutrient intake (based on the results of the food diaries) accounted for changes in mortality. What were the basic results? • men in the intervention group significantly increased their intake of polyunsaturated fatty acids, and significantly reduced their intake of saturated fatty acids, cholesterol and mono-unsaturated fatty acids compared with the control group
• the level of cholesterol in the blood decreased significantly more for men in the dietary intervention group compared with the control group, although changes in the level of triglycerides (fats) in the blood, body mass index (BMI) and blood pressure were similar between groups
• men in the dietary intervention group had higher rates of deaths from any cause than controls (17.6% of the dietary intervention group died compared with 11.8% of the no intervention group, hazard ratio 1.62, 95% confidence interval 1.00 to 2.64)
• men in the dietary intervention group had higher rates of death from cardiovascular disease (17.2% of the dietary intervention group died due to cardiovascular disease compared with 11.0% of the no intervention group, hazard ratio 1.70, 95% confidence interval 1.03 to 2.80)
• men in the dietary intervention group had higher rates of deaths from coronary heart disease (16.3% of the dietary intervention group died due to coronary heart disease compared with 10.1% of the no intervention group, hazard ratio 1.74, 95% confidence interval 1.04 to 2.92)
• an increase in 5% of food energy from omega-6 linoleic acid predicted a 35% higher risk of cardiovascular death and a 29% increase in all-cause mortality in the intervention group
When these results were added to a meta-analysis of other trials that have assessed the effects of linoleic acid, it was found that linoleic acid increased the risk of death from coronary heart disease and cardiovascular disease, although these results were not significant.
The researchers have concluded that there is no clear clinical evidence that the most common polyunsaturated fatty acid, omega-6 linoleic acid, can reduce people's risk
of developing heart conditions. "Advice to substitute polyunsaturated fats for saturated fats is a key component of worldwide dietary guidelines for coronary heart disease risk reduction. However, clinical benefits of the most abundant polyunsaturated fatty acid, omega-6 linoleic acid, have not been established.
"In this cohort, substituting dietary linoleic acid in place of saturated fats increased the rates of death from all causes, coronary heart disease, and cardiovascular disease. An updated meta-analysis of linoleic acid intervention trials showed no evidence of cardiovascular benefit.
"These findings could have important implications for worldwide dietary advice to substitute omega 6 linoleic acid, or polyunsaturated fats in general, for saturated fats."
Conclusion Contrary to received wisdom, this research suggests that not all polyunsaturated fatty acids are good for the heart (the so-called "cardioprotective effect").
This study has several strengths. It was a randomised controlled trial, using just one type of oil to increase consumption of polyunsaturated fatty acids.
However, the study also has its limitations. The dietary data collected during the original trial does not contain enough information to rule out the possibility that changes in other nutrients could have caused the effect seen.
In this trial, participants were advised to increase their intake of polyunsaturated fatty acids, mainly from omega 6-linoleic acid, to 15% of total food energy, and the results may not be generalisable to lower linoleic acid intakes.
As this trial was performed on men aged between 30 and 59 who had premature coronary heart disease, it may not be possible to generalise the results to men who do not have coronary heart disease, men of different ages, and women.
It is worth noting that vegetable oils have very different characteristics in terms of the proportions of omega-3 or omega-6 content and the types of polyunsaturated, monounsaturated and saturated fatty acids that they contain. Oleic acid and linoleic acid are likely to have different properties to linoleic acid, and so it cannot be assumed any effect seen here is typical of all vegetable oils. Further information can be obtained at www.nhs.uk
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ORTHOTIC CONSTRUCTION
Orthotic construction from the negative cast to the finished device Paul Mountford M.Inst.Ch.P., C.Ped
Pic 3
First the lab will receive your negative slipper casts, or scans in this case, and usually after initial assessment they will align the heels vertical, unless requested otherwise.
Pic 1
Pic 1 shows the positive casts, or scans in this case with the heels vertical The next stage is to create a positive to which the modifications can be added, a process still used is to pour plaster into the negative cast with the heel vertical, which usually involves a forefoot balance. This is allowed to dry then the outer slipper cast is peeled away to produce the positive cast (or solid model). As our system is computerised we are able to edit the scans which allows us to produce a positive from the scanned negative cast or the scan of the patient’s actual foot, this is as accurate as pouring plaster. Again pic 1 shows the positive image prior to modifications being applied.
Pic 4
Pic 5
The following pictures show the construction to produce the modified positive: Pics 2/3/4/5/6/7 show cross sections which are part of the design software which allow us to modify the cast and input expansions/angles which can be adjusted to any degree we like, just like adding plaster to a poured positive. Pic 2
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Pic 6
ORTHOTIC CONSTRUCTION Pic 9 this shows the completed positive on the computer ready to be sent to the milling machine. We can see quite clearly the modified aspect of the positive by the dotted area
The milling of the positive
Pic 10/11 shows the milling process
Pic 7
In picture 2 we can see how the medial arch is created, if we look at frames 2 through to 6 we can see how the medial arch is created, the yellow boundary is the actual cast line, the pink section is the modification applied, each one of these frames represents a section of the arch.
Pic 10 Pic 11
Pictures 3/4 allow us to see the final modifications; the modifications are in the lighter blue colour.
Picture 7 allows us to see exactly how the arch fill has blended into the arch, the lighter blue colour is the modification applied. The 3 sections represent the 3 bisection lines seen going through the image of the foot.
Picture 8 this allows us to see how the modifications we have created sit over the unmodified cast; we have the contact area of the device (light blue) over laid onto the 3d image of the foot/cast. We are able to see right through what will be the contact area of the orthotic against the uncorrected foot.
The positives are milled out of industrial wax, once used this can be melted down for re-use, we don’t need to keep these positives as everything is stored on computer
The milled out positives
Pic 12/13 shows the milled out positives Pic 12 Pic 8
Once we are happy with the designed modifications we finish the creation of the positive. Pic 9
In picture 13 we can see where there has been a modification created for a met raise.
Pic 13
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ORTHOTIC CONSTRUCTION Now the construction of the devices
Pic 19
These devices have been constructed to replace removable inlays from the Wolky sandal; they need to be full length and a density to fill the void created by removing the inlay. The actual orthotic shell is moulded by applying heated material over the casts and placed in a vacuum press to shape the material; these have also had an extrinsic heel applied. Pic 14/15 Pic 14
Pic 20
Pic 21 Pic 15
Now the outer materials applied to fill the void created by the removal of the inlay - Pictures 16 through to 22 show this.
Pic 22
Pic 16
Pic 17
The following pictures 23/24/25 are the sandal the devices are required to fit
Pic 23
Pic 24
Pic 18
Pic 25
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CLASSIFIED To advertise in this section and on our website Call 01704 546141 or email bernie@iocp.org.uk
RETIREMENT SALE PRACTICE – SHEFFIELD, SOUTH YORKSHIRE
Chiropody and multidisciplinary clinics for sale, built up over 17 years. £140,000 Includes goodwill, equipment and premises, with easily converted living accommodation upstairs. Will consider selling separately. Turnover in excess of £40,000. Email office@parkview-therapy.co.uk
SUFFOLK – Suffolk Country practice near Bury St.
Edmunds for Sale. Busy practice built up over 19 years, 4 days a week, home visits and surgery, still expanding. Turnover 42k, will accept 20k. Full clinic equipment for sale. Further enquires 01359 268680 or email stoner.amanda@yahoo.com
DERBYSHIRE – Practise for sale-Long EatonDerby/Nottingham border.
Successful practise for sale due to retirement. currently working 3 day surgery in owner’s home, one day domiciliary. Sale to include all surgery\domiciliary equipment, instruments. OIRO £13,000 for quick sale. Contact Ann 0115 9725391 or dorothy@djewitt5.orangehome.co.uk
COLCHESTER, ESSEX - RETIREMENT SALE
Busy Foot Health Practice Close to Colchester Essex Established 7 years. Scope for expansion. All equipment included. Transitional help if required. Please contact 07857 822906
TORQUAY, DEVON - RETIREMENT SALE
Surgery and Domiciliary Established 25 years Income £17k over 3 days. Plenty of Scope for Expansion. Price £15K Telephone 01803 211616
Classified Section LANCASTER Well established Lancaster based Podiatry business for sale. Patient treatments currently range from general chiropody to nail surgery and biomechanics. 2012 turnover upwards of £48k. Lots of repeat business, strong clinic attendance with a strong home visit rota also. 6 nursing home contracts and an average of 35 new patients per month. Website and advertising for this year already in place. Current stock and equipment available for purchase via separate negotiation. Scope for expansion or could be reduced in size according to buyers needs. Sale due to family commitments. Contact Miss M. Nolan on 07739848171 or Jennifer on 07921174112 Www.lunepodiatry.co.uk
EQUIPMENT/SUPPLIES FOR SALE
Chiromart UK “WHY PAY MORE?”
Suppliers of Autoclaves and Chiropody Surgery Equipment. Single Items to full surgery set-ups. Quality used and new. Also your equipment wanted. Surgery clearances, trade-ins and part exchange CASH WAITING… www.chiromart.co.uk Tel: 01424 731432 (please quote ref: iocp
DES CURRIE INTERNATIONAL (+44) (0) 1207 505191
Business Cards 1 sided; 1,000 - £40 /10,000 - £99 Record Cards/Continuations/Sleeves (8” x 5”) 1,000 - £68 Appointment Cards 2 sided; 10,000 - £99 Small Receipts 2,000 - £49; 4,000 - £71 Flyers 10,000 - £82 + type setting + carriage FOR ALL YOUR STATIONERY NEEDS
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