Time to discuss a clinical topic Section

Thoughts on Writing

Thoughts on Writing

Thoughts on writing

 

Why don’t podiatrists write more papers and pieces of interest. This short article and post is to encourage writing and say ask for help. A colleague inferred that Academics were stealing the limelight, ‘that’s what they do and have time for’. Academics are supposed to publish of course. Without this drive for evidence how else would they show the fruits of their labour? Colleagues probably write more in their early career as an imperative toward a specific goal, usually for a first or higher degree. The number of conversions to publishable papers however is a different matter. Indeed, this is not an easy task having just lost the incentive of the university deadline as the graduate returns to the clinical scene where his or her daily grind is measured by patient output.

Some years ago and in discussion with an orthopaedic colleague his take was simple. ‘Published papers rarely offer much value’, he said in his cynical if not draconian way. Was this to excuse his lack of interest, or was it that few papers offered much to say of critical value. Clinical research is painfully slow and so often due to limitations of design we can only probe so far. Do we wait until the next version comes along and the next and start piecing it altogether in the ever popular meta-analysis study? Someone has to start off asking the basic question, then take the plunge. That plunge is becoming increasingly more difficult. Change the world at the stroke of the pen or tap of the keyboard is not surprisingly often unattainable without longitudinal studies.

Is it true that not everyone is keen to write? Just look at Social Media; Podiatry UK or UK Podiatry and the DoPS Group on Facebook, Tweets, Instagram and Linkedin. Podiatrists write all the time about day to day experiences. They ask queries and it is a good medium to acquire knowledge quickly.

Writing takes time and few can commit a single draft without re-writes. That just knocks the stuffing out of the average person – so why bother? There are many forms of writing; case histories, reviews of virtually any publication, posts of patient comments and clinical experiences, product information of value, and that is before we come close to the academic side where a certain formality is necessary. I am all for trying your own style of writing whether it be formal or informal, although for podiatrists it is useful to include a bit of factual evidence.

Perhaps there is a fear to writing, but probably the time-factors contributes to the lack. Doubtless you are a brilliant clinician, but learn how to shout about it, of course with a little humility.

Please enjoy this month’s article .

 

David

Busypencilcase Communications July 2018

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Acupressure points on insoles. Another choice for foot pain

Acupressure points on insoles. Another choice for foot pain

Ever heard of acupressure soles? You probably have heard of the ones with magnets. What about those shoes that come with raised bumps suggestive of helping acupuncture points? Some are set to specific positions others just radiate across the insole.

As a foot health clinician I have a large dose of scepticism for many therapeutic side lines. I understand the human body, and I understand drugs, surgery and orthotics to help the painful foot. But bobbly bits in shoes, no, that is a gimmick surely?

Curiously this summer I dug out a pair of shoes that have an insock with raised plastic contours. I am not sure why I bought them in the first place but they looked nice and the colour blue appealed. I could feel those raises inside the shoe and could not convince myself they were comfortable so they just gathered dust at the bottom of my cupboard.

Science and enquiry arise through accident.

I had foot surgery in 2016 and even wrote a book last year on the subject. My surgery went well for the Morton’s Neuroma but well into my second year of recovery sensations and discomfort returned. I longed for holiday time where shoes were used but a tiny percentage of the day, bare foot and Crocs being the norm. For some unknown reason those blue shoes in the cupboard came out and strangely felt comfortable now. In fact the site where my nerve was uncomfortable became less so as was my awareness from the raised plastic projections. My foot discomfort eased so much that remedial care went on hold. I then recalled my Crocs used on holiday. They too have ridges and are curiously comfortable and had helped the year before.

I wore the blue shoes during a busy working week and then travelled to my holiday destination, a day’s effort to reach the location with walking along metres of airport corridors after changing planes half way, all part of the painful process of travelling in June.

So what’s the secret? I checked the internet and my usual research sites but nothing came up, except knee pain relief. How does this work?

Forget the knee and think foot. We know that researchers Ronald Melzack and Patrick Wall pioneered the thoughts on nociceptor nerve fibres in 1965 being interrupted by external stimuli so that pain reduced. This was called the Gate Theory. Could science explain this change in my foot comfort? All I can do is suggest that stimulation of other parts of the foot confused my brain, diverting the localised discomfort away from the site of surgery where no doubt some scarring exists around my old surgery site, hopefully devoid of its main troublesome nerve.

Am I a sceptic anymore? Well give me a scientific reason and I am always open to reason but now I believe there is a place for those little raised bobbles for some types of pain, perhaps related to nerves. For the moment my foot is happier.

 

David Tollafield writes for Busypencilcase Communications through Consultingfootpain for his regular articles in Footlocker. He no longer practices as a podiatric surgeon. You can contact him through his website or busypencilcase_rcb@yahoo.com

 

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Feature UK Podiatric Surgeons. What’s in a name? The Difference between healthcare professionals.

Foot health Month. Expanding skills amongst health professionals

 

It is difficult to know who is who in a hospital. When is a doctor a doctor and when is a surgeon called a surgeon. All females are not nurses and some males are nurses. Not all those carrying stethoscopes are doctors. CONFUSED?

As a podiatrist I am not a doctor but I am a specialist because I have added to my training substantially and am registered to perform treatment at a higher level. All podiatrists hold a basic three-year qualification. All podiatric surgeons in England hold a fellowship; those recently qualified will have a second degree within a post graduate training of a further 10 years. As with many clinicians some have a PhD and so are entitled to use doctor of philosophy even though it may be in science. British podiatrists who practise in foot surgery will explain this to patients if they hold a PhD to avoid confusion with the term ‘medical doctor’.

Many of the websites are very helpful in providing such information. Broadly there are three groups of people in medicine: medically qualified and trained doctors, nurses and allied health professionals (AHPs). Dentists fit somewhere between doctors and AHPs. Some dentists go onto specialise in surgery and medicine i.e reconstruction to the face (maxilla-facial or max-fax surgeons). There has been much consternation about dentists using the term doctor. The Max-fax surgeons became double qualified i.e too medical degree but use the older historical title Mr that the barber surgeon used. Throughout the world you will find most countries use doctor for surgeon, but not in Britain! We do like to be different…

AHPs include psychologists, physiotherapists, radiographers, occupational therapists and operating department practitioners as well as podiatrists. There are over 20 professionals which make up a very large group of clinicians who provide a variety of treatment, keeping the nation fitter. Here again some will use the prefix doctor but this will be taken to mean doctor of philosophy, not associated with medicine. As the natural educational standards rise and more responsibility is assumed by many professionals, overlap inevitably arises. Many regulated professionals other then doctors and dentists can provide medicines related to the conditions that they treat. In 2014 Independent Prescribing licenses gave podiatrists an extension to their role in helping to treat appropriate conditions.

All podiatrists study medicine as part of their qualification so that by the time we qualify we know the function at cellular level to macro-level, anatomy of muscles and diseases of the heart for example. To learn more about podiatry please link to www.feetforlife.org

All podiatrists have to be registered in British law to practise podiatry. Unqualified people who use the term ‘podiatry’ are breaking the law. The register is held by the Health Care Professions Council (HCPC) charged with similar powers to the General Medical Council in that they protect the public where clinical staff fall below the expected standards of care. Please note that Foot Health Practitioners may be registered but not under the HCPC but have a narrower scope of practice.

Regulators in healthcare

In the UK only podiatric surgeons and some orthopaedic surgeons are ‘wholly’ dedicated to elective foot and ankle surgery although orthopaedic surgeons may not practise on the foot and ankle surgery exclusively. Please note that the orthopaedic profession’s opinions are not necessarily shared by the podiatric profession although members of both professions do try to work closely over a wide range of health concerns. Podiatric surgery is recognised by the Department of Health as providing a valuable contribution to health care in the UK although curiously is not separately annotated presently. However to reassure the public this is coming within the next 2 years.

The podiatric surgeon works on the foot and associated structures which can include the tendon achilles. We deal with skin trauma due to pressure and fixed deformities as well as diagnose and manage pain.

If confused always ask your consultant what his qualification is and who his regulator is.

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Why is podiatry sliding toward the Independent sector?

Why is podiatry sliding toward the Independent sector?

Podiatry is a profession that cares for foot health. With a profession of 10,000 dedicated men and women according to The College of Podiatry sources we can only deliver limited care within the NHS and so that leaves the independent sector to provide the rest. Forty-one percent of podiatrists work in the independent sector, 23% share between NHS and their own practice leaving 35% for the NHS (Farndon 2016).

What is a podiatrist and why should you use this group of specialists? Read on to pick up the true meaning of podiatry.

With GPs ever more under pressure, podiatrists offer a number of dedicated services, not just dealing with those age old complaints often ascribed jokes about corns, ingrown toe nails and bunions. Of course these complaints are no joke. However, despite being a profession dedicated to the foot evidence from 2010-13 from the Clinical Practice Research Datalink, of over 1/2 million episodes of foot pain attending GPs only 21% went to podiatrists with 30% going to orthopaedics. The health service is failing to recruit podiatrists and the independent sector is creeping under the strain.

I have taught podiatrists at undergraduate and postgraduate level and know the efforts the profession has travelled over the last 40-years to offer a quality service directed at improving mobility. We go to the GP because the service is the ‘go to guy’. Listening to the radio or TV news or the newspaper we are now out of synch with many world leading healthcare services. The idea of ‘free’ is distorted as we don’t pay enough for British healthcare at face value.

When it comes to Foothealth there are many who can offer advice but as a podiatrist myself I cannot square that circle for want of an awful cliché and say well you don’t go to your GP for your teeth. Why would you go to your GP for your feet? The answer is simply that the doctor is the first line of call, especially if you do not know what the problem is. When I joined the NHS in 1978 the main direction of podiatry (called chiropody then) considered those over 60 ‘the elderly’. Now that term grates as I find I am now a pensioner!

Children attended mainly for warts and a fledgling service offered inlays we call orthoses. This was previously the domain of the orthotist, supported by generous consultant sourced budgets 30 years after the NHS was formed. The rheumatoid and diabetic patients were targeted as having greater need and as far as working with other groups, such as physiotherapists and other specialty consultants, this was rare.

So much has changed since those times and budget trimming as with much of the health service has eroded care delivery. As a tax paying user of the health service I now have higher expectations of my speed of delivery of health care but this is where the NHS has failed for less intrusive conditions. Foot health being one. A referral for a NHS podiatry consultation for orthoses has descended into ridiculous delays, so, as a specialist desiring one of my colleagues to help a patient, a long period opens up where little help is being offered to redirect their problem. This delay is critical and limits the benefit of many treatment programmes. While I believe in the NHS, until there is common agreement from all the political drivers toward non-life threatening conditions, the independent sector will become ever more important.

The independent sector is where many healthcare providers (podiatrists, physiotherapists, doctors and surgeon) are moving to avoid the stressors of the NHS’s unreasonable demands. The healthcare professional is asked to become more of an administrator in the NHS than a clinician and this offends those that care so much about patients. More time, access to more treatment, unconstrained processes that cripple delivery attract those of us more. Toward the end of my days in the NHS I attended useless meetings that caused me to cancel clinics. As a foot surgeon any significant meeting could affect my surgery lists, or the dreaded winter effects filled up surgical beds affecting operation cancellations. Arguing the case with my Chief Executive bore little fruit and another list was cancelled. My podiatry colleagues were no better off and any criticism of management was rejected forcing colleagues into those shadows of despair.

More than ever I see the NHS unable to deliver best podiatric care, not because of poor podiatrists but because of a systematic failure to recognise the importance of less sensitive areas of medicine. Put bluntly this means areas that carry less political gravitas.

Today podiatrists can screen for blood pressure, assess weight distribution, check for diabetic risk and other health diseases, undertake neurological and vascular assessment of the limb, and contribute to smoking cessation support. Podiatrists study medicine as well as their own field and can offer first line advice related to Foothealth and allied medical disease. The profession is split into musculoskeletal podiatric specialists dealing with muscles, tendons and joints, higher risk conditions affecting skin and other tissue damage including rare skin conditions such as congenital epidermolysis bullosa. Some podiatrists have a special interest in dermatology while others work closely with orthopaedics and podiatric surgeons to advise on the appropriate time for foot surgery.

Times have changes. A new focus for the NHS – definitely. For podiatry, well we have been adapting for years to meet patient’s needs, the only problem is patients do not know who we are and what we do. Hopefully another foot Health Month might improve that misunderstanding or not? Anyway to the go to person for feet MUST BE A PODIATRIST.

David R Tollafield is a former podiatric surgeon, member of the College of Podiatry (London) and registered podiatrist, and now author and journalist for podiatry. He writes regularly in ‘Footlocker’ his personal monthly blog. His website is consultingfootpain.co.uk and you can write to him at busypencilcase_rcb@yahoo.com. He also publishes Reflective Podiatric Practice for colleagues signed up to his newsfeed.

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June is Foot Health Month

Why should we look after our feet?

The profession of podiatry launches their annual foot health awareness this month. More about Foot Health and the College of Podiatry later. As a podiatrist and independent author, I believe our work is vital to maintaining the Nation’s health. Foot health matters to all people, not the elderly or young but everyone. But surely every health profession, covering teeth to toes makes the same promise or uses a similar strap line? ‘Tooth pain,’ ‘back pain,’ ‘foot pain,’ is the worst type of pain!

Of course, we are all passionate about health. Why take up a career in health if you are not passionate. So, to kick start why feet?

Basic Principles

We need them to walk on? Yes, of course, but they are more than just wheels/tyres driving the body forward. They are shock absorbers and they change into levers. Anything that affects those two principle functions will impede the body’s progress. The forces that act against the ground when moving require absorbing. Muscles, tendons, fat, skin and correct foot adaptation help with this contact, but also bear the brunt of impact. The kangaroo has a significant bounce when hitting the ground with some 90kg weight and avoids harmful reaction forces. Tendons have built in elastic properties to harness lost energy so it is not wasted and can be used in the next leap. Humans do not leap but joints work together with tendons to achieve a similar aim; absorb and harness that energy to be used again.

As the body moves forward, leverage occurs making the foot  a rigid stable platform for our 50-100+kg bodies. Chimps, with similar foot anatomy cannot form levers around the middle part of the foot and adopt a curious walking pattern that is less efficient and harder to sustain for any distance. Movement involves walking, running or sprinting. Feet should not hurt while standing still or moving about, but they do suffer injuries. Podiatrists as foot health specialists have now established a greater focus on sports and recreational foot health adding their first degree with extended qualifications at Master’s degree and now doctoral levels. This means podiatry provides a wider service than considered traditionally.

Car analogies

Don’t you just hate having to pay out for new tyres on the car. The treads have worn or you have a crack in the wall. Foot skin is thickest under foot. It is the soul of contact (pun intended). If the skin weakens, breaks down, this becomes a big deal. Unlike tyres there is is no ‘Kwick-fix’. Infection, pain, ulcers… not nice; but what of their impact?

The body no longer wants to move as it did. Mobility crisis means giving rise to plenty of concerns for the podiatrist. Your foot health is letting you down and we need to find the source of the pain. Is it infection, skin quality problems, fixed deformity, or are those muscles and tendons not working? Has an old injury come back to haunt you? Arthrosis (a better term than arthritis) affects shock absorption. This is where joint surfaces are damaged; often through wear and tear. In some cases, we can replace joints, but it is best to deal with the problem before that is necessary. Muscles imbalanced with tendon strain are bad news for walking free from pain.

The go-to profession

Can we fix your foot? Yes, mostly.

Some 95% of foot problems can be helped, many cured with timely intervention. Lost days from work, impact on social life and family life, side effects from medication, weight gain, are all matters podiatrists have concern for working with patient’s GPs and other health professionals. Our aim: TO KEEP YOU MOBILE.

So, is Foot Health Month just another fad? No, it is an attempt by a caring profession to reach out to people to take a greater interest in their foot health. The College of Podiatry, the driving force behind Podiatry in the UK, hope to make 2018 a notable campaign. They have said,

‘We want more people to understand the importance of foot health as part of their overall health, and for people to visit a podiatrist when they need to – and to know when they need to!’

The campaign started around 1983 by The Society of Chiropodists and shortly after incorporated the modern name Podiatry. Foot Health Month focuses on health education. The College of Podiatry (educational and academic wing) hopes to deliver information in an appealing and engaging way.

Look out for information during June from independent podiatrists and the professional body, promoting itself now under the banner. Steve Jamieson, the Chief Executive Officer for The Society (the formal body and trade union) and College of Podiatry has been concerned about mixed messages from the various titles, one of which still retains the 19thcentury title, chiropodist. Lewis Durlacher Surgeon Chiropodist to royalty wrote extensively on the foot as far back as 1845. In 2011 the profession tried to change the name of its’ Society, dropping the term chiropody, but this was rejected. June should see another attempt to solve this anomaly. ‘Footlocker’ will be publishing more on confusing titles.

If in doubt about your foot health consult a podiatrist early. The profession has not changed to podiatry from chiropody overnight, but now offers wider scope and expertise, developing over the last 40 years in both the NHS and Independent sector. Foot Health Month was established by the Society of Chiropodists after an initiative around 1983-4 led to the first promotion but has no sponsorship as the largest body dedicated to Foothealth training. Today it has many sub-specialties from sports podiatrists to podiatric surgeons. There is no designated age group that has special attention alone, but of course patients with impairment of circulation ever remain an important focus as we strive to improve lives and prevent unnecessary limb amputation.

To find a podiatrist in your area you can go to https://www.scpod.org/ but do stay in touch with me at Footlocker. Thanks for reading – look out for the next article.

 

David Tollafield is an author and former Consultant Podiatric Surgeon

 

 

 

 

 

 

 

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When was Local Anaesthetic First Taught in Schools of Podiatry?

Local anaesthetic makes life more comfortable for patients

Most podiatrists would agree that the advent of local anaesthetic, that is the ability to produce numbness in and around a painful part of the foot, impacted on the profession of podiatry significantly. Today all podiatrists can offer essential care with this pain relieving medication legally. However it was not something that just happened overnight. The profession of podiatry actually fought against itself at one point which seems bizarre by today’s attitudes of doing the right thing for the patient. This historical fact was uncovered in a PhD thesis by Dr Alan Borthwick.

In 1978 schools of chiropody (as they were called before the term podiatry) introduced the local anaesthetic certificate as part of the three year diploma course (DPodM). This has now been replaced by the BSc (Podiatry) degree, but ’78 was a momentous occasion, not that we as students quite realised we were the first cohort at London Foot Hospital to acquire this skill formally. The year before, I recall, a good friend (and best man at my wedding) had to come back after qualifying to take the course as an add-on… and pay for it out of his own pocket. How lucky we were. Soon after, Part A (theory), then Part B practical local anaesthetic courses were run to allow previously qualified podiatrists to upgrade. It may seem strange that we started with the toe block as shown.

This picture came from a u-tube film of a patient taking his own video footage so no copyright needed as the event is in the public domain! Thankfully, today, podiatrists can offer patients a range of different methods of treating without pain.

This month I am proud to publish Mr Ralph Graham’s, FCPodS, account of the hidden workings behind acquiring local anaesthetic for podiatrists which reveals some interesting historical facts. Ralph Graham was one of the founder members of the leading groups at the time that facilitated these changes.

The article is only available to registered podiatrists and students signed up to my Busypencilcase Communications articles.

 

 

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Medicine and health is more about sharing healthcare with the client.

A publication from the new journal: Advanced Research on Foot and Ankle

Advanced notice of my latest academic publication is accessible to all by free download. Do experienced students do better than novices? Do nurses do as well as podiatrists when looking at lesions? Can classification be used as part of teaching OSCE’s?

In this paper I have explored an old classification system and asked experts to make a comparison with unskilled and semi-skilled students.

The key to this new original research questions the use of classification methods without considering reliability and the value of narrative called the ‘Descriptor.’ The sensitivity of the descriptor in the hands of experienced clinicians can make a difference to the most appropriate decision making.

The revised system from the same author came from a number of pilot studies in 2013 and 2014 and was then to put forward through an ethics committee. Fifty-five podiatry students and 20 nurses volunteered to test the system. Contrasting the old paper (above-click the link) maybe useful for educationalists as there has been a gap of 33-years. Much has changed include podiatry and methods. The 1985 demonstrates how far the profession of podiatry has travelled as it is more a historic reference to the old journal style from the Society of Chiropodists.

Podiatry is about foot health and what was seen as  cosmetic approach to hard skin management can harbour greater sinister influence in affecting patient mobility, pain and walking comfort.

Although it is only part of the conclusion, consider the value behind classification of skin lesions applied to tele-medicine. The need to speed diagnosis. Obtaining access to the correct clinician is vital for expedient treatment, especially where approval is blocked by a healthcare provider based on lack of evidence or cost effective benefit. This classification can aid assessment and hopefully support clinical triage – and at its bassist, who gets treated first!

When we cry out for more educational models in podiatry or even dermatology, this new system might be worth looking at. Patients who might wish to read the different grades might even attend clinic or ring up and say,

‘I have a grade 2 callus and I think I need an ultrasound?’

Medicine and health is more about sharing healthcare with the client. We are the resource they are our customers.

This paper  support my previous paper which considered observation with photography published in October 2017. A further paper is planned on the effects of debridement. Sign up to receive my regular news feed. ‘Subscribe me. I am a podiatrist’ to busypencilcase_rcb@yahoo.com.

 

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Upgrading my website

 

One of the most difficult actions to take is how much to put in and how much to remove when changing from one professional occupation to another. I sat down with my website designer yesterday as Spring heralded a fresh season ahead and discussed the needs of the website consultingfootpain. I am very pro-patient focus for podiatry but also feel it is essential to meet the modern needs of colleagues delivering information. My view takes the angle do a little well than a lot badly.

There is so much development in podiatry and there are pressures to stay ahead of the game, but we must build on what we do well and know works. So, anyone with a view should let me know, write to me as Busypencilcase_rcb@yahoo.com so I can take on board new ideas and areas that podiatrists or patients feel should be represented. You can fill in the box below as well. Patients are more empowered than ever before and the idea of providing edited information is anachronistic.

 

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Podiatric Surgery and database PASCOM-10 hits 100,000 patients this week!

Podiatry –  a profession to be proud of

 

The College of Podiatry (London) represents the largest group of podiatrists in the U.K. Their database known as PASCOM-10, an audit system originally developed in 1997 (PASCOM-2000), has gathered on-line data for the last 8 years (mainly for podiatric surgeons) but reached an impressive 100,000 patients this week. The database is possibly the largest database held anywhere covering the specialty of podiatric surgeons and is used to capture the benefits of treatment amongst patients with foot health problems. While surgery has been an important component, the high risk foot has equally developed a significant contribution to preventing limb amputations and early loss of life, especially from chronic arthritic vascular conditions and diabetes. The latest Government working party paper on focusing on healthcare manpower recognises that podiatrists within the National Health Service have fallen amongst recruit numbers, and yet their contribution to foot-care in the UK is paramount to maintaining  mobility amongst the population for all age groups.

Dealing with pain, skin damage (tissue viability) and deformity rank as the key contributions to the foot health of the UK nation.  British podiatry is probably able to provide a wider service than any other podiatry service in Europe. The growth of muscle-skeletal services within the NHS has combined with other groups such as physiotherapy and orthopaedics. Working together with other groups in multi-disciplinary teams has become an important development for British podiatry in the last 10 years.

The top ranking podiatric conditions seen by those centres audited by PASCOM-10 includes hallux valgus (bunion) at 32%, followed by hammer toes (23%) and then arthritic stiff toe joints (11%). Ingrowing toe nail only ranks no.5 at 4% providing a strong suggestion that other conditions are considered more significant and referred to podiatrists by GP practices in the UK. In 1989 majority of surgical management by podiatrists involved ingrowing toe nails and simple skin conditions. The College formed in 1987-8 after an amalgamation took place of the different groups of podiatry professional bodies now has some 10,000 members within the professional body known as The Society of Chiropodists & Podiatrists. The profession continues to develop more treatment programmes for a wide range of groups. The organisation’s website feetforlife.org provides more information about UK Podiatry.

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Belated Homage to a Great Teacher

Fascination with typed words

At 9 years-old the fact that my words could be typed up by my Dad’s secretary was a pure delight. The script was a play based on ‘Green Acres’, a new 1965 U.S. sitcom about a farm.

My play was silly, as was ‘Green Acres’, and short, but then it was written as a class project for our drama session with my influential speech and drama teacher, as unlikely as her name was – Paddy Field. She was my inspiration into adulthood. I loved her for boosting my confidence when speaking in public something I was to need in adulthood.

Six pages of neatly spaced script looked impressive on A4 paper. I waved them proudly at the friends I had selected to be in MY play. The only other play that day had been hand written, so mine looked more professional in the eyes of a child.

Today I am still mesmerised by the appearance of my own typed script. Today, typewriters seem destined for museums rather than the slick word processors we all have. Set on pristine 80g white paper, I waste time ogling my words as they appear spurred on by the intermittent drone of my HP printer.

The subject matter is more serious these days. My affection for the sight of printed words has not diminished, but my memories of that wonderful lady never fade. Share thoughts of someone who influenced your early life.

www.consultingfootpain.co.uk

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