The first hospital trip of 2014

Well, Wednesday last week was my first trip to hospital for the New Year.

I have a new carer in the mornings, and he has been a bit erratic with his time keeping, but he has assured me that he will be with me at 6.00 am.  As I've overslept the last couple of times I've been going to hospital, and the worry if my carer will turn up on time, I keep waking up during the night to check the time.

Well I needn't have worried.  As good as his word he is with me at 6.00 am, and he gets me up, showered and dressed.

I have my pills and my breakfast, and am all ready to go, when the transport arrives at 7.00 am.  Its not the normal driver, but a very nice young lady, and she soon has me strapped in and on our way. 

We take the normal route into London, through Thornton Heath, Streatham and Brixton, and then follow the South Bank of the Thames before crossing at Waterloo Bridge.  And then we suddenly head off into East London.  I assume the driver must have had a call to pick up another patient, as its such an unusual way to go.

Anyway we get the other patient, and head off to the hospital.  On the way a van driver pulls out on the ambulance, and with some good evasive driving we only lose the wing mirror.  After getting the van drivers details, we are on our way again, and make it to the hospital right on 9.00 am.

After a dash to the toilet, I make my way to the ward and get checked in.

The nurse looking after me today is a really nice guy call Tinashe.  He has been part of the nursing team that has looked after me for years, and he is a very friendly guy.  We have our customary chat about football - he's an Arsenal fan.

I call my respiratory physio, Christine, as we had arranged to meet today.  Sadly she is off sick, but her assistant Steve, offers to come and see me.  He has the results of the lung function tests I had done late last year, but he can't find the results from the year before, to be able to say if there is any change.  My impression is, that if there has been a change it will only be marginal, so we agree that I'll email Christine, with the date of my next appointment, and discuss these then.

As Steve leaves, one of the cannulation team arrive, and put the cannula in my left arm and take some blood for regular tests.  Then its just a case of waiting for the drugs to turn up.  I am having my regular 6 weekly Methylprednisolone (250 mg).  Whilst I wait I read my book.

After sometime a young lady comes in, who I have meet before.  She is partially sighted, and for the first time she is using a white stick.  She is always very jolly and upbeat, and never seems to let her disabilities get her down - the partial sightedness is only one of many.  She always jumps up and helps me open the toilet door if she sees me struggling.  She sits and uses her iPad, which is loaded with software so that it talks to her about what she is doing, as she has difficulty seeing the screen.

After a cup of tea and a packet of biscuits, my drugs turn up just after 11.00 am.  I am hooked up to them, but know that it only takes an hour for these to go in, plus a 10 minute flush of the line.

So about 12.30 pm the drugs have gone through and the line has been flushed.  At this point my consultant, Professor Chris Denton, arrives.  He has been my lead consultant for about 15 years, and is very good.  He is really interested in his patients and takes a real interest how we are doing as individuals, and coping with our conditions.







Because of the need to use hospital transport to go to see him, I no longer attend his clinic, but I go for treatment on a Wednesday, because I know he does his ward rounds on that day.  He knows that I generally have a good understanding of my conditions, and that I am aware when something is wrong.  We therefore have an understanding that we don't need to see each other every time I am at the hospital for treatment, but if I need to see him, I call his secretary, and ask her to point him in my direction, next time I am there.

We discuss how I am generally, and I show him some pictures of me standing in the Levo C3 powered standing wheelchair.  He is really pleased that I am able to use this, but also that I feel I'm getting some benefit from it.

The reason I have asked to see him is about my Methotrexate.  I take 25 mg weekly on a Saturday.  I have been in this dose for years, and have usually taken it orally, but for sometime injected myself.  I have never had any particular problem with Methotrexate, until recently.

During the last 6 months, I have noticed that more and more regularly, I have started to feel unwell on a Saturday after taking the Methotrexate.  Sometimes this is just for a couple of hours, but more and more regularly, I spend the whole day feeling nauseous, worn out and with no appetite.

We discussed this for a bit.  All my blood tests are fine.  Professor Denton, still wants me to be taking Methotrexate, as although we aren't completely sure what its doing, as part of my overall drug regime, it seems to be helping me keep reasonably stable.  We therefore agree to reduce the Methotrexate to 20 mg weekly, and see what happens.  We could look at changing how I take my Folic Acid as this might stop the sickness.

He stresses that if my DM and IBM start to deteriorate as a result of this change, I must contact him immediately.

After he goes, Tinashe comes and removes the cannula, helps me on with my fleece, and after making my next appointment, I'm on my way.

I check in at transport just before 1.00 pm.

After having waited a while a lady comes in, in a wheelchair, pushed by her husband and with her daughter.  There aren't many seats left, but they put the wheelchair next to mine, and the husband sits down behind me.

He then proceeds to spend the next couple of minutes kicking the wheels on the back of my wheelchair.  Just as I turn round to tell him to stop, he gets up and announces that he is getting the bus home, as he is bored, and the daughter can go in the ambulance.  As he leaves a huge cloud of stale smoke smell goes with him.

The lady sits in her chair and you can hear every breath in and out is an effort.  She seems to rattle as she breaths, and everything seems to be an effort.


Not long after this she is taken out to an ambulance to go home.  About 5 minutes later - and after a 90 minute wait - I get taken out, only to find the lady sat in her wheelchair, puffing away on a cigarette!


Anyway, we get underway about 2.30 pm and after a trouble free journey, I get home just after 4.00 pm.  I am exhausted.


After dinner, I sit down to watch the football and don't get to see much of the game as I've nodded off.

Lymphoedema and Lipodermatosclerosis

I was prompted to write this blog by a posting sometime ago on the TMA community forums on the subject.

 

When I came out of hospital and rehab, in a wheelchair in September 2008, I had no idea of the additional complications that being in a wheelchair could cause.  Naively, I just thought that I'd have my Dermatomyositis and Inclusion Body Myositis, and the other existing conditions, and would now carry on with these, but in a wheelchair.  No one had told me about the added complications that could occur if you are in a wheelchair and immobile.

When I first came out of rehab, I was having regular physiotherapy sessions, where they would get me standing up, using a standing frame.  However, once they had made the decision that there was not going to be any long-term improvement in my condition, they stopped these sessions.  This was the point where everyone started to tell me that I would never stand again.

 

Shortly after this I had the first sign of the future complications that being in a wheelchair would cause.

 

This would have been about March or April 2009 - so about 6 months after coming out of rehab.  One morning when my carer was getting me up, she noticed that I had a small abrasion on one of my toes.  She put a small dressing on it and advised me to call the district nurse, to get it looked at and dressed properly.

 

Well I thought it was such a small abrasion that it wasn't worth making a fuss about, as it would be cleared up in a couple of days.

 

After about 10 days, and no improvement, I finally conceded that perhaps it might be best to get it looked at.  I called my doctor and he arranged for the district nurse to come and see me, to assess and dress the wound.

 

The nurse came out the next day, and after looking at it, applied a dressing. She advised that she would put in a prescription for more dressings and call back later in the week.

 

When the dressings turned up, I thought we must be catering for a small disaster zone.  There were different types of dressings, saline and gauze to clean the wound, tape and cream.

 

Well for about the next 6 to 8 week, the nurse came twice a week to clean and dress the wound.  Eventually it healed up, and just as it did, another abrasion opened up on a toe on the other foot.

 

In total the nurse came to me for about 6 months, twice a week until these small wounds healed up properly.  This was a consequence of being in a wheelchair, and not being able to stand and get the fluids moving properly round the body.

 

During this period, I noticed that the skin on my feet and legs, below the knees, started to become very red.  It looked like my legs were very sore, but they weren't.

 

My legs also started to swell, and during warmer weather, they would ooze a clear liquid.  As a consequence they started to need to be dressed, to try to stop the swelling and to help prevent them becoming infected, where they were oozing.  I was advised that I should sleep with my feet and legs elevated, to help reduce the swelling.

I also started to get some pain in my legs, usually at night.  During the day when I could move my legs, it wasn't rally a problem, but at night, when I can't move, it would keep me awake, until Mum had to come in and move my legs, or massage them.

 

During this time when the nurse was visiting I was referred to the local Vascular Team, to see if they could help improve the condition of my legs and feet and help with the healing of any future wounds I might get on my feet and toes.

 

The lead consultant, a lady called Ms Vig, was very nice and very concerned about my legs and feet.  She took a lot of trouble examining my legs, and listening to my medical history and how I had become wheelchair bound.

 

She prescribed some new creams to help improve the condition of the skin, and suggested that I should be admitted into hospital for 3 days to have my legs scanned, and also to have a treatment of a drug called Flolan, which would be administer intravenously over 3 days, and would be used to open up the blood vessels in my legs and feet, and improve circulation..

 

I was apprehensive about going into hospital, as this would be my first admission to stay, since being in a wheelchair, and I was concerned that being in hospital would be taking me out of my normal comfort zone, and into an environment where my care, beyond what is normally provided in hospital, would be very much outside of my control.  I also did not want to stay beyond the 3 days she had outlined, and she assured me that not only would I go to a ward where all her patients go, so she could guarantee my treatment and care, but that everything would be set up so that I had the treatment and scan in the shortest possible time.

 

So armed with these assurances, I agreed to go in.  It was now December 2009.

 

When I was admitted, it wasn't to the ward Ms Vig had said, as they didn't have a bed there for me.  The nurses on the ward didn't seem to know why I was being admitted or which consultant I was under.  Worst of all, they didn't seem to know how to cope with someone in a wheelchair.

 

I won't go into that now, but after 24 hours and not seeing a doctor, having had no treatment, and being treated like I was a nuisance by the nurses, and other patients - who seemed to think that me needing to be hoisted and helped, was just me being lazy - I wanted to go home.

 

Then I was transferred to the right ward, and everything changed.  The nurses were lovely, they listened to me and were very helpful, and the other patients were friendly.

 

Sadly, the doctor who came to see me, didn't really know why I was there, despite having my notes.  I asked to see Ms Vig, but was advised that she had gone on holiday, so I had to explain why I was there.

 

Later that day we started the Flolan.  This was administered slowly. over a long period of time in order to prevent any side effects.  I have previously had a drug called Iloprost, which is similar in what it does, but when you are having it you feel nauseous, have headaches and an aching neck, very tired, and in extreme cases you cannot tolerate light.  The Iloprost is much more aggressive in the way it acts on the body, which causes these side effects, but also very effective.  The Flolan is less aggressive, and therefore there is less likelihood of any side effects, but it can be less effective.

 

During this treatment and when the 3 days of treatment had finished, I asked about the scan, but nothing seemed to happen.  Eventually after being in for over a week, I insisted on seeing the doctor again, who again claimed to know nothing about a scan.  After a good deal of shouting on my part, he looked in the notes again, and saw that, yes, I should be having a scan.  By this time it was Friday lunchtime, and he said that would not be able to arrange the scan until the following week.

 

After I had come down off the ceiling, I told him that I had been assured by Ms Vig, that this would all have been done, whilst I was having the Flolan, so that I didn't need to stay in hospital any longer than necessary.  I advised him that I saw no reason that he couldn't arrange the scan that afternoon, and that because of his inefficiency, I was now blocking a bed, that could more usefully used for someone who actually needed treatment.  If he couldn't arrange the scan, he should be prepared for me to leave, and he could then explain to Ms Vig why I hadn't had the scan as planned.

 

He went away and 5 minutes later, a nurse came and told me that the scan would happen early in the afternoon.  She congratulated me on pushing to get this done.

 

Well the scan went ahead, but sadly the results were to late coming back to the ward for me to be discharged that evening.

 

Overnight it had snowed, and was bitterly cold.  I was discharged but the nurses wanted to send me home in just a hospital gown.  I pointed to the weather outside and asked the senior nurse, how she had been dressed when she came to work in the morning, and whether she had been warm enough.  She took my point and got me dressed in my own clothes, before letting the ambulance men take me home.

 

(I'll just make the point now that I am a great fan of the NHS and all who work in it, but there are occasions when you need to stand up for yourself.  I'm lucky that most of my doctors and the nurses who normally look after me, have known me for years, so I am usually spoilt).

 

I saw Ms Vig again, in an outpatient clinic, and she advised that nothing had come up on the scan to show that there were any vascular issues in my legs.  The Flolan, had made little difference to how my legs felt or their condition.  As there were no vascular issues, she advised that she would refer me to the Dermatology team.

So from early 2010, I started going to the Dermatology team at my local hospital.  This first doctor I saw examined my legs and feet, and prescribed some cream.  She admitted that she knew nothing about my conditions, but wasn't really interested in talking to me about them.

I went away and used the creams as advised but these made no difference.  In fact the skin just became worse.  By this time there was a build up of very dry skin on my legs.

At the Dermatology clinic, seeing the condition of my legs I was told that I couldn't be using the cream properly as prescribed.  I assured them I was and was sent home, after being told if I use the creams properly my legs will improve.  I was also told that I should sit all day with my legs and feet elevated above my heart.

They just continued to get worse.  The dry areas increased in size until they all merged into one large dry area on each leg and foot.  In order to stop the swelling, we had started to bandage the legs after applying the cream.  Each time these bandages were taken off, a load of dry skin would fall off my legs, and we were left with a pile of skin on the floor.

The next time at Dermatology, I saw a new doctor.  She told me that she knew all about my conditions, and that it was not possible for me to have both Dermatomyositis and Inclusion Body Myositis.  I must have something else.  I asked her what she thought I had, and she could not answer.  She examined my legs and prescribed a different set of creams.  I asked if compression stockings might be useful, but was ignored.

My legs just got worse.  Although the skin wasn't sore, because of all the dry skin and how this kept coming off, the skin below was very delicate and easy to break.

And this is how the pattern of things went on.  I would go to Dermatology, and they would scratch their heads, and prescribe different creams.  The condition of my legs and feet would continue to deteriorate.  I'd periodically ask if compression stockings might help and this was ignored.

 

Then in later 2011, I was seeing my main consultant, at another hospital, and I asked him to look at my legs and feet.  I told him what had been happening and he was appalled, not just by the treatment I had been getting but also at the state of my legs and feet.

 

He picked up the phone and rang a colleague in Dermatology, to ask if she would see me.  She apologised that she could not see me that day, but she could the following day.

 

I met with Dr Victoria Swale, the following morning.  She had seen my notes, and despite there being 5 files of notes, she had read at least a good part of them, because she knew about my history.  We discussed the treatment I had been getting and she asked if I had been given a diagnosis.  I said that I hadn't.

 

She then took the dressings off my legs and feet, and as soon as she saw them I could tell by the look on her face she knew what was the problem, and importantly, that she could help.

 

After examination, she took some of the dry skin off my legs, to be sent for analysis, in case there was any infection present.  However, she thought that this was unlikely. 

 

She then advised me that I had Lymphoedema and (Acute on) Chronic Lipodermatosclerosis. 

 

She made a couple of changes to the creams I was using, and how and when these should be applied.  She then advised that the real solution to this problem was to get me into compression stockings.

 

Over the next couple of weeks I had appointments to test the Doppler readings in my feet and ankles, to ensure that there was no damage to the blood vessels, and that there were good pulses in these areas.  I also saw the Tissue Viability team, who started to apply pressure bandages, to my legs and feet, in order to build up the tolerance to pressure on the skin on my legs and feet.

 

The pressure bandages, started off with 2 layers of bandaging building up to 4 layers, to increase the pressure being applied.  At the 2 layer level it was no problem, but when we got to the 4 layer level, the pressure was quite a lot, and as I wore the bandages the more they seemed to tighten.

 

On several occasions the bandages tightened so much that it felt like my legs were being crushed and we actually had to cut the bandages off, as I was in so much pain.

 

After about 2 months of the pressure bandages, I was then measured up for the compression stockings.  These are made-to-measure, specifically for me and for each leg, and are worn to just below my knees.  They last for between 4 to 6 months, when they need to be replaced, after having re-measured my legs to take into account any changes in the size of my legs.  I wear them each day, but take them off at night.  Fortunately I have very good carers who can take them on and off, relatively easily.

 

Almost as soon as I started wearing the compression stockings there has been a change in my legs.  Within 2 months, the legs weren't swelling much, and most of the dry skin was starting to go.  Within 6 months, there were only small patches of dry skin, the general colour of the skin on my legs and feet had started to return to something close to normal, and in some areas, the hair started to grow again - a clear sign of healthy skin, and that the fluids are moving normally through the skin and muscles.

 

Almost 2 years after first wearing the compression stockings, my legs are hugely improved.  Standing in my standing wheelchair will also be a factor in helping my legs improve, but without the improvement gained with the compression stockings, I might not have been able to achieve this.

 

There are two morals to this story.

 

Firstly, don't neglect your legs and feet, and try to be aware of the additional complications that can come with lack of mobility, and especially with being in a wheelchair.  Having sore, tender, painful, uncomfortable legs and feet can make you really unhappy - even when you can't walk.  It makes such a difference if they feel better, to how you feel.

 

And secondly, make sure you see the right person as soon as you can.  All the time I was seeing the Dermatology team locally I always thought I was in the wrong place, and not getting the right treatment, but I didn't want to be a nuisance.  However as soon as I saw Dr Swale, I knew she was going to help.  She knew and understood about my conditions, and most importantly, from almost the first time I saw her, things started to improve.

  

Lymphoedema

 

Lymphoedema is a chronic (long-term) condition that causes swelling in the body's tissue. This can lead to pain and a loss of mobility.

Lymphoedema usually affects the arms or legs, although in some cases there may be swelling in the:

chest

• head
• genitals

Lymphoedema is caused by damage or disruption to the lymphatic system.

One function of the lymphatic system is to drain excess fluid from tissues. If the lymphatic system is disrupted or damaged, it can lose this ability and the excess fluid will cause the tissue to swell.

Types of lymphoedema

There are two main types of lymphoedema:

• Primary lymphoedema – which develops at birth or shortly after puberty and is caused by faulty genes.
• Secondary lymphoedema – caused by damage to the lymphatic system as a result of an infection, injury, trauma, or cancer.

Secondary lymphoedema often develops as a side effect of cancer treatment. Surgery is often necessary to remove lymph glands to prevent a cancer from spreading, this can damage the lymphatic system.

Radiotherapy, where controlled doses of high-energy radiation are used to destroy cancer cells, can also damage the lymphatic system.

Read more about the causes of lymphoedema.

Who is affected?

It is estimated that 1 in 10,000 people are affected by primary lymphoedema.

Secondary lymphoedema is a relatively common condition, affecting an estimated 100,000 people in the UK.

Secondary lymphoedema occurs more frequently in women, possibly because it can sometimes be a side effect of breast cancer treatment.

Cancer Research UK estimates than one in five women may have lymphoedema in their arm after they have had radiotherapy or lymph nodes removed to treat breast cancer.

If you are at risk of developing lymphoedema due to cancer treatment, you may be offered an assessment as part of your aftercare. Read more about how lymphoedema is diagnosed.

Treating lymphoedema

There is no cure for lymphoedema, but it is possible to control the symptoms using a combination of different techniques, such as massage and compression garments.

There are also things you can do to help prevent the condition getting worse. This includes taking care of your skin to avoid infection and having a healthy diet and lifestyle.

If you have received treatment for cancer, these measures may also help to prevent lymphoedema.

Read more about how lymphoedema is treated and preventing lymphoedema.

Complications

People with lymphoedema are more vulnerable to infection. This is because infection-fighting white blood cells, called lymphocytes, which travel in the lymphatic system, are prevented from reaching the part of the body where they are needed.

A bacterial infection of the skin called cellulitis is one of the most commonly reported infections in people with lymphoedema.

Read more about complications of lymphoedema

Lipodermatosclerosis

In some people, the area becomes red and inflamed and can be painful. This problem is called lipodermatosclerosis.

The symptoms of lipodermatosclerosis include:

• hard, tight skin 
• red- or brown-coloured skin 
• the layer of fat and soft tissues underneath the skin (subcutaneous tissue) may become hard, causing the leg to look like an upside-down champagne bottle

Treatment

Options may include:

• emollients (moisturisers) 
• topical corticosteroids 
• graduated elastic medical compression stockings

There are also some self-help techniques that you can try. These treatment options are described in more detail below.

If you have varicose veins, graduated elastic medical compression stockings will often help to treat these as well. However, in some cases surgery may be necessary.

Lipodermatosclerosis (hardened, tight skin) is treated the same way as varicose eczema. If you have a venous leg ulcer, you can also read information about treating venous leg ulcers.

Self-help

There are some steps you can take to care for your varicose eczema:

• avoid injuring your skin – for example, by knocking into a chair, as this could lead to an ulcer (open sore) developing
• raise your legs when you are resting – for example, by propping up your feet on some pillows to help reduce swelling 
• keep physically active – this will improve your circulation and help you maintain a healthy weight

Exercise

Fluid builds up in the lower legs if you sit or stand for too long, so it is important to keep moving. Walking will get your muscles working and help to push the blood through the veins to your heart. The National Eczema Society also recommends:

• flexing your feet regularly
• rising up onto your toes or bending down at the knees

Emollients

Emollients are substances that help to soften and smooth your skin to keep it supple and moist. They are one of the most important forms of treatment for all types of eczema.

As varicose eczema can cause your skin to become dry and cracked, it is important to keep it moisturised to prevent further irritation. Emollients prevent water being lost from the outer layer of skin (epidermis), as well as adding water to the skin. They act as a protective barrier to keep moisture in and irritants out.

Choice of emollient

A number of different emollients are available. Some can be bought over the counter without a prescription, but if you have varicose eczema ask your GP to recommend a suitable product.

You may need to try several different emollients to find one that works for you. You may also be prescribed a mixture of emollients. For example:

• an ointment for very dry skin 
• a cream or lotion for less dry skin
• an emollient to use instead of soap 
• an emollient to add to bath water or use in the shower

The difference between lotions, creams and ointments is the amount of oil that they contain. Ointments contain the most oil so they can be quite greasy, but are the most effective at keeping moisture in the skin. Lotions contain the least amount of oil so are not greasy, but can be less effective. Creams are somewhere in between.   

If you have been using a particular emollient for some time, it may eventually become less effective or may start to irritate your skin. If this is the case, your GP will be able to prescribe another product.  

How to use emollients

If you have varicose eczema, you should use an emollient all the time, even if you do not have any symptoms.

To apply the emollient:

• use a large amount 
• smooth it into the skin in the same direction that the hair grows 
• do not rub it in
• apply every two to three hours for very dry skin 
• after a bath or shower, gently dry the skin, then immediately apply the emollient while the skin is still moist 
• do not share emollients with other people

Creams and lotions tend to be more suitable for red, inflamed (swollen) areas of skin. Ointments are more suitable for areas of dry skin that are not inflamed. 

It is very important to keep using emollients during a flare-up of varicose eczema, because this is when the skin needs the most moisture. Apply emollients frequently and in generous amounts during a flare-up.

Side effects

The most common side effect of using emollients is a rash. If you have varicose eczema, your skin is sensitive and can sometimes react to certain ingredients in an emollient. If this happens, speak to your GP, who can prescribe an alternative product. 

Be aware some emollients contain paraffin and can be a fire hazard. As some emollient products are highly flammable, do not use them near a naked flame.

Emollients added to bath water can make your bath very slippery, so take care getting in and out of the bath.  

Topical corticosteroids

If your skin is red and inflamed from a flare-up of varicose eczema, your GP may prescribe a topical corticosteroid (one that is applied directly to your skin). Corticosteroids work by quickly reducing inflammation.

Corticosteroids are any type of medication that contain steroids, a type of hormone.

Choice of topical corticosteroid

Different strength topical corticosteroids can be prescribed depending on the severity of your varicose eczema. If you have flare-ups of lipodermatosclerosis, you may need a very strong topical corticosteroid. Therefore you may be prescribed a cream or an ointment.

If your varicose eczema is moderate to severe, you may need to apply topical corticosteroids both between flare-ups and during them.

If you need to use corticosteroids frequently, visit your GP regularly so they can check that the treatment is working. 

How to use topical corticosteroids

When using corticosteroids, apply the treatment sparingly to the affected areas. Always follow directions on the patient information leaflet that comes with the corticosteroid, as it provides details about how much to apply. 

During a flare-up of varicose eczema, do not apply the corticosteroid more than twice a day. Most people only have to apply it once a day. When applying the topical corticosteroid, you should:

• apply your emollient first and wait several minutes before applying the topical corticosteroid (until the emollient has soaked into your skin)
• apply a small amount of the topical corticosteroid to the affected area
• use the topical corticosteroid for seven to 14 days
• continue to apply the treatment for 48 hours after the flare-up has cleared

If you are using corticosteroids on a long-term basis, you may be able to apply them less frequently. Your GP will advise you about how often you should be applying them.

Also speak to your GP if you have been using a topical corticosteroid and your symptoms have not improved.

How much topical corticosteroid to use

• topical corticosteroids are measured in a standard unit called the fingertip unit (FTU)
• one FTU is the amount of topical steroid squeezed along an adult's fingertip
• one FTU is enough to treat an area of skin twice the size of an adult's hand

Read more information about fingertip units and dosage of topical corticosteroids.

Side effects

Topical corticosteroids may cause a mild burning or stinging sensation as you apply them. In some areas, they may also cause:

• thinning of the skin, particularly in the crease of your knee joint
• telangiectasia (visible blood vessels), particularly on the cheeks  
• acne (spots) 
• increased hair growth

Generally, using a stronger topical corticosteroid or using a large amount of topical corticosteroid will increase your risk of getting side effects. For this reason, you should use the weakest and smallest amount possible to control your symptoms.

A Christmas Tale



 

This story goes back to 2001, when I was still pretty active.  I had been diagnosed with IBM the year before but was still walking reasonably well, without any stick, but falling down and struggling going up stairs, were becoming more of a problem.

 

The first part of this tale is set on Thursday the 20th December.  It was the night of the office party.

 

We finished work at 5.00 pm, and myself and a colleague, Stuart, made our way to a hotel just South of the River Thames, where we were staying the night.  We walked over Tower Bridge, and it was a bright and warm evening for December, and we enjoyed the view of the lights along the Thames.

 

Having got to our hotel, we showered and changed into our dinner jackets - hired for the night - before heading out and getting a taxi back to America Square, and meeting our colleagues for a couple of drinks before heading off to the party.

 

We eventually made our way down to the river, to St Katherine's Pier, where we caught the river taxi to take us along to the party venue at Canary Wharf.  I had to be helped down the steps onto the boat, and once we were aboard, we headed off, cocktails in hand.

 

We arrived at Canary Wharf Pier all to quickly and disembarked and headed toward the venue - I can't remember specifically the name of the venue.

 

When we arrived we were offered champagne, and there was much milling round talking, purchasing of raffle tickets, and generally getting into a party frame of mind.

 

After a short time we were called through, into the main hall, were the tables were set out for dinner.  After saying Grace, dinner was served.  I do remember that the food, as it usually was at the Christmas party, was very nice, but I can't remember what we ate.  Probably Turkey with all the trimmings.

 

After dinner, we would have had some speeches and then the raffle, which was then followed by a disco. 

 

Three things happened during the evening to this point.  Firstly, I got stuck on my chair, during dinner, as it was too low and didn't have any arms.  Fortunately, Stuart was near at hand and could help.

 

Secondly, the toilets were located up a very long flight of stairs, which meant I had to give myself plenty of time to get there, and had to very careful coming back down again.

 

And, thirdly, due to a rather over eager dance partner I had ended up falling, very slowly and gracefully, on the dance floor.  Again, fortunately Stuart and my boss, rushed to help me up.

 

The party finished at about 11.30 pm, and coaches were laid on to take people back to America Square, giving those going home, enough time to get to their trains.  As everyone clambered aboard the coaches, I realised that I wouldn't be able to make it up the steps onto the coach, so was preparing to find a taxi.  Stuart and another guy, Uche, saw me, stopped the coach before it drove off, came out and lifted me, literally, onto the coach.

 

Once back at America Square, and off the coach - thanks again to Stuart and Uche - we headed to a nightclub - I forget the name but evidently on a Sunday night it was a well known venue for a transvestite evening (why I remember that, I have no idea) - which was located under a building in Crosswall Street.

 

We spent a couple of hours here before deciding to head back to the hotel, just before 2.00 am. 

 

Now you might be thinking that a lot of alcohol had been consumed, and that this might account for what happened next.  However, although we had started drinking fairly early on in the evening, I had been pacing myself, as I was by this time well acquainted with the equation, alcohol + tiredness = falling down + painful injury.

 

There wasn't a taxi about in America Square so we stated to head towards Tower Bridge to start walking, and could then flag down a cab, if one came along.  As we got round the corner, into The Minories, a cab came towards us, and Stuart stuck out his hand and ran towards it.  Without thinking, and this may have been where alcohol did have an influence, I started to follow Stuart, and started to run.  It only took a couple of paces before I realised that this was a very bad idea.  I couldn't stop myself and instantly knew this was only going to end with me hitting the pavement.  Forewarned, I managed to control my fall, so I thought, to minimise the damage.

 

The cab driver, who had by this point pulled up at the kerb,  took one look at my dying swan impression, and said, "I'm not taking him, he's pissed," and promptly drove off.

 

Stuart, once again, helped me up.  I had grazed my hands, trying to break the fall, and my right knee felt a little stiff, but we started to walk, until another cab came along.  This stopped, we got in - without any drama - and got back to the hotel.

 

When we got back to the room and I started to take my suit off, I noticed that my knee was bleeding, but it didn't feel like much, so I grabbed a towel, wrapped it round my knee and fell into bed, and was out like a light.

 

About 7.00 am the following morning, I woke up and decided I needed to get up and get ready to go  to the office for work.  I pulled back the bedding, and it became obvious that during the night I must have been moving about a lot, as the towel had come off my knee.  The bed looked as if someone had been murdered in it.  There was blood everywhere.

 

I quickly sat up on the side of the bed to look at my knee.  What I had thought was only a minor cut the night before, turned out to be a very deep slash across the knee, where you could almost see the knee joint.

 

I quickly washed, and put on my clothes.  I woke Stuart, and told him what had happened, and that I needed to go to hospital to get my knee looked at. 

 

As is typical, when you really desperately need a taxi, there's never one around.  I ended up hobbling to Guy's and St Thomas Hospital, near London Bridge, and into the A&E department.  Fortunately at that time in the morning it was empty, and I was seen straight away.

 

The nurses were fantastic, and we had a great laugh at my expense.  I was hungry, tired and dehydrated, and the kept bringing me cups of water, but I couldn't have food in case they needed to do anything, depending on how bad my injury was.  I was sent off to have an x-ray, and wandered through the hospital, without any trousers on, with a badly cut and bleeding knee.  I must have looked a right mess, but I refused to have a porter push me in a wheelchair.

 

Anyway, the x-ray was fine.  It was just a very deep cut, and no damage to any bones or ligaments.

 

The nurses cleaned up the cut, and after a local anaesthetic, put in about 8 to 10 stitches, before putting on a dressing.  After thanking the nurses, I left the hospital and made my way to the office.

 

By the time I got into work, word had spread that I had badly injured myself, but I laughed this off by saying, that I must have had the best time of anyone at the party, because I was the only one that ended up in casualty!

 

After buying bacon sandwiches for my team, and a cup of coffee, I started to feel more normal.  However by mid-afternoon the pain in my knee was becoming unbearable. so I went home early to get some pain killers and hopefully sleep it off.

 

When I took the dinner suit back to the hire shop, the assistant was horrified to see the rip in the knee of the trousers and the blood coating the inside on the leg.  As he was just starting to think about charging me for the suit, I was happy to wave my receipt at him, which showed that I had purchased the damage waiver.

 

Well, you might be thinking that this tale is now complete, and that it was a pretty painful story.  But there is more to come.

 

Twas the night before Christmas.....

 

Yes it was Christmas Eve and I was at my mother house outside of Dorchester, where I was spending Christmas.  We had just had dinner and after clearing up, were just settling down to a quiet evening.

 

I needed to go to the toilet, which meant going upstairs, to the bathroom.  My knee was feeling much better, although still quiet stiff, but I was having some difficulty getting up the stairs.

 

As I got to the top step, where you need to make the transition from the stair to the landing, and where the hand rail runs out, I caught my foot on the final step and fell down.  In falling I slipped down a couple of steps, bending my right leg back underneath me.  I didn't need to look to know I had done something bad, the pain was telling me all I needed to know.

 

After being helped up, and going to the toilet, I took off my trousers, to see that in bending my knee back underneath me, I had managed to rip out all of the stitches, and open up the wound again.

 

I put on a pair of shorts, to prevent anymore blood getting on my trousers, and then drove into Dorchester, to the A&E department at the local hospital.  Almost anywhere else in the country, at about 8.00 pm on Christmas Eve, the local A&E department would be rammed full of unfortunate cases of Christmas calamity.  Fortunately for me, this one was virtually empty.

 

I was seen almost straight away by a pleasant young doctor, who took my details, and my medical history, and then looked at my knee.  I told him what had happened previously, and how it had been stitched up, and then about this evenings falling down.

 

He was very nice about everything, and took great trouble to clean the wound out, and to examine the knee to ensure that I hadn't caused any fresh damage in my fall.

 

He said that he would put in a set of deep stitches, right inside the joint, to hold the knee together below the surface of the skin, which should make for a stronger repair.  Then he would put in between 10 to 12 stitches on the surface, but as I had ripped the skin when the other stitches had come out, these would need to be set back quite a bit from the edge of the wound and would need to go through quite a bit of flesh, in order that they were secure.

 

This all sounded very sensible. 

Then came the kicker.

 

Because I had only had anaesthetic in the knee a few days before, he wasn't happy to give another shot.  This meant that he would need to do all of these new stitches without any anaesthetic!

 

If this had been one of those great old cowboy films, with John Wayne, someone would have produced a wooden spoon or piece of wood, and after giving me a good slug of whisky, I'd have been told to bite down hard, whilst the camera panned away to the sound of my muffled screams.

 

However, I was lying on the hospital bed, gripping the sides, and desperately trying not to swear at the doctor, every time he put the needle into my knee.  It seemed to take forever.  We did stop occasionally, while he asked me how I was doing, and I tried very hard to keep my replies polite.

 

Eventually, he finished, after what seemed like hours, and probably was hours.  The knee was more painful than ever, and looked a right mess with the damage from the ripped out stitches, and the newly applied stitches.

 

After putting on a dressing, the doctor went to look for a crutch.  He came back, but could find one, so I thanked him for his great needlework, wished him a happy Christmas, and promised not to come back.

 

I spent most of Christmas Day taking pain killers.

 

So that's my Christmas Tale.  I sincerely hope that none of you go through, or have ever gone through, something like this.

 

All that's left is for me to wish you all a very happy Christmas and all the best for the New Year.  Please be safe, be warm and healthy,



Disabled Toilets and 10 Things That Annoy Me!!

I often wonder, who actually designs disabled toilets?  I suspect that its some able-bodied person's idea of what they think a disabled person needs, but without having the foresight to consult a disabled person to see if it will work for them.

I can only talk about disabled toilets here in the UK, and obviously only about a small percentage of those, which I have actually tried, but suspect that the problems I encounter will be pretty much universal.

 

The first problem is usually the door.  There is probably some building regulation that requires the door to be big and heavy, probably to do with fire safety.  I'm not sure that I think the disabled toilet is the best place to seek cover from a fire, but each to their own.  Its fine having a big heavy door,, if its easy to open and close, but invariably the hinges are stiff, which then makes pulling it open or closed very difficult, if you are trying to do this whilst also trying to manoeuvre your wheelchair.

 

And then some are fitted with door returns, which keep trying to close the door, once you've managed to pull it open a short way, and then have to let go while you reposition your wheelchair, only to turn back and find you now can't reach the door because its closing itself!!

 

Once the door is open, the first thing I then check is, if the toilet is wide enough for me to be able to turn around in, in my wheelchair, once I'm inside and the door has closed.

 

All to often, the disabled toilets allow you to go in, but not turn round once your inside.  This then leaves you with the dilemma of which way is the best to go in.  Obviously you have to close the door behind you - especially if its not on a door return - so you need to back in.  But then you're not facing the toilet, so you need to turn round, but you can't because the room isn't wide enough to allow you to turn.  So you go straight in, but then you can't close the door, unless its on a return.

 

The other thing to check is the state of the toilet.  I don't think that disabled people are inherently untidy or unhygienic, they appreciate these facilities, that are there for our convenience.  However, how many times do you go to enter a disabled toilet to find the floor wet, and covered in soaked paper hand towels.  Now from my experience of able-bodied toilets, only the men's I would add, these are usually in a pretty awful state.  So I suspect that when able-bodied people use the disable facilities they don't think anything of getting water all over the floor, or mind too much if the paper towel goes on the floor rather than in the bin.  I'm not saying disabled people are blameless, but we are far less likely to leave these toilets in a state as we have no choice but to use them.  And try spending the day going round in your wheelchair, with urine soaked tyres and with wet paper towel being trailed behind you.

 

Anyway when you've found a solution to how your going to get in the toilet, checked the state of the hygiene, and closed the door, you've then got to think about locking the door.  Now if you have weakness in your arms and fingers that don't work particularly well, the normal devices used to lock the door are usually placed to high up the door and to fiddly to be worked.  So then you have to think can I use this and lock the door, and then be able to unlock it when I want to leave.  Inevitably the answer for me is not to lock the door - I don't want to spend my day locked in a disabled toilet.

 

So you've now tackled the door, got yourself inside and locked, or not, the door.  For me actually doing the business I've gone into the toilet for, is easy.  I use a urine bottle, as I can't stand up to the toilet.  I always ensure that before I leave home that I have done anything extra, so I'm only going to need to have a pee if I'm out.  But if you need to use the toilet, these are invariably standard size toilets.  Now I know from experience if you use a normal toilet, and have difficulty getting up, because of weakness in your legs, then you're going to get stuck on the toilet.

 

The toilets often have bars which can be lowered round the toilet to help push yourself up on but these can be difficult to reach and put up and down, if you have weakness in your arms.

 

So lets assume you've got in the toilet, closed the door and done your business.  Now you need to try getting the toilet roll to clean yourself.  Usually the toilet rolls in most toilets, able-bodied or not, are those massive industrial size rolls which are contained in big dispensers.  Now these are usually conveniently placed just slightly out of reach, if your sat on the toilet, so you then have to struggle to reach them.  And then the roll has been fitted in the dispenser in such a rush, that it doesn't turn properly, so all you can get out is one sheet at a time.  Or the dispenser is so loose that when you pull on the roll it just won't stop coming out.

 

You then need to flush the toilet.  Now I find that the flush is usually placed so that you need to lean over the toilet, something I can't do in my wheelchair.

 

Then once you've struggled off the toilet, and flushed, you need to wash your hands.  Usually the sink has been put at a height suitable for a person standing up. This means the sink is about chest height for someone in a wheelchair.  This does mean that you can get yourself nice and close to the sink, as you can get your chair under the sink, but if you can't lift your arms easily, how are you supposed to reach up into the sink.

 

You then have to reach the taps.  If the sink is to high, this makes reaching for the taps very difficult.  Taps with levers are fine if you can reach the levers, and these are not too stiff to move.  In the newer toilets they have taps that work on sensors, so you don't have to fiddle about with levers.  However, if the levers are stiff and you have to struggle to get these to move, they usually suddenly move, causing you to get too much water.  Also the taps with sensors have no way of regulating the water.  So your sat right up to the sink, reaching for the taps, the water suddenly comes rushing out, and splashes down into the bowl and then right back out again, all over you!

 

Then you look for the soap dispense, which is usually above the sink.  Even if you could reach it, there is no way that you can push the lever to get the soap out, without activating the tap, and soaking yourself more.  So you struggle to get some soap out, without giving yourself an impromptu shower, only to get a tiny little squeeze of soap, or so much soap comes out that you could wash your hands all day and still not have used all the soap.

 

So now you've washed your hands, and need to get the hand towel.  Again these are usually set at a height that is impossible to reach them, unless your standing. 

 

Alternative you could use the warm air dryer, but again these are usually to high to get your hands under to activate the warm air.  So you then end up trying to lean forward to get your head to activate the warm hair and still get it to blow on your hands.

 

And then you need to get the used hand towel into the bin.  The bin is often situated so that its in an area of the toilet where it won't be blocking access.  This means its inaccessible to a wheelchair user without a great deal of struggle.

 

Then you need to try and get the door open, and the get out of the toilet.  If for any reason you find yourself stuck in the toilet, there's usually some system to be able to call for assistance.  If its a pull cord, I find these are placed out of the way, so that people aren't tempted to pull them, or are tied up so that you can't reach them.  If it's an electronic system, there's no chance that this will work.

 

Disabled toilets also, often double as baby changing rooms.  This means that there is often some sort of changing table, to take up room.  Even the toilets with restricted space have tables which fold down on the wall.  How often have I tried to go into a disabled toilet and found that the table has been left down, and its impossible for me to fold it away or use the toilet whilst this is down.

 

If you try to use a disabled toilet after a mum has just changed her child, you best have a cloths peg for your nose.  Even if the mum has managed to put the used nappy and wipes in the bin, and you'd be amazed how often these are left on the floor, the smell can be over powering.

 

So before people start designing disable toilets, why don't they try talking to disabled people to see what we want and need.  And I don't mean talk to the disabled guy who can walk in to the toilet, I mean talk to people with a range of disabilities.  Don't assume everyone in a wheelchair will be accompanied - we do like to independent as well.  Don't assume that everyone in a wheelchair has full use of their arms and can reach for things.

 

10 Things That Annoy Me.

 

1.  I have a name.  It is not "Love" "Darling" "Dearie" "Sweetie" or "Duckie."  Just because I am in a wheelchair does not give people the right to patronise me.  I have a name, so use it.  If you don't know it, ask me what it is.  But do not assume that I your Love, Dear or Duck.

 

2.  Smokers.  Now its not smoking - that would be hypocritical, being an ex-smoker.  Its when people, such as carers, come to get me up and the first thing you're confronted with, is the smell of the last cigarette they had to have before coming into the house.  Eau de Fag Butt is not what I want to wake up to in the morning.

 

3.  People being late.  When I was working , people who were late for meetings used to just wind me up.  These were the people who were invariably late in, in the mornings but very punctual in going home in the evenings.  Much the same applies now.  People seem to assume that as you are disabled, it doesn't matter if they are late to appointments with me.  I can't possibly have anything better to do.

 

4.  Being late also applies to carers when they are getting me up in the morning.  I like a 7.00 am call, or earlier.  But that does not mean you can turn up at 7.30, or later, as suits you, because that means you are taking control of my day, and I'm losing part of my day.

 

5.  People who start to shake your hand, and then try to back out.  When I was at work, you naturally shook hands with a lot of people, and a good firm hand shake, to me was a good sign about a person, whereas a limp hand shake also told me volumes.  Now I'm in a wheelchair, I find it difficult to raise my arm and hand.  Also the fingers on my hands are bent and don't straighten properly.  But there is nothing worse than a person offering their hand to shake, and then seeing the difficulty I'm having and instead of being patient, grabbing hold of my wrist and shaking my arm. 

6.  People who ask how I am.  These fall into two categories.

Firstly, we have the people who ask, but who have absolutely no interest in the answer.  They ask the question but wouldn't be interested  even if I started to tell them.  You can see it in their eyes as they ask the question, "Please just say your fine." 

Secondly, we have the people who ask but only as a segue way for them to tell me how sick they are.  Again they are not interested in my answer, but are only to willing to tell me how close they are to deaths door with their cold.  Well guess what, buster.  I can trump almost anything you have, but your just not interested to hear it.

7.  People who think I can't be ill, and laugh.  I am a very positive person - despite all this moaning here - and will always try to see the funny side of most things.  I often say to people that if they walk in and I can't have a laugh with them, then they know something is very wrong.  But being sick doesn't mean I'm not able to have a laugh or see the funny side of life.  In fact, I think its an essential part of life.

8.  People who ignore me simply because I'm in a wheelchair.  (This is slightly ahead of people who patronise me because I'm in a wheelchair.)  People seem to take the view that because you're in a wheelchair, there must be something wrong with you - well they are partly right.  What I have wrong with me is physical.  I still have a perfectly active and functioning brain.  This means I am perfectly capable of engaging in an intelligent conversation.  If you talk to me I am not going to start screaming and causing a scene.  If however you approach me and ask, "Are you alright, lovey?" as if you are talking to a 5 year old, I may just reduce you to tears.

9.  People who are sick - and the irony of this isn't lost on me.  I have very little patience with people who are sick - never have done.  When I was working - up until the point where my conditions really started to take over - I very rarely took time off due to sickness.  I seem to remember that over a 10 year period I had one day off sick.  But then you get other people who seem to have days off at the drop of a hat.  They seem to think its a "right" to take time off and that they are "due" a certain number of days off each year.  And then they come back top work and have to tell everyone how ill they have been.

10.  People who sniff rather than blow their nose.  This is just revolting.  I had a carer who about every 10 seconds would sniff, and then in between these about once a minute would do a really disgusting deep snotty sniff.  I just wanted to shout, "Blow your nose!!" whilst throwing the box of tissues at her.

A visit to the IBM Research Clinic

On Friday of last week I had my annual appointment at the IBM Research Clinic at the Centre for Neuromuscular Diseases, at Queens Square London.

 

As usual when I have a appointment at a hospital, the day started early, with Margaret my carer coming at 6.30 am to get me up, showered and dressed ready for the day. 

 

My appointment was at 10.00 am, and I had been told to be ready for collection by the hospital transport two and a half hours before my appointment.  The transport from this hospital is always late, but ever the optimist, I'm ready by 7.30 am, as requested.

 

The transport arrives only 45 minutes late, but this still gives us plenty of time to be at Queens Square on time for my appointment.  After I'm strapped in, we set off, but have to pick up another patient, just a bit off our direct route.

 

The traffic isn't to bad and we arrive at the other patients.  The driver goes and knocks on the door and waits for an answer.  After a couple of minutes a lady comes down the road, walks past the driver, opens the door to the house, goes inside and shuts the door.  A couple of minutes later the patient emerges from the house and starts to walk towards the ambulance.  As he gets almost to the ambulance he remembers that he has left something behind, and has to go back indoors, shutting to front door, before coming out 5 minutes later.  Despite always being told to be ready, so as not to delay the transport, this has taken over 15 minutes.  The patient appears to be a regular on trips to the hospital, as he is known to the driver.

 

We finally get going, and the traffic has now built up quite a bit and it soon becomes apparent that we are going to be late for my appointment.  One of my pet hates is being late for appointments - I'd rather be 20 minutes early than 20 seconds late.  I wait until about 9.40 am, so that I can judge how much further we have to go, and then ring the clinic to say, I'm on my way but will be about 30 minutes late.  They are very understanding, and tell me that its OK.

 

We eventually get to Queens Square about 25 minutes after my appointment time, and to save the driver trying to find a proper parking space, I tell him to drop me any where and I can then make my way to the clinic.  He finds a space, right by a drop kerb, just round the corner from Queens Square - in the same street as Great Ormond Street Hospital.  He gets the straps off my chair and I am ready to go.

 

I arrive just over 30 minutes late at the reception.

 

I am seeing one of the Clinical Research Fellows, called Dr Pedro Machado.  Many of the people who see Pedro, particularly the ladies, refer to him as the "lovely" Pedro.  This is actually very apt.  He is a very nice Doctor, who is very enthusiastic about his work and he is always really interested in the patients he sees, and you get the real feeling that he really does care and want to help.  Nothing is too much trouble for him.

 

Even though I am late and apologise, he says not to worry and we make our way through a labyrinth of corridors in the building to a consulting room.

 

When I was at the clinic last year, Liz Dewar from the Physiotherapy Department, sat in with us and she offered to see me, regarding the possibility of trying to stand.  Pedro asked me about this and what had happened.  I told him that we had had some success with the standing frame at the hospital, but that I had now purchased a standing up powered wheelchair, which I use every day at home to stand for between 15 and 20 minutes.  He was really interested in this and how it worked, but when I started to tell him about the physical benefits I thought that standing on a daily basis was having, he was really delighted.  I told him about the video that I had done of me standing in the chair, and that Liz had a copy of this, and he said that he would see her and get a copy.

 



 

We spoke briefly about how I was generally, and how I felt I am compared to last year when I had been at the clinic.  One of the primary objectives of the clinic is to look at the progression of IBM over a long term, in a variety of patients, to try to build up a picture of how the condition progresses.  Part of this is that each year we do a very extensive number of tests on the muscles to determine and measure the strength in the muscles.  These are the normal tests that most myositis sufferers are familiar with, where a Doctor will, for example, ask you to raise your arm, and then push against you, to measure your resistance.  However, the number of tests done by Pedro, are far more than those done by any other doctor.

 

The results from this years tests, are very similar to last years, which shows that my condition is pretty much stable.  This is what I had thought, and hoped, and is a very good sign.  I think this in part is down to the regular physiotherapy sessions I have about every 2 weeks at home, and to the standing.

 

Following this Pedro gives me an update on the drug trials, in connection with IBM.  I have already posted about this on Facebook, but have included this details at the bottom of this blog, for anyone who has missed them.

 

Just before 11.30 am, we finish up, as Pedro has another patient coming in.  We have had a very interesting and constructive hour.

 

As I am leaving, I meet John Robertson, a fellow IBM'er. who I have corresponded with for sometime through emails, Facebook, on the TMA forums, but this is first time we have meet.  We have a nice chat before John is called in for his appointment.

 

I then make my way across Queens Square and into the National Hospital for Neurology and Neurosurgery, and firstly find a toilet, and then book in for the transport to take me home.  After a wait of almost 2 hours, a lady finally comes an collects me.  She drives one of the small vans, that they sometimes use to transport patients.  Although the vehicle is clearly to small - my head is on the ceiling of the van, so I know I'll be banging my head every time we go over a pot hole or speed bump - by this time I just want to get home.

 

I finally get home about 3.45 pm, and I am exhausted.

 

Arimoclomol

A new funding grant application has just been presented to the FDA and it is hoped that they will have an answer on this in Mar/Apr 2014. If this is successful then the trial will still have some bureaucratic hurdles to get over and is therefore unlikely to start until late 2014.

The company that originally held the rights for this drug has sold these to a company in Denmark. This new company was looking to develop Arimoclomol for another condition, even rarer than IBM, and it was only when the team from UCLH went and did a presentation about the first part trial, that the company became aware of its potential application in the treatment of IBM.

This Danish company is a small pharmaceutical company. It does not have the budget/funds to be able to fund the drug trial itself. However, Pedro understands that the Board of this company are currently in discussions, to consider if they can approach their financial backers, with a view to them raising the funds required, if the FDA turns down the funding application.

The next part of the trial will involve about 200 patients. These will be split between the USA and UK, but there are discussions about other countries being involved. The criteria for the new trial, has not yet been set.

Novartis Bimagrumab/BYM338

The original trial was to test the safety of this drug, in humans. It was successfully shown to be safe, but there were also some encouraging results. Of the patients receiving the drug - and this was a single dose - under MRI, there was found to be on average an 7-8% increase in muscle. This doesn’t necessarily mean an increase in strength of function, but just an increase in muscle. However, one of the criteria for this trial was that the patient should be ambulatory and complete a 6 minute walk test. Of those patients who received the drug on the trial, there was an up to 10% improvement in the results of this test – this could have been the time to cover the same distance, or that they completed a further distance in the time.

In the UK, Pedro stated that they had been hoping to start the trial in January 2014, but there will be a delay whilst some further regulatory requirements are meet, but he is hopeful that the trial will now start in Apr/May 2014. He anticipates that the trial here in the UK will involve 30 patients, and that these will be split between 3 or 4 regional centres. One will be UCLH in London, and the others will be between Newcastle, Southampton and Manchester. He could not say what the numerical split of patients would be.

He thinks that patients for the trial will be randomly selected from the database of patients at each of these centres, and from any research patients. The patients must have a confirmed diagnosis of IBM, with a muscle biopsy that fully confirms this. To explain this a bit more, I have been diagnosed with IBM, and have a muscle biopsy that shows all the signs of IBM, but the biopsy isn’t in itself conclusive. Therefore it is possible that I might have another condition, very similar to IBM – which I have had DNA testing for – but they are unable to confirm another diagnosis. Therefore, I have a diagnosis of IBM, as they have nothing else to call it – in very simple terms.

Patients will also have to be taking less than 10 mg of Prednisolone daily, and some other immunosuppressant drugs will exclude patients, as these may interact with the BYM338 and affect results.

Patients will also need to be ambulatory, but can use any walking aids.

There may be other criteria beyond these but these will be the main ones.

The drug will be given over a 12 month period – one infusion each month. However if patient A receives their first infusion in May 2014, and the last patient doesn’t join the trial until Nov 2014, patient A will continue to receive the drug until the last recruited patient has had their full 12 months of treatment.

If a patient joins the trial and drops out at any point after the first infusion, for whatever reason, their results will still be included in the trial, and they will not be replaced.

There will be 4 levels with the trial. 25% of patients will receive a placebo, 25% will receive a low dose, 25% will receive an intermediate dose and 25% a high dose. It is not known at which level the drug will be most effective and it could be the case that at the low dose that there is no effect on the patient. Likewise, it could be that with the high dose, that there is an increased risk of side effects.

The drug is new and is being developed, and there is a potential risk to be included in the trial. Pedro reiterated some of the points raised by Dr Greenberg in his presentation to the TMA Annual Conference about the potential risk to the cardiac muscle.

My feeling is that Pedro is cautiously optimistic about both of these trials. He certainly gave me the impression that he is excited about these trials and the potential for both drugs.

A Long Day Out

On Wednesday last week, I was back at the Royal Free Hospital, in Hampstead, for my 6 weekly infusion of Methylprednisolone.

 

Normally we get up at 6.00 am to be ready for the transport to pick me up at 7.00 am, but this morning we all overslept.  Mum hadn't put her alarm on - her excuse being that she always wakes up before it goes off.  I'm usually well awake before 6.00 am, but was still fast asleep when Mum came in.  And Margaret my carer also overslept.

 

I eventually started getting up at 6.15 am, and was just sitting on the side of the bed when Margaret came.  She quickly got me showed and dressed, and as she pulled back the curtains about 6.40 am, the ambulance was just arriving.

 

I quickly had my tablets and a slice of toast, and then went out to the transport.

 

Those of you who read my blog last week will recall the horror journey I had had the previous Friday on my way to have my Lung Function Test.  This morning I have a regular driver, so I know I'm in safe hands.  I tell him about my journey the previous week, and he gives me the name of the transport manager, and says I must complain to him.

 

Anyway, we get strapped in and are underway.  The journey is uneventful, and we pick up another passenger on the way, and are at the hospital just before 9.00 am.

 

I made a quick dash to the toilet - something I need to do after 2 hours sat in the ambulance - before making my way to the ward for my treatment.

 

Usually, the nurses work very efficiently to try to keep patients there for the shortest amount of time.  They try to ensure that drugs have been prescribed the night before, and ordered from the pharmacy, so these are ready on arrival.  They get cannula's in quickly, and make sure you have everything you need, so that treatment's can start early.

 

Normally on these days at the hospital I can usually expect to arrive about 9.00 am and be finished by 11.30 am, and ready to go home.

 

Well today was one of those days when things weren't going to happen quickly.

 

I was seen by one of the nurses, and checked in.  She was then occupied with a couple of patients who had come in earlier and seemed to need quite a lot of input, mainly because they were at the start of treatments that required regular observations.

 

I have been coming to the Royal Free Hospital for about 15 years and have seen mostly the same nurses, for this time.  They are more like friends than nurses, and we get on very well.  I know how they work, and they treat me very well.  So I don't push them if things take a long time, as I realise that there is usually a very good reason, and they will get to me as soon as they possibly can.

 

Sadly today the ward is short of 2 nurses.

 

Steph, the nurse looking after my room then attempts to put a cannula in my arm.  Like many of us who have regular treatments, and have poor circulation, my veins are very hard to locate and get a needle in.  Steph has never attempted to put a cannula in my arm before and soon regrets trying.  After two attempts she gives up and rings for one of the cannulation team to come and help.

 

Two other patients come in.  One is a young guy of about 16 who is with his father.  It is obvious that this is the first time that the boy has been in for his treatment as they have lots of questions about what is going to happen. 

 

The other patient is obviously a very demanding man, and wants everything done NOW!  He seems to be oblivious to the fact that there are other patients there and to the fact that the ward is short of staff.  If something isn't done, then he runs off to find a nurse to chase them up.  He even interrupts the nurse whilst she is taking another patients observations.

 

About 10.30 am the guy comes up to put my cannula in.  He needs to take some blood as well, so intends to use the same needle.  He gets the cannula in easily enough, but can't get any blood out, so he has to put another needle in for this. 

 

So that's 4 needles in my arm in the space of an hour and half.

 

At about 11.30 am, Steph comes over with my drugs - they had lost my drug chart, and although we all know what treatment I'm having they cannot dispense the drugs without the signed drug chart.

 

It only takes at hour for the drugs to go in, and then a further 10 minutes just to flush the line.  So by 12.45 pm, I'm all finished, and have even had a bit of lunch.

 

Steph, comes and takes the needle out, and not having been able to get blood out of it earlier, it now bleeds all over the place, despite her putting pressure on the site of the needle.  It eventually stops and she makes sure that the dressing on the site of the needle is very secure.

 

I was due to see my respiratory physio, but she is busy this morning, so I have arranged to see her next time I am in.  She will look at my Lung Function Test results and show these to the Professor, and will call me if there is any areas for concern.

 

So after getting help to put my fleece back on, I make my way down to the transport lounge.  After checking in, I see the transport manager, and he is very concerned by what I tell him.  He types up a statement from what I have told him, and I sign this, and this will form the basis of a disciplinary warning for the driver from Friday.

 

I have to wait about 90 minutes before my driver comes and gets me.  We have another patient to take home, which is a bit off our normal route.

 

We leave just before 3.00 pm - which is normally about the time I'd hope to be getting home.  The traffic isn't to bad getting across London, but by the time we have dropped off the other passenger in Wimbledon, the traffic has built up quite a lot.

 

I eventually get home about 5.15 pm, and I'm exhausted.  After pie and chips for dinner, I get in my armchair to watch football, and struggle to keep my eyes open.  I see the end of the game - just - and then go to bed.

 

Its been a long and exhausting day, which will take a couple of days to recover from.