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Post by robertisaacs on Sept 15, 2008 9:03:44 GMT
One for the dermatologists among us.
Well? Are they?
I was mulling this the other day. Obviously being a virus its difficult (impossible?) to do any in vitro studies. Its unethical to do in vivo studies (rubbing infected children on uninfected ones probably not something parents would agree to).
So how do we know? Observation of incidence is the only way i can think of.
So who gets em? Well children generally. And they do hang around in changing rooms and swimming pools which would fit with them being catching. Mind you it would also fit with children having inexperianced immune systems and fragile skin walking on dimply wet floors causing micro trauma and allowing the ingress of a naturally occuring bit of skin flora.
We have all, i suspect, treated VPs in patients who have not been anywhere they could have picked them up!
VPs are surrounded by so much folklore and myth its hard to avoid presumptions based on what we have always beleived.
So what do we think? Contagious or oppertunistic?
Regards Robert
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Post by blinda on Sept 15, 2008 11:28:00 GMT
Hmm, we know that studies have shown than the human papillomavirus is contagious, particularly in areas with; However, opinion is divided over what makes one individual more susceptible to infection than another. Not everyone in the same household contracts/develops VPs although all share a communal bathroom. It is common knowledge that they have a peak incidence in late childhood and adolescence and then the occurrence sharply declines, but is still found in all age groups. Recent studies have suggested that the expression of antimicrobial peptides is an important mechanism for resistance to microbial infection, including the human papillomavirus. For example the antimicrobial peptide LL-37 has been identified as being expressed by keratinocytes in verruca vulgaris (Trozak et al, 2007). Further studies are being conducted to find out why individuals differ in the amount of antimicrobial peptides produced in an immunologic response. It could be previous exposure to the virus, resulting in these antigens. I remember being sent to a `chicken pox` party as a child. It was my mother’s intention that I contract this virus early, thus developing the antigen to avoid developing shingles later in life. Perhaps she should have sent me to a verruca party. Cheers, Bel Trozak D, Tennenhouse D and Russell J (2007) Antimicrobial Peptides.Current Clinical Practice: Dermatology Skills for Primary Care: An Illustrated Guide Humana Press, Totowa, NJ page 59
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ronm
Full Member
but a simple man working against insurmountable odds
Posts: 141
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Post by ronm on Sept 15, 2008 13:18:25 GMT
speaking totally empirically as i cannot recall where i got this from, i tend not to debride the non-painful v.p. , the thinking being the calloused v.p. is less infective.
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podmum
Full Member
"There is no dark side of the moon"
Posts: 169
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Post by podmum on Sept 15, 2008 15:03:40 GMT
the thinking being the calloused v.p. is less infective. I would disagree with this thinking as had pt in today with quite a number of vp's with overlying callus, her 2 yr old has 1 vp (not treated!!!) but her OH doesn't have any. This could be a case of his antimicrobial peptides protecting him. Also stress is being put forward as a contributing factor which would make sense as the immune system is suppressed whilst stressed. I always ask if the pt was under particular stress at work/home life when VPs first occur......
being sent to a `chicken pox` party as a child I was sent to many houses where German measles was rife - never had it!!!
Podmum
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Post by twirly on Sept 15, 2008 17:26:41 GMT
My 2p worth ;D Trying to locate a study/lecture notes to confirm this. Viral innoculation of HPV virus on host cell creating viral replication. Is this not more likely to occur in an area where skin integtity is breached eg. graze, cut etc. ? Therefore, if an individuals healing was delayed (place anecdotal anythingy here .....) then the denuded area would remain open & vulnerable for a longer period of time. Thereby increasing the risk of a 'potentially' infectious element to claim a new host. However, opinion is divided over what makes one individual more susceptible to infection than another. Not everyone in the same household contracts/develops VPs although all share a communal bathroom. It is common knowledge that they have a peak incidence in late childhood and adolescence and then the occurrence sharply declines, but is still found in all age groups.
In early childhood when the little darlings cut, graze or injure their delicate little bodies then mummy leaps to the rescue with anti viral cuddles (& lots of magic cloths {read warm, wet & soapy}) to make it awly better. Late childhood (read female: 7-15 years & male: 0-55 years) then mummy is likely to give child a clip around the ear & indicate how 'Not to be so daft n watch what they're doing next time.' So.... my unproven (unless I can find that bit of paper) theory is that perhaps it isn't hormonal change etc that increases the risk of developing a VP but that as we get older we lose our childlike affinity for plasters. Discuss: (but please don't throw rocks I am delicate) X Mand'
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Post by blinda on Sept 15, 2008 17:45:13 GMT
Agreed. All microbial infections whether viral, bacteria or fungal lurve a portal of entry i.e. breach in the otherwise protective epidermis.
Therefore, VPs are contagious AND opportunistic pathogens. But why do some individuals and not others develop VPs when exposed to the virus? It is well documented that those with immuno compromised systems (as Podmum alluded to) cannot fight the infection but why is it those who appear fit as fiddles also do?
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Post by twirly on Sept 15, 2008 20:00:48 GMT
Agreed. All microbial infections whether viral, bacteria or fungal lurve a portal of entry i.e. breach in the otherwise protective epidermis. Therefore, VPs are contagious AND opportunistic pathogens. But why do some individuals and not others develop VPs when exposed to the virus? It is well documented that those with immuno compromised systems (as Podmum alluded to) cannot fight the infection but why is it those who appear fit as fiddles also do? Could this be the answer to the question? Fit = Active. Active = Activity. Activity = Increased risk of encountering opportunistic nasties. + (for free ) Increased activity = Increased risk of getting nasty cuts & abrasions. Just trying to think outside the box. Can I go back in it now please, it's cold out here?
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Post by Martin Harvey on Sept 15, 2008 22:45:31 GMT
Hi all, off topic slightly, but on the subject of wart treatments, has anybody else tried 2% Zinc Sulphate solution administered by Iontophoresis? I read about its parenteral use around 5 years ago by Sharquie et al (TREATMENT OF VIRAL WARTS BY INTRALESIONAL INJECTION OF ZINC SULPHATE Khalifa A. Sharquie, MBChB, PhD; Adil A. Al-Nuaimy, MBChB. Annals of Saudi Medicine, Vol 22, Nos 1 -2, 2002). They used hypodermic administration and claimed a 98.2% cure rate in 173 lesions in 53 Pts. I took the less contentious route of using my Iontophore machine. It has seemed to work OK in Pts who could not stand LN2 cryo and were unable to comply with 60 - 70% Sal acid treatment protocols, but this naturally does not stand up as EBM. If anyone else has Ionto' facilities might be interesting to do a multi centre study.
Cheers,
Martin
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Post by Admin on Sept 16, 2008 6:09:56 GMT
. Some cut...... Therefore, if an individuals healing was delayed (place anecdotal anythingy here .....) then the denuded area would remain open & vulnerable for a longer period of time. However, opinion is divided over what makes one individual more susceptible to infection than another. Not everyone in the same household contracts/develops VPs although all share a communal bathroom. It is common knowledge that they have a peak incidence in late childhood and adolescence and then the occurrence sharply declines, but is still found in all age groups. In early childhood when the little darlings cut, graze or injure their delicate little bodies then mummy leaps to the rescue with anti viral cuddles (& lots of magic cloths {read warm, wet & soapy}) to make it awly better. Late childhood (read female: 7-15 years & male: 0-55 years) then mummy is likely to give child a clip around the ear & indicate how 'Not to be so daft n watch what they're doing next time.' So.... my unproven (unless I can find that bit of paper) theory is that perhaps it isn't hormonal change etc that increases the risk of developing a VP but that as we get older we lose our childlike affinity for plasters. Hi Twirly, Interesting observation which I believe holds more than a grain of truth. Fits in well with Placebo Theory too. Cheers,
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Post by davidsmith on Sept 16, 2008 8:44:43 GMT
Hi all This paper might be worth a read HOW EFFECTIVE IS SALICYLIC ACID AND CRYOTHERAPY IN THE TREATMENT OF VERRUCAE PEDIS A LITERATURE REVIEW SUBMISSION IN PART ASSESSMENT FOR BATCHELOR OF SCIENCE HONOURS IN PODIATRY UNIVERSITY COLLEGE NORTHAMPTON SATYAN PATEL APRIL 2005 www2.northampton.ac.uk/pls/portal/docs/1/1175802.PDFHere's a couple of interesting extracts 2.2 EpidemiologyIn 1995, Johnson carried out a study to examine the incidence of verrucae pedis amongst shower room users and locker rooms users. A total of 146 adolescents were recruited from public schools and a local swim club, just aged between 10 – 18 years. Each participant had to have an interview and a foot examination before taking part in the study. A strict methodological protocol was followed by the physician to make a precise diagnosis of a plantar wart. The results showed a great significant difference in the incidence of plantar warts with shower room users (27 %) having a greater risk than locker room users (1.25%). The author therefore concluded that public shower users are at a greater risk for plantar warts than are locker room users. In agreement, Many authors have reviewed that schoolchildren and adolescents are more susceptible to verrucae pedis (Kilkenny et al. 1998, Kilmartin & Tollafield 1997) because of the barefoot activities undertaken at school, like swimming (Benton et al. 1992b) whilst Cresswell (1984) states otherwise, that ‘inappropriate shoes and socks are the likely candidates for the spread of verrucae pedis.’ The incidence of verrucae pedis is likely to 13 increase now that swimming is compulsory in all schools (Merchant 1974). In a study by Evan & Gentles (1973) they recorded a high of 6.9% overall incidence of verrucae in fewer than 16 year olds and also that the incidence was higher in children who frequently used heated covered swimming pools than open air pools. According to Bunny (1972), ‘those who use open air pools are less likely to be infected.’ Infection with verrucae pedis often follows visits to swimming pools (Graham 1963) and the reason for this is that the body loses one its defence mechanisms in order to keep the skin supple, therefore the skin becomes macerated and the sweat pores dilate allowing easy penetration of infection. Overall, it can be said that verrucae coincides with individuals that undertake barefoot activities at school, like swimming, therefore, the infected individual would want to know how long before the verrucae disappears. 2.4 ImunologyIt is clearly understood that both humoral and cell mediated immunity are involved in the regression of warts (Logan & Zachary 1989 and Benton et al 1992b). However, the relationship between the two types of immunity is questionable (Adams & Neale 1985). It has been reported that cell mediated immune response (Bunny 1986) and circulating antibodies are responsible for the spontaneous regression of warts (Penttinen & Pyrhonen 1972). Antibodies associated with high levels of immunoglobulin IgG and IgM are identified in patients whose verrucae disappeared spontaneously. Patients with low levels of IgG and high levels of IgM are less likely to have spontaneous resolution of warts (Youngman 1983) but are more likely to recur (Penttinen & Pyrhonen 1972). In previous studies by Barbosa et al. (1998 & 2001) and Alchorne et al. (2003), it has been reported that plantar verrucae are more common and hostile in immunosuppressed patients, such as those infected with HIV. In their findings, they mention that infection associated with HPV type 2 is much common than any other type of infection associated with HPV in HIV + patients. Barbosa (1996) also mentions that ‘spontaneous resolution may tend to be longer than that of a healthy individual, with also a high recurrence rate and that malignant transformation of plantar warts may be experienced.’ Berger et al. (1991) have reported a high incidence rate of HPV infection in renal transplant patients and also in patients with Hodgkin’s disease and systemic lupus erthematosus. The lesion is no different then those not infected with HIV. Cheers Dave
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Post by blinda on Sept 16, 2008 9:01:08 GMT
Thanks for the link Dave, interesting stuff.
Cheers, Bel
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Post by davidsmith on Sept 16, 2008 10:58:22 GMT
No probs Bel
This one might give some insight into epidemiology and demographics of foot infection also. It focuses on T.P. but discusses findings on V.P. aswell.
Foot Infections in Swimming Baths J. C. GENTLES, E. G. V. EVANS British Medical Journal, 1973, 3, 260-262 Summary A 10% random sample of all bathers at a public swimming bath were examined for tinea pedis and verruca. The overall incidence of tinea pedis was 8 5% and of verruca 4 8%. The incidence of tinea pedis in 205 male adults was 21-5%, in 288 boys 6-3%, in 60 adult females 3 3%, and in 220 girls 09%. The incidence of verruca in juveniles ranged from 42% in boys to 10.5% in girls. It was clear that both infections spread within the baths, and since a relatively small proportion of users admitted to taking precautions to avoid contracting or developing infections it seems advisable that more publicity about recommendations on foot care should be provided. Introduction The role of communal bathing places such as indoor swimming pools in the spread of foot infections has been well established. The incidence of infection in bathers at such establishments, however, has never been fully investigated nor have there been many attempts to determine a procedure which might minnimize the risk to bathers. This paper presents the results of an investigation of the incidence of infections with dermatophytes (tiinea pedis) *at a new swimming -pool in the West of Scotland before the introduction of a procedure aimed at reducing the spread of infection. The incidenice of verruca was also noted. Department of Dermatology, University of Glasgow, Glasgow G1i 6NU J. C. GENTLES, B.SC., PH.D., Reader in Medical Mycology Departments of Dermatology and Microbiology, University of Leeds, and General Infirmary at Leeds, Leeds LS1 3EX E. G. V. EVANS, B.SC., Lecturer in Medical Mycology Methods The swimming bath is a covered, heated, international-class pool opened 18 months before the survey. An average of 8,000 bathers enter the pool each week, a large number of whom are visitors from surrounding townships. On entry those under 16 years of age are classified as juveniles. A 10% random sample of bathers was selected by means of an electronic counting machine from those using the pool over a period of one week. The selected bathers were first interviewed and personal details including swimming habits were recorded on specially prepared cards. Their feet were examined and their dlinical condition, including the presence of any verrucae, noted. Scrapings were taken, whenever possible, from the 4th toe clefts of both feet and from any other clinically suspicious sites. In most cases the material collected from each subject was pooled. When the skin of the toe clefts was so smooth that it was impossible to collect material without inducing trauma the bather was regarded as clear of infection. Samples were processed using routine methods for laboratory diagnosis of superficial fungal infections-namely, culture on 4% malt extract agar of 12 inocula at 28°C and direct microscopy in 20% potassium hydroxide. The statistical validity of the results was assessed using the x2 test. Results A summary of the results is shown in table I. A total of 8,291 bathers entered the pool during the sampling week and of these 773 (9.3%) were interviewed and examined. A further 75 were selected but either did not appear for examination or refused. Of the 773 persons examined a specicmen could not be obtained from 118 (15%) and on a further 226 (29%) occasions the material that could be obtained was insufficient to allow either the full number of inocula for culture or microsBRITISH MEDICAL JOURNAL 4 AUGUST 1973 TABLE I-General Results of Survey No. Infected Baths Entry Sample Baths Entry Sample Tinea Pedis Verruca Overall total .. 8,291 773 (9-3%) 66 (855%) 37 (4 8%) Adults (> 16 years) 2,172 265 (12-2%) 46 (17%) 2 (0 76%) Juveniles (< 16 years) 6,119 508 (8-3%) 20 (3-9%) 35 (6 9%) copical examination. Thus complete laboratory examination was done for 429 (56%) subjects. The infection rates may therefore be slightly higher than indicated, though clearly those from whom it was not possible to obtain an adequate specimen are less likely to be infected. The overall incidence of tinea pedis proved by laboratory investigation wias 85%, being more prevalent among adults (17%) than juveniles (3-9%) (P = < 0001). For verruca the overall incidence was 48% with the incidence in adults and juveniles of 0-76% and 6-9% respectively (P = < 0 001). There were also differences in infection rates according to sex (table II). There was a 'higher incidence of tinea pedis among males than females in both age groups (P = < 0-005); the highest incidence occurring in adult males (21-5%). The number of adults with verruca was small, 'but statistical analysis of the figures for juveniles showed a higher incidence among females than males (P = < 0-001). TABLE II-Infection Rates According to Age and Sex Adults Juveniles M. F. M. F. Total No. in sample .. 205 60 288 220 No. infected with 44 2 18 2 tinea pedis .. .. (21-5) (33%) (6-3%) (0 9%) No. infected with 2 0 12 23 verruca .. .. (1%) (0°0%) (4-2%) (10-5%) The dermatophytes isolated are shown in table III. The predominant species was Trichophyton mentagrophytes var. interdigitale which accounted for 62 1% of all cases. T. rubrum (13-6%) and Epidermophyton floccosum (10-6%) were the other casual organisms, with two cases (3 %) of mixed infection and seven cases (10-6%) diagnosed by microscopy only. There was no correlation between the age or sex of the infected person and the species of dermatophyte isolated. TABLE III-Species of Dermatophytes Isolatedfrom Tinea Pedis Infections Total (% of Total) Cases Trichophyton mentagrophytes var. interdigitale 41 62-1 T. rubrum . .9 13-6 Epidermophyton floccosum . . 7 10-6 Mixed (E. floccosum, T. mentagrophytes) 2 3 0 Microscopically positive (culture failed) .. 7 10-6 Infection rates among juveniles are analysed more closely in table IV, taking into account whether they attended with school classes or during free-swimming periods. The infection rate for tinea pedis was higher during free-swimming sessions (51%) than school sessions (1-7%) (P = < 01). The reverse was true for verruca with an incidence of 10.2% during school sessions and 5-1 % during free-swimming periods (P = < 005). The highest incidence of verruca recorded (196%) was among the group of 56 girls aged 7-11 years attending during school sessions. 261 TABLE IV-Effect of Environmental Factors on Incidence and Type of Foot Infection in3uveniles No. Infected Total Entry Tinea Pedis Verruca School Visits .. 177 3 (1-7%) 18 (10-2%) Free-swimming 331 17 (5-1%) 17 (5-1%) For tinea pedis the clinical and laboratory data did not always correlate. Peeling in the toe clefts, as the most severe symptom, was found in almost as many subjects (41-1 %) in the uninfected group as in the infected group (45-5 %). The incidence of more advanced clinical symptoms-namely, maceration, erythema, and fissures-was appreciably higher in those with tinea pedis; 33-3 % compared with 8-5 % in the uninfected group (P = < 0 001). Nevertheless, the number of clinically "normal" feet in the infected group was high (21-2 %), and in juveniles clinical abnormalities were more indicative of infection. It was also found that only 12% of those with tinea pedis were aware of their infection and that 40% of adults and almost 70% of children did not know that communal bathing places were a common source of infection. Of those who knew of the dangers almost all children but only 75% of adults took some precautionary measure such as careful washing and drying of the feet or application of talcum powder after bathing; the others stated they knew of no procedure likely to be helpful. There was a relation among juvenile males between the frequency of bathing and the incidence of tinea pedis (P = < 0.025). Of the 288 boys 117 (41%) swam at least once a week and 125 (44 %) more than once (some four or five times) a week, and in this latter group were 14 (78%) of the 18 infections. For 220 girls the frequency of use was less, 101 (46%) were weekly bathers and only 56 (26%) attended more than once a week. The incidence of tinea pedis could not be related to the use of shower facilities, other swimming pools, or service in the Forces. Alm-ost everyone used the shower facilities, and in the age group 31-50 years, within which almost all persons with service in the Forces occurred, the proporton of the infected group who had been in the services was 78% (21 out of 27) compared with 77% (72 out of 94) of the uninfected group. Discussion The inves'tigation was made specifically for the purpose of comparison with future surveys at this swimming bath after the introduction of measures aimed at reducing the spread of fungal infection. It is apparently the first survey of its kind, and in the absence of results for comparison it is not possible to say if the incidence of tinea pedis is higher in this group of suibjects than in the population at large nor if these results are typical of swimming baths in general. Though almost 70% of the sample regarded themselves as regular bathers-that is, using the baths at least once a week-the duration for which they had been regular swimmers varied considerably and, moreover, the baths had been open for only 18 months at the time of the survey. It is remarkable how similar our overall infection rates in adults of 17%, in adult males of 21-5%, and females of 3-3% are to the rates of 16-2% overall, 23% in males, and 4% in females found by English and Turvey (1968) in their survey of new patients at a chiropody clinic, which, as they suggested, is probably the nearest approach to a survey of tinea pedis in the adult population at large. For juveniles our results are comparable with those of English and Gibson (1959 a) since most children in their 262 BRITISH MEDICAL JOURNAL 4 AUGUST 1973 survey also visited swimming baths either at school or public sessions or both. In their boys of 7-10 years of age they found 2-2% to be infected and this compares with 5 5% for our boys aged 7-11 years; for boys 11-14 years English and Gibson found an infection rate of 6&6% compared with 7-8% in our 12-15 years age group. These authors found that the availability and use of swimming baths was the only factor which could explain any variation in the incidence of infection, and among our boys, wit;h 78% of infections among those who swam more than once a week, there can be no doubt of the relation between infection rates and frequency of bathing. For girls the frequency of use was less but the difference in infection rates between the sexes can hardly be related to ithe difference in regularity of bathing. It can, however, be related to opportunity for exposure. English and Gibson (1959 b) have shown clearly that dermatophytes are found most often in parts of baths used by populations with a high incidence of infection such as male changing rooms, and emphasized the importance of the "vicious circle of foot infection and floor contamination." Our results also indicate the importance and effect of exposure in that the transfer of infection apparently took place most often in changing rooms and shower stalls where the sexes do not mix. Moreover, a higher incidence of tinea pedis was found in juveniles examined during free-swimming sessions when adults were also present than at school sessions, and the overall incidence at weekends was 11-3% compared to 8-4% during weekdays. It should be noted that, in general, the regular swimmers attended on the same day(s) each week and that most children who were seen during school sessions attended the baths also at free-swimming sessions. A predominance of foot infections with T. mentagrophytes var. interdigitale in various sections of the population was found by Gentles and Holmes (1957) for coal miners using pit head baths in various parts of Britain, by English and Gibson (1959 a, 1959 b) for children, Walshe and English (1966) in toenail infections of adults in Bristol, and by English and Turvey (1968) for adults in London. It is not therefore surprising that this species comprised more than 60% of our isolates. Our proportions of the three species of dermatophytes isolated from adults conforms closely to that reported by English and Turvey (1968) and isolations from juveniles agree closely with the proportions found by English and Gibson (1959 a). It was found as reported by previous investigators (Holmes and Gentles, 1956; English and Gibson, 1959 b) that clinical criteria are unsatisfactory for diagnosis of tinea pedis. Moreover, relatively few infected bathers were aware of their infections. More disturbing, however, is the proportion of people who are unaware of the dangers of communal bathing and the failure of a number of those who do know of -the risks to take precautions. There would appear to be a need for publicity and instruction. The opportunity to make this investigation arose because of complaints of foot infections allegedly contracted at the swimming baths. Though tinea pedis was involved the major complaint was of the sudden increase in the incidence of verruca, and this condition was therefore noted during our examination. The overall incidence of verruca in our juveniles (69%) is higher than recorded in any previous surveys of this condition in schoolchildren, despite the fact that in an unknown number of instances children were excluded from school swimming sessions because of their verrucae. Allen and thingyinson (1968) found an overall incidence of 2 5% but there was no difference in prevalence according to sex. They did find, however, that the incidence of verrucae was higher in children who frequented heated covered swimming pools (40%) than among those using open-air pools (2-5%). In other surveys Hollman (1969) found an incidence of 1-0-2-0% and Tranter (1969) of 1-0-30%. The latter also found a positive relation between the frequency of swimming and the incidence of verrucae. Our findings indicate that the involvement of the swimmiing baths in the spread of infection and the 'vicious circle" of infection and floor contamination emphasized by English and Gibson (1959 b) for tinea pedis clearly applies for this disease also, since the incidence was higher during school visits (10-2%) dan at public swimming sessions (51%) and in girls (10-5%) than in boys (42%). We are greatly indebted to the staff of the swimming bath, to the medical officer of health of the town concerned and his staff for their help and co-operation, and to Glaxo Laboratories Ltd. for material support. References Allen, W. H., and thingyinson, V. A. (1968). Medical Officer, 119,261. English, M. P., and Gibson, M. D. (1959 a). British MedicalJournal, 1, 1442. English, M. P., and Gibson, M. D. (1959 b). British Medical Journal, 1, 1446. English, M. P., and Turvey, J. (1968). British MedicalJournal, 4, 228. Gentles, J. C., and Holmes, J. G. (1957). British Journal of Industrial Medicine, 14, 22. Hoilman, C. E. (1969). Medical Officer, 121, 313. Holmes, J. G., and Gentles, J. C. (1956). Lancet, 2, 62. Tranter, A. W. (1969). Medical Officer, 121, 317. Walshe, M., and English, M. P. (1966). British Journal of Dermatology, 78,
Dave
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Post by dtt on Oct 5, 2008 18:52:21 GMT
Hi Ron So how do you treat that when the Pt presents in pain from " basically" the other sort where the overlying callus has become thick & brittle ? Don't understand What is the difference in modalities and for what reason ?? Whether ths lesion (s) are painful or not the treatment by your criteria would make little difference on the infection side?? I don't treat at all unless they are affecting the pts quality of life. Then I explain the options alternatives and the side effects of aggressive treatment ( pain ) and let them choose. A covering of "clear nail varnish" , "duck tape" or whatever sorts the infection risk as much as possible in either case IMHO ;D Cheers M8 D
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ronm
Full Member
but a simple man working against insurmountable odds
Posts: 141
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Post by ronm on Oct 6, 2008 8:37:38 GMT
derek i'd probably debride me neither there's probably as much evidence for this as there is for the not debriding theory cheers ron
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