Anticoagulant and Antiplatelet Therapy

Peri-operative management of anticoagulation and antiplatelet therapy 7 October 2016

British Journal of Haematology Volume 175, Issue 4
Peri-operative management of anticoagulation and antiplatelet therapy 7 October 2016

WARFARIN
Recommendations
Warfarin should be stopped for 5 days before an elective procedure if anticoagulation needs to be discontinued (1C).
Patients with venous thromboembolism (VTE) more than 3 months earlier can usually be given post-operative prophylactic dose low molecular weight heparin (LMWH) (or a suitable alternative) rather than bridging therapy (2C).
Patients at very high risk of recurrent VTE, such as patients with a previous VTE whilst on therapeutic anticoagulation who now have a target International Normalized Ratio (INR) of 3·5, and patients who have had VTE less than 3 months previously should be considered for bridging (2D)
Patients with atrial fibrillation who have a CHADS2 score of ≤4 and who have not had a stroke or transient ischaemic attack (TIA) in last three months should not receive bridging (1A)
Patients with a bileaflet aortic mechanical heart valve (MHV) with no other risk factors do not require bridging whilst it should be considered in all other MHV patients (2C).
We recommend that post-operative bridging is not started until at least 48 h after high bleeding risk surgery (1C).

DOACs
Recommendations
Patients with normal renal function undergoing planned low risk procedures should not take a direct oral anticoagulant (DOAC) for 24 h before the procedure (2B)
Patients with normal renal function undergoing planned higher risk procedures should not take a DOAC for 48 h before the procedure (2B)
For patients with renal impairment see Table 2 (2D).
Following minor or low risk procedures in patients with low bleeding risk, anticoagulation can be recommenced 6–12 h post-procedure if haemostasis has been fully secured (2C)
Following high risk procedures and in patients with an increased bleeding risk or in any situation where any increased risk of bleeding is unacceptable, DOACs should not be re-introduced at full dose until at least 48 h post-procedure (2C)
In patients with high thrombosis risk it is appropriate to consider prophylactic doses of anticoagulation before re-introducing full therapeutic dose DOAC (2D)
DOAC measurement by indirect methods using dilute thrombin time, ecarin clotting time and calibrated anti-Xa assays should currently be interpreted with caution in the management of patients receiving a DOAC who require emergency surgery (2B)
A normal thrombin time can be interpreted as indicating that there is a minimal circulating concentration of dabigatran. Normal prothrombin time (PT) and activated partial thromboplastin time (APTT) do not exclude significant concentrations of dabigatran, rivaroxaban or apixaban (1A)
If an anticoagulant effect cannot be excluded, neuroaxial anaesthesia should be avoided (1C).
Prothrombin complex concentrates should not be routinely used in patients on DOACs prior to emergency surgery (2D)
Tranexamic acid is likely to reduce bleeding in patients who have a residual anticoagulant effect (1C).
Drugs and colloids that impair the haemostatic mechanism should be avoided in the peri-surgical management of patients receiving DOACs (2D)
Idarucizumab should be used to reverse dabigatran therapy prior to emergency invasive procedures and surgery where the bleeding risk is considered significant (1C)
Andexanet, when available, should be used to reverse apixaban, rivaroxaban or edoxaban prior to emergency invasive procedures and surgery where the bleeding risk is considered significant (2C)
ANTIPLATELETS
Recommendations
When being used for secondary prevention of cardiovascular disease, aspirin monotherapy can be continued for most invasive non-cardiac procedures (including neuroaxial anaesthesia) but, if the perceived bleeding risk is high, aspirin can be omitted from day −3 to day +7 with no net detriment (2C)
Aspirin can be continued both before and after coronary artery bypass surgery (1B)
Hip fracture surgery can take place early in patients on clopidogrel (1B)
For urgent low bleeding risk surgery in patients on antiplatelet agents routine platelet transfusion should not be given (2C)
For urgent high-bleeding risk surgery in patients on antiplatelet agents
o Given the uncertain net benefit of platelet transfusion, consider the use of pre-operative intravenous tranexamic acid (2C)
o If, despite tranexamic acid, there is excessive peri- or post-op bleeding, or if the bleeding risk is perceived to be very high, consider infusion of 2 pools of donor platelets. This may improve haemostasis if given at least two h after the last dose of aspirin though even higher doses of donor platelets 12–24 h after the last dose of clopidogrel may have a lesser effect (2C)
In patients with a recent acute coronary syndrome or coronary artery stent on dual antiplatelet therapy low bleeding risk procedures should proceed without interruption of antiplatelet therapy (1C)
In patients with a recent acute coronary syndrome or coronary artery stent on dual antiplatelet therapy elective high bleeding risk procedures should, if possible, be postponed in patients still requiring dual antiplatelet therapy (1C). If surgery cannot be deferred, aspirin should be continued and clopidogrel or ticagrelor interrupted from 5 days pre-op or prasugrel from 7 days pre-op (1C).

For Further reading please click the link below.

Haematology guidelines on perioperative management of anticoagulants

 

ASGBI Moynihan Prize 2018 £1000

ASGBI Moynihan Prize 2018

As part of the 2018 International Surgical Congress, taking place at the ACC in Liverpool from Wednesday 9th to Friday 11th May 2018, we will be awarding £1,000 together with a medal for the best project delivered at the Congress.The Moynihan Prize is the Association’s most prestigious scientific award. The prize of £1,000 together with a medal is presented to the author of the best project delivered at the International Surgical Congress. The person reading the paper must be the principal research worker and less than 15 years from graduating. In the case of multiple-author papers, the medal will be presented to the person presenting the paper and the award may be divided between the authors.

The paper should have a clinical application or lead to service/quality improvement. The paper must not have been submitted previously to any other national or international association nor published in any Journal at the time of submission. Short-listed papers that are found to have been presented elsewhere, or have been accepted for presentation elsewhere, will be disqualified. The paper must not be a case report or meta-analysis.

Additional information, including how to submit your abstract, is available here, and any queries can be directed to Rochelle Roach. Submission deadline: 9.00am on Wednesday 10th January 2018 

PCSA’s Summer Newsletter and Conference Details

PCSA’s Members’ Newsletter Summer 2017

Dear Member,

Conference season has come around again and your Committee will have a lot to report at the AGM on Sept. 30th. See the 2nd page of this newsletter for the conference program. We would encourage you to book early as places are filling up fast. There is a 15% discouun for PCSA members if you book before 1/9/17. To book please use this form Booking Form Sept 17 = V2 = Tralee

There has been a hiatus in the roll out of the ICGP Accreditation Programme and some disatisfaction with the lack of a follow-on to the very successful Pilot Community Based Surgery Programme. This is not anybody’s fault but reflects the need to agree a funding model with the HSE, which has inevitably become tied upin the wider GMS contract talks. These will take some time, but community surgery has been discussed at an early stage. I am condifent that the new contract will both encourage all practices to retain surgical services but also provide for service developments that could enhance patient access and safety. We hope to see the recognised involvement of GPs in providing procedures such as skin cancer work, vasectomy and perhaps cultural circumcision.

Meanwhile, we are very actively promoting work that underpins such developments, including our expanding Community Based Surgical Audit, our vcollaboration with the ICGP on the iPCRN, the NCCP Guideline Development Group and with the HSE in relation to vasectomy, cultural circumcision and skin

cancer.

The scientific programme at this year’s conference will reflect these and other strands of our activity. The AGM will include a discussion of the proposed Primary Care Surgical Network of practices sharing a common approach to service development and commercialisation. The AGM will also see the election of of various officers including the Chair and Secretary positions.

I want to thank my fellow Committee members for their ongoing enthusiasm and committment to our work and you, our membersfor your support and engagement since our foundation in 2012.

Here’s hoping to see you in Tralee next month!

Niall Maguire

Chairman (087 97 28793) (niallpmaguire@yahoo.com)

Contacts: Dr Niall Maguire, Chairman at niallpmaguire@yahoo.com, Dr David Buckley, PCSA Secretary at info@asctralee.com or via www.PCSA.ie, Dr David O Connell (Membership Secretary,) Dr Paul McElhinney (Webmaster) Dr Christy O Rourke (Treasurer)
Dr Frank O Leary (PRO) Dr Mukesh Lalloo, Dr Cormac O Dubhghaill, Dr Sylvia McKenna ,Dr Tony O’Sullivan, Dr Mark McCormick,
Dr Ernan Gallagher, Dr Shastri Persad, Dr. Enda Devitt.

Your committee met on December 10th 2016 and continues to attend important meetings with external organisations to advance our aims and objectives.

SKIN CANCER SENTINEL

https://www.surveymonkey.com/r/CancerSentinel

Please click on this link or past in your browser each time you receive a discharge letter on a referred patient. We need to monitor hospital performance. The survey takes about two minutes.

ROSS ARDILL MEMORIAL PRIZE 2017

Audit, research, case-series, innovations, work in progress.

€500 for best paper & €200 for best poster. niallpmaguire@yahoo.com before Sept 14th

Join or Renew Membership?
Register/Payment page www.pcsa.ie or contact membership secretary davoconnell@rcsi.ie €100 pa.
(50% reduction for Trainees and Nurses)

Do visit the new PCSA website and join in educational case discussions, read guideline documents, contribute to news and information on education, research, audit and service

development.www.pcsa.ie

Dr Mukesh Lalloo represented the PCSA at the Annual Conference of our sister association at Leamington Spa in May. Dr Jonathan Botting and Prof Vijay Kumar will make a return visit to our conference in September.

Website logon problems? Some members have had a difficulty with accessing the new website since our upgrade.Please email Paul , our webmaster who will endeavour to resolve any issues.The new site is worth the wait! Thanks for your

forebearance. mcelhinp@tcd.ie

Cryosurgery Masterclass and 6th Annual Scientific Meeting and AGM

Date: Friday 29th and Saturday 30th September 2017
Venue: The Rose Hotel, Tralee, Co Kerry, Ireland. www.therosehotel.com

Friday – 29th September 2017- Cryosurgery Masterclass

9:25am

Welcome and Introduction

Dr Niall Maguire

9.30am- 10:00am

History of cryosurgery + method of cell death

Dr Paola Pasquali

10 – 10:30am

Cryogens + equipment

Dr David Buckley

10:30-11am

Patient selection + indications

Dr Paola Pasquali

11-11:30am

Tea + coffee / meet the sponsors

11-30-12pm

Technique + complications

Dr Paola Pasquali

12-12:30pm

Nurse lead cryosurgery

Dr David Buckley

12:30-1pm

Genital warts

Prof Colm O ‘Mahony

1- 1:30pm

Teledermatology for pre and post op care

Dr Paola Pasquali

1:30-2:30pm

Registration for PCSA annual scientific meeting

2:30-3pm

UK National Community Surgery Audit

Dr Jonathon Botting

3- 3:30pm

Genital lesions and rashes

Prof Colm O ‘Mahony

3:30-5:30pm

Rotating Workshops – pick two

  1. Cryo for wart/verruca/actinic keratosis
  2. Tissue viability + wound healing science
  3. Sebaceous cysts and lipomas
  4. Cryo for NMSC + keloids

Dr David Buckley
Mari O Connor, Tissue Viability Nurse. Dr Jonathan Botting Dr Paola Pasquali

8pm

Gala dinner + guest speaker

Prof Colm O ‘Mahony

Saturday 30th September 2017: PCSA annual scientific meeting.

Time

Topic

Speaker

Basic session:

9-9:30am

Benign tumours of the skin

Dr Shastri Persad

9:30-10am

Elliptical excision+ layered closure

Dr Niall Maguire

10-10:30am

Setting up a primary care surgical clinic.

Dr David O Connell

Experienced session:

9 – 9.30am

Dermoscopy for BCCs

Dr Jonathan Botting

9:30 – 10am

NMSC on the head and neck.

Dr Billy O Connor

10 – 10:30am

Suspicious pigmented lesions.

Mr James Clover

11am-11:30am

Keynote address:
“See and Treat” the future of community based surgery.

Prof Paul Ridgway, Prof surgery, TCD

11:30 – 1pm

Ross Ardill papers + prize

2-3pm

AGM

Chair Dr Niall Maguire

3-5pm

Rotating Workshops:
Each one hour long – pick two

  1. Vasectomy(beginners=3-4pm; experienced vasectomists = 4-5pm)
  2. Closing wounds without sutures: Glues, staples, secondary intention,
  3. My favourite suture techniques
  4. Simple flaps

Dr Richard Look-Tong

Dr Shastri Persad Dr Enda Devitt Mr James Clover

5pm

Close of meeting

External CPD credits and GMS study leave entitlements.
We recommend you book early, as spaces are limited. For further information contact the conference secretary: Olive at e mail: reception@theashestreetclinic.com Tel 066 7125611  Fax 066 7122626

Audit: The first round of the CBSx Audit is complete. Round two follows in the autumn. If you use Health.one join for round two and three? niallpmaguire@yahoo.comand Conference

 

World Vasectomy Day

View this email in your browser
BREAKING NEWS! Just announced–MEXICO will be the official host of World Vasectomy Day this year! For more, click HERE, and while you’re on the website, make sure your listing in the directory is complete, and then PLEASE make a donation by Friday to help us double our funds!!! (HERE)

We’re excited!

Mexico will host this year!

We count on vasectomy providers for part of our support! Without you, we couldn’t accomplish all that we do.
In the past 4 years, World Vasectomy Day has inspired over 21,000 vasectomies, not counting the thousands more that were informally reported in Bangladesh and India.

Our outreach, publicity, and penchant for disruption have also helped inspire (among many other accomplishments):

• Bali to refurbish their mobile buses to do rural outreach
• Planned Parenthood to consider expanding vasectomy outreach in the US
• The international family planning community to recognize the need for men to be as informed as women if they want to achieve their FP2020 goals
• India to adopt World Vasectomy Day for a fortnight each year
• Kenya to overcome all odds and attain a 300% increase in vasectomy uptake in 2016
• Mexico to wholly embrace their own annual World Vasectomy Day – last year they performed 2,599 vasectomies in a single day!

Now we need your help to finance our 5thWVD on November 17, 2017! 

An anonymous donor has offered to match donations if we can raise $5,000 in the next 2 weeks. Please help us maximize this valuable opportunity with your tax-deductible donation today, doubling your donation and doubling your impact on global vasectomy access and awareness. A good starting point isthe amount you receive for performing one vasectomy, but more truly makes the difference in our work around the globe! Please stand with other vasectomy providers and support World Vasectomy Day–DONATE HERE  (We’re a 501 c (3) so for those in the US, this may be elegible as a tax deduction)

 

Have you updated your listing for our new directory?

Our doctor directory is free advertising for your practice. Men come to our website all the time looking for doctors, and we created the directory to help them find YOU! Click HERE and make sure you and your website are properly listed.

A tax deduction, a free listing, a great cause—what’s not to love?! It is only through awareness and support that our progress is possible.

The WVD team:

Dedra Smith, Producer
Jonathan Stack, Executive Director
Alison Hoover, Communications Director
Oliver Nasht, Content Director

ASPC’s Gareth James interviewed for a Vasectomy article in the Daily Telegraph

The Rise of the luxury Brosectomy

“This guy’s possibility of even getting laid for the rest of his life is pretty low. Is this really a necessary procedure?”  It’s not a question you’d expect to hear in the waiting room of a urology clinic, just moments before a man’s vasectomy. But then, this wasn’t a normal waiting room.

Jeb Lopez, 44, and his best friend Rob Ferretti, 36, had paid $3,250 for a ‘vasectomy party’ at Obsidian Men’s Health clinic. They’d taken the day off work, and now they were sitting in colour-coordinated dressing gowns, enjoying a big screen TV, snacks, and a tumbler of Glenfiddich whisky on ice that would be available even during the procedure. Afterwards, they would celebrate with steak, and then go home to upload their experience to YouTube.

Welcome to the world of the ‘brosectomy’.

“Bro, it was awesome”, Lopez says in the video, as he returns from the operating table. “I want to go back in there. It was awesome. I want to come back tomorrow. I want to hang out here.”

While Lopez may be the only man alive to have uttered those words in the aftermath of a vasectomy, the pair are not alone in deciding to go as a group and turn the procedure into a fun day out.

Speaking to the Wall Street Journal, urologist Paul Turek, who has clinics in California and San Francisco, said group trips are a growing trend. He described a recent group who arrived by limousine.

On his blog, Turek pointed to the health benefits of treating the procedure in this way, describing one group who “took fewer pain pills, felt better faster and returned to work earlier than the average, go-it-alone-out-on-the-plank, tube-tied patient”.

Though they are technically reversible, vasectomies should be considered permanent birth control for men and this can be a daunting prospect.

Shane Geib M.D, the urologist who operated on Lopez and Ferretti at his Obsidian Men’s Health clinic just outside of Washington D.C, told The Telegraph that men often view the procedure as a major one.

“One thing that Mark [Richman, co-founder of the clinic] and I realised is that if you get a 35 to 40-year-old guy, this is a big deal to him”, he explained. “If you brush over it and say ‘oh, suck it up, you’re being a wimp’, the guys don’t like that, they take real offence.

“Particularly compared with the age equivalent in women, most men aren’t really used to going to the doctor. Even if they don’t come in groups, a lot of guys will send one guy, kind of as a sacrificial lamb, to check out the office. ‘Is this a nice place? Do you like the doctors? How are the staff?’ Then that guy can report back.”

Geib acknowledges that the luxury experience provided at Obsidian remains unorthodox, and relies on the tightly managed nature of a boutique surgery, together with his own personality and the relationships he and Richman have developed with their patients. In other words, it’s not a model you could transpose to any old clinic.

Geib’s proposition sounds reasonable, but here’s the million dollar question: can we expect to see the trend spread to the UK?

“You could make a case for it, but I’m not convinced it would really take off”, says Dr Gareth James, a GP, vasectomy surgeon, and Audit Lead for the Association of Surgeons in Primary Care.

“There’s a chap called Professor Michel Labrecque over in Canada who gets the morning list of 20 patients all sat down and he goes through it all with all of them as a group, and then bing bang bong, he goes through them at a rate of knots. He’s literally in the room doing one while the other one’s being prepped.

“He says he gets very good feedback doing that, but when we’ve discussed it with patients they go ‘ooh no we don’t want to do it as a group, no, no, no’. So again, I don’t know whether there’s some British reserve there!”  Having audited vasectomy procedures, Dr James has found the results you might expect: the take-up for private surgery in the UK being relatively low and the vast bulk of the procedures take place on the NHS.

“We know our patients incredibly well and it’s a two-way street”, he says. He and Richman are the only surgeons at Obsidian, partially because “it has to be somebody who doesn’t mind going the extra mile for patients, to go in at night or at the weekend and won’t mind being texted at weird times on the weekend. Most of the patients are incredibly respectful. We’ve never really had any problems.

“As far as alcohol for the procedure is concerned, first of all, no-one would ever drive home. We Uber them home if their spouse doesn’t come down. And of course, not everyone drinks, but certainly when you get a couple of guys together, having a couple of drinks is part of the ambience that they want.”

The average cost for having the procedure carried out privately was £342 in his audit, a far cry from the thousands of dollars required for a luxury spa day-style surgery in the USA, and in his own experience Brits don’t tend to see it as a procedure requiring a private clinic. “Out of the last thousand patients, I’ve probably done two privately”, he continues.

“It sounds quite a fun idea and I think it would be quite a good thing to get some blokes involved with their mates, but there’s not much call for it.”

In some areas of the UK, NHS Clinical Commissioning Groups have put forward vasectomies as low clinical priority, meaning they are not funded on the NHS. Perhaps in those areas, the private practice might begin to include luxury options?

Caroline Brock is General Manager of one such practice, Tollgate Clinic in North East Essex, who says it’s not anxiety about the procedure but the cost that keeps men away.

“In some areas of the UK, such as North East Essex, vasectomies are no longer available on the NHS. This has a big impact on whether men choose to have a vasectomy”, she explained. “Despite being one of the most reliable methods of contraception and one of the most cost effective long term, the evidence is that at £345 a self-pay procedure, it just isn’t affordable for many men and demand falls by about 50pc.”

There is, of course, a major difference between discussing the procedure’s take-up in affluent areas of Washington D.C and Beverley Hills, and ordinary towns, cities and rural areas in the UK. But the difference seems to extend beyond cost, too. There seems to be a culture in the UK of taking the whole thing a bit more seriously.

“The UK has seen many campaigns to increase Men’s Health Awareness and encourage them to visit their GP or take up an appropriate appointment. However, trying to incentivise men to have a vasectomy by offering men’s spa days or alcohol isn’t likely to catch on as the NHS sees vasectomy as an important, irreversible decision in a man’s life, a decision that should not be influenced by the wrong incentives that could affect the eligibility of their consent to the procedure”, Brock said.

Geib would likely point to an hour long consultation with each patient that takes place ahead of the surgery, in which he or Richman make entirely sure that the implications of the decision are fully understood, as evidence that his methods are sound.

He sees what he’s doing as part of a broader trend to try and demystify the procedure, which to his surprise, can still come with a stigma. “A much bigger trend compared to the bringing of friends is that lots of men or married couples have just decided not to have children at all”, he noted. “We get a lot of people from Washington D.C who come in and say that they heard that ‘you don’t judge us because we decided not to have children’.

“I never really understood what that meant but apparently other clinics and urology offices have made some off colour comments to these families. I had a couple last year I did and both are professionals, and they went to their urologist who made some really unusual, odd comments in trying to dissuade them from permanent birth control. I think the way Mark and I have looked at this is that as long as this is a person of sound mind who can give consent [then that’s fine].

“We obviously have a lengthy discussion about how it should be considered permanent and while yes there are ways to reverse it, I’ve probably had one or two in my 17 years of practicing that wanted to reverse their vasectomy. It’s quite uncommon. It’s all part of trying to demystify the process and make it a more pleasant experience.”Whether it’s down to British reserve or simply the fact it’s often available free on the NHS, it seems unlikely that men in the UK will join the ‘vasectomy party’ party anytime soon. But it’s safe to say most would agree that as long as families are able to make informed decisions, the move to demystify the procedure and discourage men from feeling wary of it can only be a good thing. Now, where’s that Glenfiddich?

 

 

PCSA Conference in Ireland

ASPC would like to notify all of its members that the PCSA Annual event is approaching. All ASPC members have dual membership with the PCSA in Ireland. Details for the event to be held in Tralee, Kerry are below.

Event: Primary Care Surgical Association Cryosurgery Masterclass and 6th Annual Scientific Meeting and AGM
Where: The Rose Hotel, Tralee, Co Kerry
When: Friday 29th and Saturday 30th September 2017

Friday – 29th September 2017- Cryosurgery Masterclass
9:30-10:00am History of cryosurgery + method of cell death Dr Paola Pasquali
10:00-10:30am Cryogens + equipment Dr David Buckley
10:30-11:00am Patient selection + indications Dr Paola Pasquali
11-30-12:00pm Technique + complications Dr Paola Pasquali
12:00-12:30pm Nurse lead cryosurgery Dr David Buckley
12:30-1:00pm Genital warts Prof Colm O ‘Mahony
1:00-1:30pm Teledermatology for pre and post op care Dr Paola Pasquali
2:30-3:00pm UK Nation Community Surgery Audit Dr Jonathon Botting
3:00-3:30pm Genital lesions and rashes Prof Colm O ‘Mahony
3:30-5:30pm Rotating Workshops – pick two
1. Cryo for wart/verruca/actinic keratosis Dr David Buckley
2. Tissue viability + wound healing science Tissue Viability Nurse
3. Biopsy+curettage punch/shave/incisional, etc) Dr Shastri Persad
4. Cryo for NMSC + keloids Dr Paola Pasquali

8:00pm Gala dinner + guest speaker Prof Colm O ‘Mahony

Saturday 30th September 2017: PCSA annual scientific meeting.
Foundation Session
Basic session:
9:00-9:30am Benign tumours of the skin Dr Shastri Persad
9:30-10:00am Elliptical excision+ layered closure Dr Niall Maguire
10:00-10:30am Setting up a primary care surgical clinic Dr David O Connell

Experienced session:
9:00-9.30am Dermoscopy for BCCs Dr Jonathan Botting
9:30-10:00am NMSC on the head and neck Dr Billy O Connor
10:00-10:30am Suspicious pigmented lesions Mr James Clover
11:00am-11:30am Keynote address: “See and Treat” the future of community based surgery Prof Paul Ridgway, Professor of Surgery,TCD
11:30–1:00pm Ross Ardill papers + prize
2:00-3:00pm AGM Chair Dr Niall Maguire
3:00-5:00pm Rotating Workshops-pick two:
1. Vasectomy(beginners 3-4pm, improvers 4-5pm) Dr Richard Look-Tong
2. Closing wounds without sutures: Glues, staples, secondary intention, etc. Dr Jonathan Botting
3. My favourite suture techniques Dr Enda Devitt
4. Simple flaps Mr James Colver

Generous external CPD credits and GMS study leave entitlements.
We recommend you book early, as spaces are limited.
For further information, contact the conference secretary:
Olive at e mail: reception@theashestreetclinic.com
Tel: 066 7125611; Fax: 066 7122626