STATEMENT ON PODIATRIC SURGEONS BY THE INSTITUTE OF CHIROPODISTS AND PODIATRISTS
Podiatrists are clinically autonomous practitioners who are qualified in the diagnosis and treatment of pathology of the foot and associated structures without oversight from the medical profession.
The profession of podiatric surgery has been established in the UK for more than 30 years with over 40 Consultant Podiatric Surgeons appointed by consultant panels within the National Health Service.
Podiatric surgeons are specialist foot surgeons who have trained exclusively for up to 12 years in the surgical and non-surgical treatment of the foot and associated structures. All podiatric surgeons are registered by statute by the Health Professions Council and make clear in writing that they are specialists and not registered medical practitioners. Podiatric surgeons always define their speciality and never use the title ‘surgeon’ without the descriptor ‘podiatric’. Any claim by any organisation that this is not the case is therefore mischievous and deliberately misleading.
The intensive training in treating the foot by podiatric surgeons has resulted in the development of highly skilled and meticulous surgical techniques which are frequently carried out under local anaesthetic. By contrast, orthopaedic surgeons complete a medical degree before going on to further training in the management of bone and joint conditions which affect the whole body but they do not exclusively treat the foot, which requires specialised knowledge.
Podiatrists undergo a three or four year university training leading to a BSc(Hons) degree award in podiatric medicine Those graduates wishing to become podiatric surgeons must undergo a minimum 2 year post registration period of continual professional development before commencing a Master’s degree course in the Theory of Podiatric Surgery. This course is validated by the Royal College of Surgeons, Edinburgh. After successful completion, candidates may apply for a surgical training post which, when completed results in a practical examination of a comprehensive range of foot surgery.
Successful candidates may then apply for NHS Specialist Registrar posts to further develop their podiatric surgical experience. The Specialist Registrar posts normally extend to 3 years or more and upon successful completion entitle the podiatric surgeon to apply for NHS Consultant Podiatric surgeon posts.
The highest standards of clinical governance are observed throughout training and all podiatric surgeons are required to carry out continual audit. Peer review takes place on an annual basis and practical skills are subject to quinquennial review. This is not the case with all surgical specialties.
Consultant podiatric surgeons are recognised by the Institute of Chiropodists and Podiatrists who will arrange indemnity insurance accordingly.
HPC renamed Health and Care Professions Council
On Wednesday 1 August 2012 the HPC changed their name to the Health and Care Professions Council (HCPC).
The change has been made by the Health and Social Care Act 2012, which will also see the HCPC taking on the regulation of social workers in England. Although not everyone registered with the HCPC works in ‘health’ or ‘care’, the new name will better describe their expanded remit.
They will be the same organisation and will continue to undertake the same functions. Correspondence from them after Wednesday 1 August 2012 will be from the HCPC.
You will also see the new name and revised logo on their website and publications.
Their web address will change to www.hcpc-uk.org and their email addresses will end ‘@hcpc-uk.org’. Current registration certificates and cards will remain valid and their standards will be unchanged.
Urgent - Safety Notice
Adrenaline (Epinephrine)
An IOCP member has brought attention to the fact that certain medical suppliers serving the Podiatry profession are supplying 1 in 10,000 Adrenaline (Epinephrine) pre-loaded injection syringes, without drawing attention to the fact that these are NOT suitable for the routine treatment of Anaphylaxis.
For the treatment of Anaphylaxis the preferred concentration of Adrenaline used should be 1:1000 administered Intramuscularly (IM) - usually in the anterolateral aspect of the thigh - in the following doses: (repeat these after 5 minutes if no improvement)
Adult 500 micrograms Intramuscular (0.5ml)
Child more than 12 years 500 micrograms Intramuscular (0.5ml)
Child 6 -12 years 300 micrograms Intramuscular (0.3ml)
Child less than 6 years 150 micrograms Intramuscular (0.15ml)
A 1:10,000 concentration of Adrenaline is one of the drugs used in cardiac resuscitation. At this concentration it should only be administered Intravenously (IV) for this purpose, and only by appropriately trained Health Professionals in an environment that permits monitoring of continuous ECG and pulse oximetry and frequent non-invasive blood pressure measurements as a minimum.
Even in cases where individuals are trained in immediate life support techniques that include IV Adrenaline, the UK Resuscitation Council advise that such training is: “….insufficient experience to use IV adrenaline for the treatment of an anaphylactic reaction. In patients with a spontaneous circulation, intravenous adrenaline can cause life-threatening hypertension, tachycardia, arrhythmias, and myocardial ischaemia (Resuscitation Council Advanced Life Support Manual 6th Edition, January 2011)
In cardiac arrest (PEA/Asystole) or life-threatening arrhythmia (VF/PVT), Intravenous Adrenaline would be titrated and not administered undiluted from a pre-loaded syringe, it would usually be administered via an on-going fluid challenge. A measure of its potency via the intravenous route is illustrated by the fact that a child may respond to a dose as small as 1 microgram/kg of body weight. This requires very careful dilution and checking to prevent dose errors.
1:1,000 Adrenaline for Anaphylaxis treatment is usually encountered in Epipens®, Anapens® and similar auto-injectors, as well as, less usually, single-use glass ampoules. It must be stressed that the use of 1:1,000 Adrenaline, administered at recommended doses via an intramuscular route, is a relatively safe treatment for Anaphylaxis that may save a life. As explained above the IM doses given in Anaphylaxis can be repeated after 5 minutes which demonstrates their safety.
1:1,000 Adrenaline must never be administered Intravenously, it could rapidly kill.
Queen Margaret University, Edinburgh
to Offer L.A. Courses
in Conjunction with the IOCP
QMU is offering the following short course for November 2012:
Local anaesthesia for HCPC registered podiatrists.
The aim of the programme is to provide the theoretical underpinning and practical skills required for podiatrists to safely and effectively administer local anaesthesia.
The course is approved by the HCPC and successful completion will result in annotation on the HCPC register.
Our course consists of two study blocks:
1st block: Four full days of study at QMU on 2,3,4,5 November 2012.
2nd block: In conjunction with the Institute of Chiropodists and Podiatrists, a practical component will be offered at their training centre in Southport (other venues on approval from QMU) over two weekends.
If you are interested in finding out more about this course contact Lois McKinnon, course administrator, by email:
lmckinnon@qmu.ac.uk or telephone 0131 474 0000 (voice-activated system: ask for Lois McKinnon when prompted).
Podiatrists and facial aesthetics -
a position statement from the
Institute of Chiropodists and Podiatrists
Non-surgical facial enhancements by either the administration of dermal fillers containing Hyaluronic Acid to volumise the mid-dermis under lines and wrinkles and so reduce them, or by the injection of muscle relaxants such as purified botulinum toxin type-A to mitigate the strength of muscles used in frowning are a well –researched and popular aesthetic treatment in the UK and worldwide.
In order to clarify the situation of Podiatrists also involved in this market sector, the following key guidance points are given. Further detailed information is appended below them.
· Prescribing podiatrists must ensure that they only prescribe or administer medicines where legally permitted to do so and work strictly within all legislation applying to medicines.
· Prescribing or administration rights may only be used within the scope of podiatry, for example prescribing purified botulinum toxin type-A for a dynamic equinus foot deformity is within scope, prescribing it for facial aesthetics is not.
· Podiatrists working as aestheticians must ensure that clear boundaries exist between their activities as a podiatrist and those as an aesthetician.
· Botulinum toxins are prescription-only medicines throughout most of the western world, including the UK, and as such can only be obtained against a prescription issued by an appropriate practitioner. To be ‘appropriate’ that practitioner must be working within their scope of practice.
Legislation does not specifically address the issue of medicines administration except where the product is for injection . Botulinum toxin type-A products are defined as a medicine and for injection, so their administration is defined by law. Medicines for injection may only be: self-administered, administered by a doctor or subject to certain limitations, an independent nurse prescriber or supplementary prescriber or by anyone acting in accordance with the patient-specific directions of a doctor or, subject to certain limitations, an independent nurse prescriber or supplementary prescriber.
In considering the prescribing of, for example Botox®, by a podiatrist prescriber, use of the term ‘appropriate practitioner’ used in the applicable legislation should be noted. Therefore, in the event that a podiatrist prescriber wished to prescribe and administer prepared botulinum toxin type-A for dynamic equinus foot deformity due to spasticity in ambulant paediatric cerebral palsy patients, two years of age or older where this was clinically assessed to be a suitable treatment, they would be judged ‘an appropriate practitioner’ and plainly acting within the defined scope of practice of podiatry. The foregoing procedure would naturally be subject to them having appropriate training in the product and its administration.
In the event that a podiatrist prescriber wished to prescribe Botox® for facial aesthetic treatments, this would be clearly outside their scope of practice and they would not be ‘an appropriate practitioner’. Therefore any prescription issued by them for this purpose would be in contravention of the medicines act 1968 and subsequent amendments and therefore illegal.
The foregoing paragraph should be noted in the context of the fact that as podiatrists are statutorily regulated by the Health and Care Professions Council (HCPC), under the provisions of the Health Professions Order 2001, they are adjudged to be responsible for actions that are performed both within and outwith their professional activities. For example, a podiatrist who, entirely unconnected to their work, committed a criminal offence could be adjudged to be impairing their professional standing and therefore subject to sanctions by the HCPC affecting their registration status, in addition to any actions taken against them as individuals within the parameters of criminal law.
Dermal fillers, although designed for injection are classified as medical devices and as such do not require a prescription and can be purchased by any individual. UK law does not classify by whom or in what manner medical devices may be used. Dermal fillers can be utilised in podiatry when injected into areas of high pressure in the tissue under the foot, to mitigate the effects of such pressure by volumising the protective fibro-fatty padding on the bottom of the foot which can become ineffective due to a variety of factors, including glycosylation of tissue in Diabetes Mellitus.
The active ingredient of dermal fillers, Hyaluronic acid, is also frequently used in podiatry by way of injection of suitably prepared products containing it (e.g. Ostenil®) into synovial joints of the lower kinetic chain damaged by mild to moderate osteoarthritis. Such products are also medical devices, not medicines.
Although p
repared from one of the most potent neurotoxins in existence, produced by the bacillus Clostridium Botulinum, the resultant purified medication; prepared botulinum toxin type-A, has an excellent safety profile when used within its licensed dosages and purposes. For example, whilst twice the licensed dose of the cardio-tonic Digitalis and five times the licensed dose of the commonly used local anaesthetic, Lidocaine, is toxic, it is estimated that it would require some fifty times the usual licensed dose of prepared botulinum toxin type-A given in aesthetic procedures for toxicity to develop in a human
Current licensed uses of botulinum toxin type-A vary by the make of the product, but Botox® manufactured by Allergan(Inc.) can be quoted as a representative example:
Botox® is indicated for: The symptomatic relief of blepharospasm, hemifacial spasm and idiopathic cervical dystonia (spasmodic torticollis), the management of severe hyperhidrosis, which does not respond to topical treatment with antiperspirants or antihidrotics, the prophylaxis of headaches in adults with chronic migraine (headaches on at least 15 days per month of which at least 8 days are with migraine)
Botox® is also indicated for focal spasticity, including the treatment of: Dynamic equinus foot deformity due to spasticity in ambulant paediatric cerebral palsy patients, two years of age or older and wrist and hand disability due to upper limb spasticity associated with stroke in adults. It is also indicated for the temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at frown (glabellar lines), in adults
It is recognised and it is indeed entirely lawful and within their human rights, that podiatrists, particularly those in private practice, may wish to gain alternative skills in, for example, manipulation therapy, herbal medicine, acupuncture, hypnotherapy, counselling or any number of other personal care related skills. Such skills where they impact on area’s that are clearly not within the scope of podiatry must however be practised as stand-alone procedures and not as ‘extensions’ of podiatry. The same conditions must apply if podiatrists choose to undertake training in the administration of facial aesthetics products. Any procedures that are performed should be demonstrably performed not as a podiatrist, but within the scope of any training that they have received in such procedures, and strictly according to law as applicable to any products used.
The laws that apply to such administration would be those pertaining to any other individual, be they a podiatrist, a beauty therapist , pharmacist, health care assistant or someone entirely unconnected to health related employment.
In the event that someone working as an aesthetics practitioner, who was also a podiatrist (whether a prescriber or not) wished to administer botulinum toxin type-A for facial aesthetics, as in the case of any other individual they must note that to comply with the law it should only be done under the named patient-specific direction of an ‘appropriate prescriber’ who takes responsibility for such administration. Irrespective of the fact that they may be highly knowledgeable and skilled in the pharmacology and use of botulinum toxin type-A for procedures within the scope of podiatry, a podiatrist cannot be an ‘appropriate practitioner’ for the purposes of prescribing botulinum for facial aesthetic purposes.
In such cases the Institute, although recognising that this is not a podiatry matter, would advise individuals performing such procedures who were also podiatrists, to ensure in writing via consent forms or similar, that people to whom they administer such procedures clearly understand that this is not a podiatry procedure and the practitioner is not acting as a podiatrist.
©The Institute of Chiropodists and Podiatrists 2012. Version 2.
National scheme launched to reduce risk of diabetes in minority ethnic communities
Diabetes UK has launched a national Diabetes Community Champions programme, funded by the Department of Health, to train health workers from minority ethnic backgrounds to raise community awareness of diabetes risks and complications.
It is vital that people from minority ethnic communities have an understanding of diabetes, because South Asian people are up to six times more likely to develop Type 2 diabetes and people of African Caribbean descent are up to three times more likely, compared to people of a White European background. Also people from minority ethnic communities have a greater risk of developing Type 2 diabetes from the age of 25, compared to age 40 in people of White European descendants.
Diabetes Community Champions learn about the risk factors, symptoms, myths and misconceptions that are prevalent in some cultures. After training they go out into their communities to raise local awareness by holding events, giving talks and encouraging people at high risk of developing Type 2 diabetes to visit their local GP or community pharmacist for a diabetes test.
Type 2 diabetes risk linked to low
testosterone levels
Low levels of testosterone in men could increase their risk of developing Type 2 diabetes, a study funded by Diabetes UK suggests.
Researchers from the University of Edinburgh have found that low testosterone levels are linked to a resistance to insulin – a hormone that controls blood glucose levels.
Testosterone acts on fat cells
This study is the first to directly show how low testosterone levels in fat tissue could be involved in the onset of Type 2 diabetes. Testosterone, which is present throughout the body, acts on fat cells through molecules known as androgen receptors. These receptors enable testosterone to activate genes known to be linked to obesity and diabetes.
Obesity is a known risk factor for Type 2 diabetes. However, the researchers stated that the study showed that low testosterone is a risk factor irrespective of body weight.
The research showed that mice with impaired testosterone function were more likely to be insulin resistant than mice in which testosterone functioned normally. These findings could help explain why older men are more at risk of developing Type 2 diabetes, because testosterone levels fall in men as they age.
Impaired testosterone function linked to weight gain in mice
The study also showed that mice with no androgen receptors in their fat tissue were more likely to show signs of insulin resistance compared to mice with androgen receptors. The mice that lacked androgen receptors also became fatter, compared to other mice and developed full insulin resistance, when both types of mice were fed a high-fat diet.
Scientists believe that a protein called RBP4 plays a crucial role in regulating insulin resistance when testosterone is impaired. They found that levels of RBP4 were higher in mice in which the role of testosterone was impaired.
The Edinburgh team say that its findings could lead to the development of new treatments that regulate production of RBP4 and reduce the risk of Type 2 diabetes in men with lower levels of testosterone.
They are now planning to study people with Type 2 diabetes to see if their levels of testosterone correlate with levels of RBP4.
Healthy balanced diet important to reduce risk
Dr Iain Frame, Director of Research at Diabetes UK, said, “We already know that low testosterone levels are associated with increased obesity and therefore with increased risk of developing Type 2 diabetes, but this study provides evidence that there can be increased risk even when body mass is not affected.
“Yet while testosterone-impaired mice developed insulin resistance whatever diet they were given, the effect was considerably more pronounced on those fed on a high fat diet. This reinforces Diabetes UK advice that a healthy balanced diet is important for everyone, and particularly for those already at high risk of developing Type 2 diabetes.
“Further work is needed to translate these initial findings into clinical practice, as it is important to emphasise that results in mice may not necessarily have direct relevance for humans. But good basic research such as this represents early steps towards potential new treatments, and we are pleased to see research we have funded producing useful results which may benefit people living with diabetes at some point in the future.”