|
Post by robertisaacs on Dec 6, 2008 9:59:26 GMT
Hey leon.
No, DTT (Derek to his friends) is not policza. However from time to time People who have wished to disrupt this site and spoil it for those who wish to learn have been known to register more than once under different names to divert threads. Via the wonder of technology these people are easy to track and we can keep an eye on them. Rather sad that they have nothing constructive to do with their time but there it is.
I am delighted you are finding useful information on Dereks (DTT) website! It is a very helpful , although not easy to find via a search engine! When i put verruca into google i could'nt find it at all! Fortunate for you that you have found it, as it is a very useful resource. Your ability to find relevant information will stand you in good stead as you improve your knowledge.
And a happy co incidence indeed that the site you happened across, of all the podiatry sites in the world, belonged to one of the half dozen podiatrists you were speaking to so you could seek clarification from the man himself!
And finally, i'm happy you are NOT rude enough to say dupek. Calling somebody who is trying to help you an A***hole, even in polish, is unacceptable on this site.
Regards Robert
|
|
|
Post by chifhpod on Dec 6, 2008 11:20:20 GMT
Hi all, I've been doing some fact-finding. I have discovered two papers that I would recommend as important reading for all of us. Both are emedicine from WebMD and both are quite recent. Human Papillomavirus Gearhart PA et al www.emedicine.com/MED/topic1037.htmGerhart is an Obs & Gynae man This will help Leon and update us all. There are now over 100 HPV types described, 80 of which have had the entire genome sequenced. (Jan 2007) Warts, Nongenital Rinker MH, Shenefelt MS www.emedicine.com/derm/topic457.htmRinker is a Physician working in Dermatology Rinker gives the background and explains which HPV types are implicated with particular lesions. Ist rule - know the enemy! She then goes on to consider topical treatment modalities. Usefully, she lists salicylic acid as the first-line therapy. She reports reports of 70-80% cure rates from home application, but regretably there is no further information. There are many other possible applications, but not many of them are available to fhp/podiatrist. Cryotherapy is well detailed. Laser (pulsed dye and Nd:Yag - not LLLT) and Electrodessication are said to have limited usefulness. Enjoying the thread. The art of debate is surely to give and take. Why are so many inadequate, socially inept and precious people drawn to forums? From the above reading I want to further question, if we all agree that for instance, salicylic acid is the bee's knees of treatment, why can we not agree on its best strength/method of application/duration/for optimal effect? So by the time we have selected the 'best' modality for our individual patient and customised it to their needs, are any two treatments ever delivered in exactly the same way, even with the same agent? How are we ever to know what works for the benefit of the evidence database? Seems to me that no two of us share the same understanding - on anything! We need a proper starting point. We need some CLINICAL evidence! Isn't that a synonym for experience? First agree WHAT works, then debate HOW it works.?
|
|
|
Post by dtt on Dec 6, 2008 12:49:12 GMT
Hi Martin Quite amusing as well ;D Hi Leon You really must try not to get so upset with me I must get one of the polish staff at my nursing home to translate that for me even if its to find out if you have a better command of the polish language than you do of English. I'm sure it is quite amusing Martin and Robert have summed up the situation.... I find it quite surprising that the banter ,wind ups etc that take place on the sites( which as Martin said usually ends with a pint in the bar) has been taken to a "personal level" by intruding into my private /professional life by actually seeking out information about me via my web site Leon ,you actually made a direct quote from my website which had you read it you would have noticed it is "copyright protected" and by copying here you have infringed that copyright BUT Just to let you know I'm perhaps not the "dupek" you think I am, we wont take it any further this time See mr nice guy really ;D Cheers D
|
|
|
Post by robertisaacs on Dec 6, 2008 13:43:02 GMT
Chifhpod
Great post and good links!
I would disagree that Sal acid is the bees mid leg joints. Personally i would rate Cryo above sal acid. Within that, i often shed a nostalgic tear for the halycon days of nitrous oxide and the spembly kit. Liquid nitrogen is good but i prefered the n20.
OMG NO!!! Far, far from it. Experiance is a fine thing but it does not equate to evidence. We are all, without exception, far to easily prey to subconcious bias, heuristics, logical fallacies, cognitive illusions etc etc. Evidence, also a fine thing, aims to reduce these sources of error to as great a degree as possible.
We'll not get into the realms of which is more important here. There is an existing thread on that, or feel free to start a new one. But they are by no means synonmous.
Don't know who you mean here. But Lets not get personal aye what? As you say give and take is vital in a good debate but i think an even more vital thing is to attack arguments with as much vigour as you like, but leave the person making them alone! As a correlary of this it is needful to not take an attack on something said about what you SAY as an attack on YOU.
A lesson that some on pod arena would do well to learn! ;D
Regards Robert
|
|
|
Post by blinda on Dec 6, 2008 15:33:12 GMT
Hey chifhpod Thanks for the links, very interesting reading. Don`t know whether you may have already seen this, but there was a brief discussion on `VPs - Are they contagious?` on this forum a couple of months ago. One paper, which was a recommended read was; www2.northampton.ac.uk/pls/portal/docs/1/1175802.PDF Personally, I don`think sal acid is the Eric-the-half-bees knees either. Robust VP in vitro/vivo research is incredibly difficult to carry out/obtain ethical approval for, but would agree that it would be beneficial to observe and record the effectiveness of the different strength’s of salicylic acid. Cheers, Bel uk.youtube.com/watch?v=2iSssOpLTPM
|
|
|
Post by Martin Harvey on Dec 6, 2008 16:52:35 GMT
This is the latest review abstract from Cochrane (all copy writes acknowledged and this short extract distributed for the purpose of academic research only):
In simple cases I will Rx a home treatment supplemented by periodic debridement in the surgery if appropriate or desired by the Pt. In other, usually chronic, cases where surgery based treatment seems to be clinically appropriate my Personal choice is for aggressive cryotherapy. Cochrane highlights this as follows:
As you can see, aggressive cryo gives a Number Needed to Treat of 5 which is the closest of any other methods to the salicylic acid NNT of 4 (the best of all NNT's in the review) in the case of pooled data on salicylic acid variants as follows:
It is worth adding in passing that in order to survive Aggressive liquid nitrogen Cryo (the Pod survive it that is), it really requires either local anaesthesia or a drunken patient. Personally I find it easier to give them a nerve block instead of a rum bottle and if appropriate an Rx for an effective post operative analgesic, either Paracetamol at its therapeutic dose of 1000mg QID or an opioid if greater control is required (not that spawn of Satan Ibuprofen)
So, to try and come back to the OP; do I rate AgNo3 as a total cure? - personally, I'm with the old timers; Runting et al, and say no. It may have its place but personally my vote for full-resolution topicals goes with salicylic acid preparations.
So, does this mean that I think salicylic acid is the best topical VP cure? Well, I have to say (with apologies to Churchill) that I think it the worst topical wart cure on the planet........... apart from all the rest.
Cheers,
M
|
|
|
Post by robertisaacs on Dec 6, 2008 18:05:35 GMT
You soft old thing Martin. I generally just give them something to bite. Although i agree that we should offer LA more on general principles.
What length freeze do you consider to be aggressive? I usually start with 30 s (3*10) then go to 4 or 5 * 10 if this does not work.
Regards Robert
|
|
|
Post by Martin Harvey on Dec 6, 2008 18:31:50 GMT
If you will prod me without me corset on..............
Hi Rob,
In the absence of contra's I try 2 X 30 seconds and review after 1 week. Subject to review I may repeat, increase or decrease the Tx then review again after 2 weeks. If I encounter rapid tissue breakdown evidenced by weeping of serous fluid from under the wart etc, then at review I will leave off for 2 weeks and start up from 2 X 15 seconds. Ultimately I will go to monthly reviews until either successful resolution, the patient gets fed up or I feel it inappropriate to continue and refer. It may be fair to suggest that successful aggressive cryo becomes more of an art and less of a science after a while, inasmuch as you tend to be guided by factors such as colour of epilesional tissue during freezing and texture after etc based on experience.
In our current set up in tamworth (simply because I have the liquid nitrogen facilities) Im usually the court of last resort from the surrounding GPs and Pods before surgical curettage. This means that virtually all the ones I see, unless they are self-directed walk ins, are chronic (up to 10 years) which means these are really tough babies, hence the eye watering Tx times.
Over last 5 years records suggest I'm hitting approx 87% resolution, 10% loss to further treatment and 3% onward to the plastic surgeons.
Cheers,
M
|
|
|
Post by blinda on Dec 7, 2008 20:44:36 GMT
Nice one Martin, thanks for the latest Cochrane extracts. Karma for my dermy friend.
So, before we explore the dancing naked at midnight theory, please expand on the rational behind your abhorrance of brufen following liquid nitrogen application. Is it;
a) Because it masks the cardinal signs of infection? b) Cos it inhibits COX1, inflammatory activity? c) Cos it inhibits COX2 platelet aggregation? Or, d) You are concerned about the patient’s GI tract?
Cheers, Bel
|
|
|
Post by Martin Harvey on Dec 8, 2008 1:06:03 GMT
Ah 'Bel,
Thankee kindly for yr kind words to an old country chiropodist. Your perception and intelligence is only matched by your beauty.
Yep, on all counts;
The enzymes in the cyclo-oxygenase group play an important role in inflammation when they act on arachidonic acid to produce prostaglandins, thromboxanes and leukotrienes. It was initially assumed that there were only two COX's (1 and 2) but there is now a definitely isolated COX 3 and subsets of COX 1 ( alpha and beta). It may be logical to assume there are more waiting to be discovered. COX 3 and COX 1 a and b are poorly understood and debate continues about what they do.
COX 1 and 2 are believed to be better understood which is why I always find it hair-raising (what little I have left) at the amount of non steroidal anti-inflammatories dished out like prescriptions for sweets and sold over the counter. For example, in 2004 one study (Ref 1) suggested that over 20 million NSAID treatments were prescribed – at a direct financial cost of £247 million which was over 3% of the total annual prescribing budget For the same period another report (ref 2) estimated the human cost to be 3,500 adverse gastro-intestinal (GI) events (perforations, ulcers, bleeds, etc.) which required hospitalisation and 400 deaths which were attributable to NSAID use ( Ref 1: - Health and Social Care Information Centre. Prescription Cost Analysis: 2004. Ref 2: Hawkey CJ, Langman MJ. Non-steroidal anti-inflammatory drugs: overall risks and management. Complementary roles for COX-2 inhibitors and proton pump inhibitors. Gut. 2003;52:600–608. doi: 10.1136/gut.52.4.600 .)
Even more frightening is the fact that the knowledge about the carnage caused by NSAID's is not new. By the mid 1990's it was well understood and well reported (i.e : TM MacDonald, SV Morant, GC Robinson et al. Association of upper gastrointestinal toxicity of non-steroidal anti-inflammatory drugs with continued exposure: cohort study. British Medical Journal 1997 315: 1333-7.and RA Moore, CJ Phillips. Cost of NSAID adverse effects to the UK National Health Service. Journal of Medical Economics 1999 2: 45-55.)
To expand on your very concise and accurate summation:
COX's are enzymes that are produced constitutively (always produced for housekeeping and repair duties) as well as during inflammation. COX 1 is important in haemoregulation, ion transfer, platelet function and neuromodulation to name just a few 'housekeeping' duties. COX 2 is upregulated during inflammation and makes greater quantities of prostanoids.
NSAID's ostensibly target COX 2, some very very effectively such as the 'miracle' selective COX 2 inhibitor vioxx of painful memory to Merck pharmaceuticals (they have set aside $4.85 BILLION for potential lawsuits from US Citizens alone, deaths are estimated to be > 97,000 from embarrassing little things like thrombotic events due to the cardio vascular endothelium stopping maintaining itself) but in fact all NSAID's will bind to COX 1 to varying effect. Flurbiprofen, Ibuprofen, Naproxen and Indometacin (indomethacin) are all quite biased to COX 1 binding. Diclofenac is biased to COX 2.
BUT ....... (and the researchers in the drug companies should know this quite well by now - and do) the COX pathways are not the simple little tidy direct routes that appear in undergrad textbooks and they are interlinked in ways that even now are not properly understood. The other COX's and subsets are very possibly confounding factors, but whatever the reason, we tinker with inflammation at our peril. The basic fact is that healing is a vital requirement of maintenance and repair and as we both know, you cannot heal without at least a constitutive (COX 1) inflammatory response, its impossible, can't happen, zilch, nada, etc etc. The reason it does not hurt all the time is because you need thromboxanes, prostaglandins and leukotrienes acting in concert to sensitise and stimulate nerve endings. If COX 2 is not being upregulated (which does not usually happen in housekeeping mode) then the complex interlinked reactions that cause pain do not happen, hence it dont hurt while you are undergoing routine maintanance that is not a response to traumatic or other pathogenic stimulii.
A couple of area's that require ongoing repair as a normal part of life are vascular and gastric endothelium. When either have that repair mechanism inhibited because the housekeeping prostanoid manufacturing pathway has been interfered with in an effort to interfere with the induced (by inflammatory mediators) pathway then bad things can happen. Such as : the gastic linings deteriorate, are not repaired and start to bleed, the vascular endothelium becomes rough and causes eddy's in the blood flow and promotes embolisms etc. People drop dead from myocardial infarcts etc - all most inconvenient.
Also, on a similar vein (sorry will stop soon but this is a soapbox of mine ) if there is no trauma induced inflammation then NSAID's make lousy painkillers but Doctors - and others who should know better, still dish them out even for the like of headaches. It shows a total disregard of basic science, they can only stop pain when there is COX upregulation. Paracetamol and the opioids are far far more effective for pain control and used properly are remarkably safe. Paracetamol is sometimes criticised for causing liver damage but this only happens in normally healthy people at dosages in excess of double the recommended 4,000 mg in 24 hours when cytochrome P450 isozymes in the liver get trashed and cause toxic build up. At normal dosages long-term medication with paracetamol has far lesser effect on COX's and is a darn site safer than true NSAID's.
Its the same with the opioids, the transdermals such as Fentanyl or Butrans and related drugs such as codydramol etc don't noticeably effect COX paths. Admittedly there are issues to watch out for such as respiratory depression and bowel action inhibition but these can be managed and tend to be less fatal than death from an MI or a blown-apart stomach lining.
So, in short, I suggest to Pts that they refrain from NSAID's when I am giving any treatments that rely on effective healing. So this includes prolotherapy injections, viscosupplementation of synovial joints and fibrofatty plantar padding augmentation with polyacrylic hydrogel injections.
Now.......................... what about the dancing naked at midnight theory, please expound (decorously of course!)
All the best,
M
|
|
podmum
Full Member
"There is no dark side of the moon"
Posts: 169
|
Post by podmum on Dec 8, 2008 18:57:58 GMT
Martin Karma for the last posting ;D Re timings for cryo it might be worth mentioning that N2O and liquid nitrogen are the most effective cryogens. If anyone reading uses Histofreeze or Cryospray they will find the timings given in your posting ineffective due to the differencial of temperature between the cryogen and the body temperature and may come to the conclusion that sal acid is the bees knees (do they have knees?) Podmum
|
|
|
Post by Martin Harvey on Dec 8, 2008 19:10:42 GMT
Thanks Mum.
Good point you raise about the timings, just to confirm they are based on liquid nitrogen administered by spray from an applicator Dewar.
Re Bees Knees:
all the best,
M
|
|
|
Post by blinda on Dec 8, 2008 21:09:29 GMT
I could be really rude and add `the dogs.....` but i wouldn`t be so puerile.
|
|
|
Post by Admin on Dec 8, 2008 21:51:18 GMT
I could be really rude and add `the dogs.....` but i wouldn`t be so puerile. Not what we heard ;D
|
|
|
Post by chifhpod on Dec 9, 2008 9:14:44 GMT
I can see that the time has come to review where this thread has taken us.
The best evidence that we have, intended as guidance to the eradication of verrucae (The Cochrane Review) is to all intents and purposes useless! It amounts to what can be gleaned from a series of poor quality, unrelated projects as determined by an unnamed panel of 'experts' reviewing the disorganised and methodologically dubious work that has been done so far. It makes no suggestion of a 'best practice regime', and all it really confirms is that there is little or no good quality evidence.
Good clinical practice and experience have been rejected out of hand (OMG -NO!) with no other option identified instead. So where is our (better) evidence to come from, futuristically?
Apocryphal evidence has been offered which has more to do with personal ego than making a contribution to knowledge. 'I nuke 'em with my £2,000 liquid nitrogen spray gun' does little to assist a thread on silver nitrate that lead onto keratolytics. Is the potency of your nitrogen delivery apparatus in any way comparable to the length of your car bonnet, by any coincidence?
No two of us agree upon the action of keratolytics, or their mode of action. Interesting it might be, but wound healing is not the same as wound creation - which is what a keratolytic does.
Even if we confine our attention to those parts of the debate that have discussed salicylic acid, the mode in which it is put up, the strengths in which it is presented, the vehicles in which it is carried, its action upon epidermal tissues, have all been left as yet unaddressed or unanswered.
In the process, at least two participants have taken offence at the treatment they or their comments have received.
This has been one of the more entertaining and potentially useful threads on this forum (5 pages).
Has it returned its potential?
Contributors will have their opinions.
Readers will decide.
|
|