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B1245 pink 7


AUTUMN 2006
PinK Conference 2007
2-3 February
Cranage Hall Conference Centre,
Holmes Chapel, Cheshire

Registration will be at 12noonon Friday 2 February and theconference will close at Prescribing – The Benefits as 12.30pm on Saturday 3
a Specialist Parkinson's Nurse
All delegates will be offered asingle room and there will beno surcharges for BARBARA STUTTLE CBE is Chair of The Association for Nurse Prescribing and
Director of Primary Care & Modernisation for Thurrock PCT. From February
Theme for next year's 1999 until July 2002 she was on secondment to the Department of Health as a
conference is ‘New Project Manager in Nurse Prescribing and was instrumental in the
Developments andAutonomic Problems in PD', implementation of the National Rollout of Nurse Prescribing throughout the
focusing on the multi- London and South Eastern Regions.
disciplinary team andadvances in future Parkinson's disease for me is one of those conditions you never forget. Patients and developments, including families, who live with the condition every day, have their lives changed in so many ways.
Specialist nurses in the field play a significant part in affecting people's lives, enabling them For further information visit to live as high a quality of life as possible.
Prescribing powers, I believe, enables these specialist nurses to provide a quality service A cheque for £25 will be which enables the patient to live an optimum quality of life. required to support yourplace which is non- Patients are generally diagnosed with this condition by a neurologist and/or geriatrician.
refundable and will be used Although having spoken with a specialist nurse in Parkinson's, she informed me how she can to fund PinK bursaries in wait at traffic lights and identify someone predisposing to Parkinson's. The intricacies of this disease are often above the depth of knowledge a GP would have, because they are generalists. Therefore they will treat symptoms andin my experience, are welcoming to any offers of help and support from specialist nurses.
Supplementary prescribing enables a clinical management plan to be drawn up with the independent prescriber. This may well involve the hospital consultant, GP as well asspecialist nurse (supplementary prescriber) and the patient. This to me, is no more or less a care plan so all parties would know exactly what everyone is doing and what is expected of the progressions of the disease for theindividual patient.
For the supplementary prescriber, this enables them to tailor-make changes to medications in the laid down boundary, whether medicines or dosages, as the patient'scondition alters. For the patient, it means medications can be adjusted as their conditionchanges to ensure medicines are given appropriately.
Unfortunately, clinical medicines plans in my view have been given a bad press after being seen as a bureaucratic process. All they are is a communication aid. Surely clear As referred to in
directions are not difficult if it ensures clear messages are given? the last issue of
In view of the future direction of the health service, I consider Specialist Parkinson's PINK, the NICE
nurses need to be independent prescribers so they can deliver appropriate treatment at guidelines for PD
the right time to maintain the patient's optimum quality of life.
are now published
As all nurses work to their competency and now we have access to the whole BNF, it is and can be found
imperative all prescribing nurses work to their competency, that as soon as the patients condition changes, they will refer back to either the GP or neurologist.
continued over the page Prescribing Information can be found on page 6 Sponsored by Orion Pharma continued from front page Often relationships with the patient and specialist nurse are extremely good - making them the first point of contact from the patient should any changes occur in the condition. It would be hoped that the nurse would be able to respond swiftly to the patient, therefore ensuring the patient has speedier access to medicines. There remains a major difficulty in relation to funding - how do specialist nurses access prescribing budgets? As we move more into commissioning and provision it is essential that all nurses, and in particular specialist nurses, produce robust service plans asto the benefits of their service. This needs to include the impact of saving medical time and the unnecessary admission to hospital for some of the patients. By being able to prescribe, this enhances the above and I am sure there are more benefits that would be part of the service plan.
Many nurses who I meet who are now prescribers, cannot believe the difference it has made to their practice, how much it has improved care to their patients and credibility with medical colleagues.
I consider Specialist Parkinson's Nurses need to undertake the prescribing training to enhance the service they give to their patients so you are able to give a comprehensive service.
Barbara Stuttle Getting The Medication Right … And on Time
Anne Martin, a PDNS for Bromley NHS Trust, describes a new system she has introduced which aims
to introduce greater control to the way medication for Parkinson's disease is delivered in nursing and
In Bromley I support about 60 nursing and recent occasions here in Bromley, two Professionals often kick against change residential care homes for respite care and clients were discharged to homes late at but the Parkinson's Disease Society's ‘Get permanent placements. night and arrived with one dose of it on time' week highlighted where the Sinemet written on the discharge letter problem with medications lies - and to me Often these patients are and with a different dose on the boxes. this is one way of moving on. seen at the homes to preventthem having to travel to clinic With the availability of the new PD If you would like a copy of Anne Martin's in hospital without a carer medication card, the hope is that on PD Medication Card contact your local present, with no idea what admission, the medications the client is Orion sales specialist.
medications they are on, or, taking are recorded accurately on their even with a carer present cards and then taken ‘in' with them. Then, Unable to attend?
who has no idea about the any changes made while in hospital, are recorded and signed for on the card by Please let us know
the discharging doctor and this goes back If the client used a to the nursing home with the client.
Please remember, if you are down to
medication card that was Consequently, any drugs dispensed can attend the next PINK conference but for
carried with them at all times, be checked against what is recorded on some reason are unable to do so, please
especially on respite care, give us as much notice as possible.
their medications would be Although we ask delegates to pay a
recorded accurately and then It also enables autonomy for the client £25 charge to cover their attendance
written up by the GP as it gives them some control over their and hotel, the actual cost to PINK is
on the medications medications and also reduces the risk of far higher.
charts without delay.
clients saying ‘a little yellow tablet' or In fact we have worked out that if we
‘blue tablet' when they fail to bring their At present, clients frequently receive add up travel, hotel, general preparation
medications into clinics or into the medication labelled ‘take as directed'; and speaker honorarium costs, the total
homes, or fail to carry a repeat this seems to be a particular problem cost for the 90 delegates works out at
prescription with them. with Sinemet and means that records cannot be written up. This often results in Another example would be when nursing These costs are covered through an
a delay in medications being given. As a or residential homes send the client into education grant to the PINK group
direct consequence, this can lead to casualty without a list of medications. It is from Orion Pharma and other
hospital admission when medications hoped people could get used to the idea have been stopped.
of a Parkinson's medication book, like the The actual cost for each delegate is
anti-coagulant book, this would be sent in The other problem that medication cards £138. If a place is therefore not used up,
with the client - we hope.
could help to prevent is the poor these are costs which PINK still has to
fund – and is obviously money we could
discharges we often experience when By introducing this system it has got to put to an alternative use.
patients leave hospital and enter either be better than the one we have at the residential or nursing home care. moment, where we have no way of If you sign up for next year's conference
recording medications. The risk of giving but then discover you cannot attend,
Written up wrongly
wrong medications, wrong dosages, please give us as much notice as
In this day of managing beds rather than delays in giving medications and not really possible. Last year we had to turn down
patients' discharges, this can be any time knowing what they are on would be applications so with sufficient warning it
of day or night and as a result medications is likely we will be able to fill in any
greatly reduced by this system. are often written up wrongly. On two


PINK Research Project –
an update from Dr Carol Haigh

Compliance and concordance in people
with Parkinson's Disease and their carers

Any experienced researcher will tell you that one of the momentum. The focus main difficulties about research is that, like packing to go on group leaders have holiday, it always takes longer than you think. had time to read theirway through the very This has been true of the PINK/University of Salford useful text book on collaborative project on compliance and concordance in people with Parkinson's Disease and their carers. management that they Although many people expect ethical review and approval have been supplied to be the main cause for delay in research, I am pleased to with and are raring to go. report that our application to the Multi-site Research Ethics So, throughout the summer the focus groups will be held Committee (MREC) was approved with only minor up and down the country. The literature review people have amendments required. been busy sending their reviews to be moulded into one Part of the reason for this was the invaluable in-put that comprehensive review of compliance and concordance in we had from the members of PINK which allowed for any people with Parkinson's disease and their carers which queries to be addressed - simply by highlighting the should form the first potential publication for this project. expertise of the clinicians involved. By the end of the summer we hope to be able to start looking at the data to begin analysis with a view to havingthe final report written by February/March next year.
The main reason for the post MREC approval delay has simply been the practicalities of meeting the Research It must be recorded that the enthusiasm and Governance Requirements of six different NHS Trusts at commitment of all of the team involved in this research has various locations around the country. Certainly the remained high and the opportunities for learning have experience of co-ordinating a number of participants over been significant. diverse areas of the UK has been an interesting and It's not too late to get involved. if you think you would like to take part in the data analysis please e-mail Dr Carol However, now the project is progressing well and gaining Haigh on c.a.haigh@salford.ac.uk CONFERENCE 2006 Feedback Report
Overall the feedback from this year's negative issue commented upon by within the time constraints but we will PINK conference was extremely both delegates and committee do our best to maintain the standards members was the lack of space set in previous years.
available for the display stands – this From the evaluation forms we The evening entertainment received has also been considered in our plans received, the venue and facilities were quite mixed reviews. It was considered more than adequate and acknowledged that evenings at most people were able to access the Three cheers
conferences are the time to network venue without too much trouble. and meet with colleagues from all We were very pleased to see that not corners of the UK whom we see too The general consensus seemed to be one single negative comment was infrequently. We are certainly that delegates preferred the previous made regarding the speakers and their bearing this in mind as we plan next arrangement of starting at lunchtime contributions. They were described on on Friday and finishing mid-day on numerous evaluation forms as, Saturday, a fact the committee has ‘interesting', ‘informative and thought We would like to say thank you to all taken on board.
provoking'. Three cheers for the who completed evaluation forms. Your comments and feedback will help us Obviously there was something of a and future committees to create hitch with the sound system but this We also received lots of inspiring agendas for conferences which meet was unfortunately beyond our control suggestions for topics to be covered in your requirements and needs.
and we want to thank everyone for the future. Unfortunately we could bearing with us. The only other never hope to meet everyone's needs PINK committee


CONSIDERING A MASTER CLASS COURSE?
MICK CASEY, a Parkinson's disease nurse specialist in Doncaster for four years, describes his recent
experience of a Master Class course.

The Master Class course is aimed at period of further intensive study, interest in Parkinson's disease. This consultants, staff grades and before starting my masters degree.
raised questions on what medications specialist registrars in their final year Having several nursing registrations were available in order to offer of training. This is an intensive and a degree in nursing gave me the choices to patients. Some areas in course in which the candidates learn confidence to undertake the required my region have restrictions on certain about the management of Parkinson's medicines under locally agreed disease at an advanced level. It is formularies. This obviously influences The master class I attended was held over two three day modules, treatment choices depending on run on a very organised schedule of the first in Newquay and the second learning. Formal lectures were held each day as well as interactive I believe it is at the discretion of the workshops. Questions and answer A great deal of networking took faculty whether places for PDNSs are sessions were held throughout place on the course. This was most made available. I feel that acting in a valuable as the skills across the whole consultant nurse role in my post as Every candidate had to complete a group ranged from people with a vast lead PDNS in Doncaster, probably project during the period between the amount of knowledge to those who increased my chances of securing a two modules of study. These projects had just started caring for people with place. All applicants are required to were individually presented during submit their reasons for wanting to sessions set aside in the second attend the course. I submitted I enjoyed the course immensely and module. Each stage of the course several letters via email and the would recommend it to all who are was audited and evaluated. Mentors obligatory 250-word statement. able to access it. It would seem a were assigned to each candidate so logical step for PDNSs to set up their that supervision was accessible own master class course accredited throughout the whole duration of As a healthcare professional, I have by the appropriate body.
always strived to improve my Mick TP Casey, BA Hons, Dip N, knowledge and skills. As a PDNS, The project I chose was a regional RNMH, RN, SPDN, CHCN, PDNS. the master class was the ideal survey of prescribing choices (Graduate of the Master Class).
opportunity for me to undertake a amongst prescribers with a special 2. What do you enjoy most about
6. What is the worst job you
Jerry Playfer your job?
have ever had?
Working in a team and gossip! Barman! - I lasted one day! 1. Who most influenced your
career?

3. What is your most
7. What is guaranteed to make
Carole Gardner, was the first ward you smile?
sister I worked with as a HouseOfficer. Unlike today, we entered the Only recently, I went out on a Talking to PD nurses! wards very unprepared as far as domiciliary visit to a Chinese patient.
practical procedures and time The interpreter was delayed, so I spent half an hour taking a pigeon Englishhistory and painstaking examination of Carole taught me how to put up a an elderly Chinese man. When the drip, how to pass a catheter and was translator arrived, she said the Chinese tremendously supportive in my first name was female, at which point, three months as a qualified doctor, the old gentleman's wife emerged giving me confidence for my future from a back room and I had to start PROFILEcareer. I admired her dedication and the process all over again!
professionalism which has always Playfer is a
made me a strong champion of nurses, including marrying one! 4. If you could change one
Secondly, I was attracted to geriatric thing about your job what
medicine by the example of would it be?
Professor Jimmy Williamson, who The job is perfect! was a superb physician with a real has a special
knowledge of Parkinson's disease interest in
and a great humanitarian approach to 5. What book, film and piece of
medicine. He encouraged and disease. He is
music would you take to a
supported my development as a geriatrician when I started my President of the
research in Liverpool. Book - The Great Gatsby, Film - Notting Hill - Music - Coldplay CD


Primary Care – We Need
to Look at Different Routes
for Service Provision

GREG ROGERS, a GP in East Kent, describes a model of care
delivery he has helped develop for epilepsy patients – and believes it
could work equally well for treating PD patients within primary care. Specialist nurses
would be fundamental to its success.
Do you often feel dragged into yet another which will soon run in the five PCTs of East Kent. change which means financial cuts and more To qualify for this, a lead GP is nominated and has basic training in epilepsy management and oversees the straight forward care of people with epilepsy in their surgery. If Allied to this is less straightforward needs come to light, the GPwSIs in the real threat of redundancy.
epilepsy are approached for help and advice. I must say if the media reported This system of GPwSIs and the Epilepsy LES facilitates me as a ‘soft target,' for the prompt discharge from out-patient clinics of people redundancy, I would not only feel very who have some modification of their treatment left to do.
threatened, but also very under-valued The consultants can be confident to discharge these for my professional work. patients, in the knowledge that they will not ‘slip through Could the way forward be to the net' following discharge, knowing if problems occur, lead with these changes rather they will be re-referred back to secondary care.
The scheme aims to provide a seamless care for this population and also free up out-patient clinics to be specialist interest in responsive for those with acute or complex needs. epilepsy [GPwSI in Surely this could also be extended for the treatment of Parkinson's disease? this coming largely from a desire to work for the hidden How do the specialist nurses fit in with this? To create population who continue to suffer from epilepsy but who seamless care the interface close to secondary care for seem to have only a weak voice in society and indeed in refractory or complex care relies largely with the specialist nurses. The routine needs of people with epilepsy could be With a caseload of more complex cases which greatly improved by primary care – however since the late necessities the ear of the secondary care specialist, the 1980s the routine care of people with epilepsy has largely specialist nurses are fulfilling a role that a GPwSI could been placed in secondary care, which means primary care not meet. This role requires frequent discussions and has lost many of the skills it once had in this area. could only be fulfilled by a health professional whose solejob is Epilepsy [or PD] and who is mobile.
Restricted access to epileptologists is a national problem and primary care surely needs to regain the place as Also the answering of patient queries by phone five days provider of routine care. a week and education on the wards and within institutionsis surely best managed by a nurse specialist.
One solution I have been working on requires education and the development of a network of GPs specialised in I would imagine becoming an indispensable part of the the care of epilepsy [GPwSIs in Epilepsy] that provide team is the safest way to secure a job - while spreading peripatetic care. oneself too thinly to ‘make a difference' could make thisposition weaker. By being peripatetic, part of their brief is also to share these skills with their colleagues in practice. With the There are as yet only a few GPwSIs in PD and no support of the East Kent PCTs, I have trained eight GPs to nationally adopted LES for PD. Surely however it is become GPwSIs in epilepsy, serving a population of over essential to look ahead and work with those developing 600,000 and take direct referrals from colleagues. routes of service provision? They may look very differentto my ideas here but being involved in modelling of such Following this development, the PCT have developed a schemes will not only be in the best interests of the Locally Enhanced Service [LES] for epilepsy which at people we work with, but in the long run, for ourselves.
present is only being offered in East Kent Coastal PCT but Stalevo Case Study Stalevo® (levodopa, carbidopa, entacapone),
KAY HOOD, a Parkinson's disease nurse specialist within a busy movement disorder clinic in Stobhill
Hospital, Glasgow reports on a recent experience prescribing Stalevo.

I have four years experience as a PDNS levodopa bioavailability and more stable periods of anxiety and she complained and have day to day contact with clients concentrations of levodopa in the brain of general aches and pains. who have advancing disease, and, (Olanow, 2001; Schrag, 2005).
It is important to note that the majority consequently more troublesome disease We were also keen to observe whether of these symptoms were alleviated by symptoms as well as side effects from patients reported any additional benefits her next dose of medication.
their treatment. than those taking levodopa plus a Following discussion it was agreed to Therefore it is always encouraging to commence on Stalevo tablets 100mg hear of new preparations available to inhibitor in two separate tablets.
one tablet Q.I.D. The basic manage their problems.
Administering entacapone separately pharmacology of the medication was It was pleasing to hear that Stalevo without levodopa is ineffective – discussed and it was agreed that MR tablets (a combination of levodopa, prescribing Stalevo would avoid this.
would be reviewed at clinic in six weeks.
carbidopa and entacapone) were licensed The following is a case study to On review there were no detectable for use in November 2003. It is thought examine the effect of Stalevo therapy.
motor signs, her mood had improved that Stalevo may provide a less pulsatile Case Study
significantly and she reported no delivery of dopamine, resulting in more "wearing off" effects or fluctuations in stable levels of dopamine reaching the MR is a sixty five year old lady who her condition. The Stalevo regime was striatum (Stocchi et al 2003, Rinne et al was diagnosed with Parkinson's disease well tolerated with no harmful side 1998). More stable dopamine delivery is in 1999. Unfortunately she had been effects and the client was happy to thought to delay the need to increase the unable to tolerate any of the dopamine continue to use it as she felt a major dose of levodopa/DDCI (Larsen 2003).
agonists due to side effects. After tryingto convince her to commence traditional benefit. The combination tablet allowed We were particularly keen to observe levodopa/DDCI therapy she agreed to do the regime to be simplified and halved the effect Stalevo therapy had on so, due to increasing disability.
the daily dosage that would have been patients who were not experiencing the taken if prescribed traditional same duration of effect from traditional After initially being prescribed entacapone and Sinemet tablets. In June levodopa as they had previously. Stalevo Levodopa of Sinemet 62.5mg TID, 2006 the client concerned continued to is an enhanced levodopa formulation increasing to Sinemet Plus, one tablet perform well on the above regime.
containing the dopadecarboxylase QID, the condition of the patient inhibitor(DDCI), carbidopa and the remained stable. However, earlier this catechol-O-methyl transferase (COMT) year, when she was reviewed at the Rinne UK et al 1998 Neurology 51 1309-1314 inhibitor, entacapone. The inclusion of a nurse led movement disorders clinic, she Stocchi F et al 2003 Neurology Science 24 217-218 DDCI blocks down the breakdown of reported that her Parkinson's symptoms Larsen J P et al Eur J Neur 2003;10:137-146 levodopa in the periphery but levodopa were beginning to return before her next Olanow CW, Watts RL, Koller WC. An algorithm is still broken down into 3-O-methyldopa dose of levodopa was due (wearing off).
(decision tree) for the management of Parkinson's in the periphery. Symptoms reported included increased disease (2001): Treatment Guidelines. Neurology By also including the catechol-O- stiffness and tremor and on examining 2001; 56 (Suppl 5):S1-S88. methyltranferase (COMT) inhibitor, her gait speed it was markedly slower Schrag A. Entacapone in the treatment of entacapone, this route of metabolism is than previously. On further discussion Parkinson's disease. Lancet Neurology 2005; blocked. This leads to an increase in and examination her mood was low with 4:366-370. Stalevo (levodopa / carbidopa / entacapone) Prescribing Information Indication: Treatment of patients with
Parkinson's disease and end-of-dose motor fluctuations not stabilised on levodopa/dopa decarboxylase (DDC) inhibitor treatment. Dosage and administration:
Orally with or without food. One tablet contains one treatment dose and may only be administered as whole tablets. Optimum daily dosage must be determined by
careful titration of levodopa in each patient preferably using one of the three tablet strengths. Patients receiving less than 70-100 mg carbidopa a day are more likely
to experience nausea and vomiting. The maximum Stalevo dose is 10 tablets per day. Usually Stalevo is to be used in patients who are currently treated with
corresponding doses of standard release levodopa/DDC inhibitor and entacapone. See SPC for details of how to transfer these patients and those not currently
treated with entacapone. Children and adolescents: Not recommended. Elderly: No dosage adjustment required. Mild to moderate hepatic impairment, severe renal
impairment (including dialysis): Caution advised. Contraindications: Hypersensitivity to active substances or excipients. Severe hepatic impairment. Narrow-angle
glaucoma. Pheochromocytoma. Concomitant use of non-selective monoamine oxidase inhibitors (e.g. phenelzine, tranylcypromine). Concomitant use of a selective
MAO-A inhibitor and a selective MAO-B inhibitor. Previous history of Neuroleptic Malignant Syndrome (NMS) and/or non-traumatic rhabdomyolysis. Warnings and
precautions:
Not recommended for treatment of drug-induced extrapyramidal reactions. Administer with caution to: patients with severe cardiovascular or
pulmonary disease, bronchial asthma, renal, hepatic or endocrine disease, or history of peptic ulcer disease or of convulsions, or past or current psychosis; patients
receiving concomitant antipsychotics with dopamine receptor-blocking properties, particularly D2 receptor antagonists; patients receiving other medicinal products
which may cause orthostatic hypotension. In patients with a history of myocardial infarction who have residual atrial nodal, or ventricular arrhythmias, monitor cardiac
function carefully during initial dosage adjustments. Monitor all patients for the development of mental changes, depression with suicidal tendencies, and other
serious antisocial behaviour. Patients with chronic wide-angle glaucoma may be treated with Stalevo with caution, provided the intra-ocular pressure is well
controlled and the patient is monitored carefully. Caution when driving or operating machines. Doses of other antiparkinsonian treatments may need to be adjusted
when Stalevo is substituted for a patient currently not treated with entacapone. Rhabdomyolysis secondary to severe dyskinesias or NMS has been observed rarely
in patients with Parkinson's disease. Therefore, any abrupt dosage reduction or withdrawal of levodopa should be carefully observed, particularly in patients who
are also receiving neuroleptics. Periodic evaluation of hepatic, haematopoietic, cardiovascular and renal function is recommended during extended therapy. Monitor
weight in patients experiencing diarrhoea. Contains sucrose therefore should not be taken by patients with rare hereditary
problems of fructose intolerance, glucose-galactose malabsorption or sucrase-isomaltase insuffiency. Undesirable
effects:
Levodopa / carbidopa - Most common: dyskinesias including choreiform, dystonic and other involuntary
Orion Pharma is the sponsor movements, nausea. Also mental changes, paranoid ideation and psychotic episodes, depression, cognitive dysfunction.
Less frequently: irregular heart rhythm and/or palpitations, orthostatic hypotensive episodes, bradykinetic episodes (the company of PINK and is one 'on-off' phenomenon), anorexia, vomiting, dizziness, and somnolence. Entacapone - Most frequently relate to increased of the leading companies in dopaminergic activity, or to gastrointestinal symptoms. Very common: dyskinesias, nausea and urine discolouration.
Common: insomnia, hallucination, confusion and paroniria, Parkinsonism aggravated, dizziness, dystonia, hyperkinesias, the healthcare sector in the diarrhoea, abdominal pain, dry mouth constipation, vomiting, fatigue, increased sweating and falls. See SPC for details of Nordic area of Europe. laboratory abnormalities, uncommon and rare events. Legal category: POM. Presentations, basic NHS costs and
marketing authorization numbers:
Stalevo 50 mg/12.5 mg/200 mg, 30 tablet bottle £21.72, 100 tablet bottle £72.40, MA
For further information visit numbers: EU/1/03/260/002-003; Stalevo 100 mg/25 mg/200 mg, 30 tablet bottle £21.72, 100 tablet bottle £72.40, MAnumbers: EU/1/03/260/006-007; Stalevo 150 mg/37.5 mg/200 mg, 30 tablet bottle £21.72, 100 tablet bottle £72.40 MA numbers: EU/1/03/260/010-011. Distributed by: Orion Pharma (UK) Ltd. Oaklea Court, 22 Park Street, Newbury,
Berkshire, RG14 1EA, UK. Full prescribing information is available on request. Stalevo is a registered trademark. Date of
Prescribing Information:
April 2006.
Information about adverse event reporting can be found at www.yellowcard.gov.uk. Adverse events shouldalso be reported to Orion Pharma (UK) Ltd on 01635 520300.
Item date: September 06

Source: http://www.setpoint.co.uk/pdfs/Pink7b.pdf

Gs16 surgery for ingrowing toenail (adult).fm

Mr. Sanjay Singh MBBS, MS, FRACS, FRCS (UK) 2 - 4 Charles Street Tel: 02 4474 3774 Fax: 02 4474 3775 Write questions or notes here: Surgery for Ingrowing Toenail (adult) Further Information and Feedback:You can get more information about this procedure at aboutmyhealth.orgTell us how useful you found this document at www.patientfeedback.orgBrochure code: GS16

Final baseline

1.0 INTRODUCTION TO THE STUDY Forum Syd, a Swedish Non Governmental Organization (NGO) working together with The Livelihoods Foundation (LEO), a Kenyan NGO to support the Empowerment of Rural Population in Nyatoto Community in Central Division of Homa Bay County in Kenya, Africa. Forum Syd has solicited support from SIDA, Sweden to fulfill this objective. LEO