The newsletter of the Bowel Disease Research Foundation Number 2 j November 2010 Editor Martyn Hall

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After many weekends training with friends and Bromley Ramblers, and generous sponsorship, at last I was on the flight to Beijing to meet up with 7 other ladies undertaking the China Trek for BDRF. We joined up with Julian and Roger, our Team leader and guide, and Doctor Bill, the team doctor – no easy task when you have 3 surgeons and 2 GPs in the group! Towards the end of our transfer to the Jinshanling Hotel we spied through the dusk our first glimpse of the wall which was to be our challenge for the next 5 days.

Day 1: We reached the wall at Jinshanling directly from the Hotel. This part of the wall dates back to the Ming Dynasty and had been restored. We had an easy first day, although it seemed pretty tough with steep slopes and steps together with many watch towers. Lunch arrived courtesy of a local farmer and was much appreciated. In the afternoon the condition of the wall deteriorated up to Simatai where it was being restored. 3 guards stopped us going further. We partly retraced our steps and then walked down to pick up the coach back to hotel.

Continued on page 8

Great Wall of China Trek 15-23 October 2010

BDRF project paper to be published in Gut

A paper, produced by a BDRF-funded team at Sheffield University led by Dr Wen Jiang, will be published shortly in the prestigious journal Gut. (See page 6.)

New projects: record number and value

BDRF’s Trustees, at their meeting on November 1st, decided a commit a larger sum to bowel disease research than the three previous rounds combined.

Following peer review (by independent experts) they agreed to fund nine projects – the most yet for a single round – at a total cost of £341,000. For the first time they had accepted larger applications, of up to £150,000.

These projects cover a wide variety of serious bowel disease: bowel surgery in general; colorectal cancer; faecal incontinence; anal cancer; rectal prolapse; fistula.

This brings to 28 the number of research projects BDRF has funded since 2008, at a cost of £673,000. These projects are located throughout the United Kingdom and include two in the Republic of Ireland.

(See page 3 for details of new projects.)

Contents

Chairman’s Letter 2

Research bursaries 2

New Projects 3-6

Current Projects 6-7

Trusts and companies 8

At the end of their trek the walkers relax. (From left to right) Jane Linsell, Sarah Rose, Jane Guy, Chrissie Laban, Doon Lovett, Antonia Deuters, Asha Senapati, Judy Allen.

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Letter from the Chairman, Asha Senapati

Asha Senapati, Chairman, BDRF

BDRF continues to flourish with new avenues and fresh initiatives being explored. Income has increased sufficiently for us to be able to fund large-scale research projects over a two to three year period. Multicentre projects of national importance are now within our remit and the influence of BDRF has never been greater.

One new initiative just getting under way is the Research Trial Recruiter (RTR) project. Recruitment into surgical trials has always been fraught with difficulty mainly due to the lack of resources on the ground to enlist patients.

Funding of RTRs in colorectal departments in hospitals up and down the country will provide the time required for recruitment to be done in a timely, efficient and patient-centric fashion. With support from the National Institute for Health Research (NIHR) 10 such posts are already in place with 10 more about to be appointed. This initial network of 20 RTRs will provide the backbone for recruitment into surgical trials in coloproctology and hopefully move forward this research as never before.

Support for BDRF has recently been exemplified by a charity trek along the Great Wall of China. In October this year eight women (including the Chairman) trekked along rugged terrain, impossibly steep steps and narrow precipitous ridges for 5 to 7 hours a day over 5 days. Sore feet, stiff legs, aching backs and a cardiac workout as never before allowed us to raise over £20,000 for the Foundation.

Our discomfort, however, was truly made up for by not only the amazing sum that so many generous people gave but also by the astounding spectacle and grandeur of the Great Wall itself. It stretched for 8000 km across nearly half of China and it was humbling to be doing our paces upon it. We called ourselves Bowel Action! and were thankful that most Chinese could not read English.

BDRF continues to help all patients with bowel disease particularly those with surgical problems. RTRs and treks in China are but small contributions to the greater cause of helping treat and cure bowel cancer and many other bowel diseases that cause such misery.

Calling ACPGBI members

Are you a fundraiser? Would you like to help raise funds to go directly towards BDRF’s research projects? If so, please contact Martyn Hall (details below.)

Treasurer wanted. George Foster, BDRF’s long-serving Treasurer, has indicated he wishes to stand down in late 2011. If you might be interested in the position and would like more information, please contact the BDRF office (details below.)

Research Bursaries 2011-12

Call for applications

BDRF has raised over £250,000 during the past year. We will be awarding bursaries of up to £150,000 each (maximum per award) to fund research projects in colorectal disorders. All major bowel diseases are eligible; projects may last from one to three years. There are two categories of bursary:

• Up to £30,000

• £30,000 — £150,000.

Applications open on March 1st and are equally welcome in either category. We shall not be accepting applications for audit projects this year.

Closing date for applications: 15 July 2011.

See website (www.acpgbi.org.uk) and follow link to BDRF for details on how to apply.

What do we do?BDRF initiates and funds medical research in the UK and Ireland into bowel disease.

Uniquely in the UK, it covers all serious bowel diseases: bowel cancer, inflammatory bowel disease and bowel incontinence.

BDRF gives priority to projects which offer real hopes of progress for existing patients.

Bowel Disease Research Foundation (of the Association of Coloproctology of Great Britain and Ireland) Advancing the cure and treatment of bowel disease

Registered Office Royal College of Surgeons of England 35-43 Lincoln’s Inn Fields London WC2A 3PE

Telephone 020 7304 4775

Email mhall@bdrf.org.uk

Fax 020 7430 9235

Limited Company registered in England and Wales. Company No. 6309182. Registered Charity No. 1120460

Design & print: www.intertype.co.uk

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New projects

Does Dexamethasone Reduce Emesis After Major Gastrointestinal Surgery (DREAMS Trial)

Lead applicant: Nazzia Mirza, Specialist Registrar

Institution: University of Birmingham

Cost: £131,688

Aim: Bowel surgery is undertaken on over 60,000 patients a year in the UK. It can result in a prolonged post-operative recovery period, including several weeks in hospital, which can hinder recovery. Persistent nausea and vomiting is an important cause of prolonged hospital stay following bowel surgery as the bowel is slow to start working after the operation.

This study will investigate whether giving patients an injection of steroid (Dexamethasone) before surgery can reduce the amount of nausea and vomiting and improve appetite, thus allowing greater independence and earlier hospital discharge. It is important that there is a measurable benefit from this treatment as steroids can adversely affect a patient’s recovery, predisposing them to infection risks.

No useful study of this treatment has been undertaken in patients undergoing bowel surgery. Previous studies have been too small to provide a clear answer and were limited to a single hospital, making findings less general.

We will undertake a study of 550 patients undergoing bowel surgery in twelve hospitals. Patients will be randomised 1:1 between Dexamethasone or not. This will allow us to determine whether there is ongoing benefit to these patients. The benefit to the health service (economic savings from less expensive medication and fewer days in hospital) will also be assessed.

The effect of sacral neuromodulation on cortical processing of anal canal inputs in patients with faecal incontinence

Lead Applicant: James FX Jones, Senior Lecturer

Institution: University College Dublin

Cost: £42,800

Aim: The nerves which supply the pelvic floor can be injured during childbirth, and this can subsequently cause the distressing condition of faecal incontinence. Recently, electrical nerve root stimulation (sacral neuromodulation or SNM) has been applied successfully to such patients.

This is a clinical study of women with faecal incontinence. Patients deemed suitable candidates for SNM will be enrolled. The effect of SNM on the cortical awareness of the pelvic floor will be measured.

The hypothesis is that SNM will significantly decrease the time taken for signals to reach the brain and increase the amplitude of evoked electrical brain waves.

We anticipate the findings of this research will deliver a direct and immediate benefit to patients suffering from incontinence and, through development of a useful biomarker of the sensitivity of patients to SNM, act as an independent predictor of therapeutic success.

Location of projects mentioned

A

D

E

H

B

G

FC

I

New projects

Over £30,000A BirminghamB DublinC Birmingham

Up to £30,000D OxfordE CambridgeF LeicesterG Imperial College,

LondonH Royal Marsden

Hospital, LondonI St Marks

Hospital, London

Current projects

1 Sheffield, Wen Jiang2 Edinburgh, Richard

Brady3 Coventry, Nigel

Williams

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2

1

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MicroRNAs based blood assay for early detection of colorectal cancer

Lead applicant: Mr Muhammad Imran Aslam, Clinical Research Fellow

Institution: University of Leicester

Cost: £30,000

Aim: Over 100 new cases of bowel cancer are diagnosed every day in the UK. Unfortunately, more than half these patients have advanced disease at the time of detection. Early detection of bowel cancer by screening reduces cancer-related mortality.

Currently, there is a national bowel cancer screening programme in place. The screening test used (faecal occult blood testing) lacks the desired convenience and accuracy leading to a significant number of unnecessary invasive tests and missed diagnoses.

Researchers have shown that different diseases, including cancers, are associated with a unique fingerprint of genetic material (called microRNAs) in the blood. The study will use a simple blood test to identify those microRNAs which are associated with bowel cancer and can ultimately be used for screening. The study also aims to determine if these microRNAs can accurately predict the stage and degree of spread of colon cancer.

Collagen abnormalities in patients with rectal prolapse

Lead Applicant: Mr Ian Lindsey, Consultant Colorectal Surgeon

Institution: University of Oxford

Cost: £30,000

Aim: Rectal prolapse occurs when the rectum (the terminal part of the large intestine) descends to lie outside the

anus. It is a common problem, affecting up to 10% of the population.

It is characterised by the external protrusion of the rectum and is extremely distressing for patients. It may also be a cause of faecal incontinence and in elderly patients may be the cause of admission to care homes.

Understanding of the causes of rectal prolapse is poor. Traditionally it was viewed as a disorder of elderly women who acquired pelvic floor weakness during childbirth. However, this fails to account for the condition occurring in men or in women who have never had children.

We aim to increase understanding of the causes of rectal prolapse by studying the structures that support the rectum to determine why they may be weaker in patients with prolapse, and the reasons this weakness develops. We will do this by sampling the tissues that are attached to the rectum in patients with and without prolapse and studying their chemical composition.

The expression of colorectal cancer cell adhesion molecules and their affect on anti-inflammatory immune cell function

Lead Applicant: Dr Bertus Eksteen, MRC Clinician Scientist & Honorary Consultant

Institution: University of Birmingham

Cost: £40,000

Aim: Colorectal cancer (CRC) is the second most common cause of cancer death in the UK and accounted for 16,007 deaths in 2007. Laboratory analysis of CRC shows that some tumours have a paucity of immune cells while others have an abundance

of anti-inflammatory immune cells (AIC): these are capable of disrupting the ability of our immune system to kill cancer cells. The presence of AIC correlates with worse clinical outcomes.

We propose that CRC cells manipulate their expression of adhesion molecules, which are important in attracting immune cells. These immune cells, attracted to the CRC site, may either prevent immune cells entering the tumour, allowing the tumour to escape detection, or may attract AIC to protect them from the body’s immune system.

We plan to examine if this is the case by using surplus tissue obtained at cancer surgery and measuring the patterns of expression of adhesion molecules. We will then test the functional relevance of these molecules and inhibit the relevant ones. By performing these investigations, we hope to identify molecules which can be targeted to restore the body’s own defences to fight CRC.

Comparison of the diagnostic accuracy of 3D volume acquisition MRI with CT in staging colonic cancer

Lead applicant: Mr Chris Hunter, Clinical Research Fellow

Institution: Imperial College London

Cost: £15,956

Aim: Before treatment, patients with newly diagnosed cancer undergo ‘staging’ to assess how advanced the cancer is. This determines what treatment is best, and is becoming increasingly important as more treatment options become available. In colon cancer, ‘staging’ is currently performed using CT scanning, but is not completely accurate. Due to a

New projects continued

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New projects continued

number of advances in MRI scanning, we think ‘staging’ with MRI may be more accurate than CT, as it is in rectal cancer.

Patients with colon cancer who do not need pre-operative chemotherapy will be included in the trial. They will undergo their normal pre-operative CT and will also have two pre-operative MRI scans.

If all goes well, their cancer will be removed by surgery. After the operation, the cancer will be ‘staged’ microscopically (by histological examination, which is the most accurate method of ‘staging’ cancer, but can be performed only post-operatively).

The accuracy of the previous CT and MRI scans in assessing how far the cancer has spread will be compared, using histology as the gold standard against which accuracy is judged.

Is there greater tumour response as determined by tumour cell density at 6 weeks or 12 weeks following completion of chemo/radiotherapy?

Lead Applicant: Ms Jessica Evans, Surgical Research Fellow

Institution: Royal Marsden Hospital, London

Cost: £14,000

Aim: About 15,000 people are diagnosed with rectal cancer every year in the UK. Currently 35-45% of such patients receive radiotherapy before their operation to reduce the chance of local and distant recurrence.

The effects of radiotherapy are time-dependent yet, perhaps surprisingly, the optimum time post-radiotherapy to operate remains unknown.

We will determine whether MRI can accurately and reliably determine

response to treatment. If MRI can predict response it may be used to guide further management. This includes identifying patients who have responded so well to treatment that no tumour remains and so they can avoid surgery, with its associated morbidity and mortality.

We have established a multicentre study to examine the timing of surgery, comparing 6-8 and 12-14 weeks. We aim to determine the degree of tumour response to radiotherapy by measuring tumour cell density between the two time groups. Thus we plan to determine if greater tumour response – reducing the probability of local and distant recurrence – occurs when surgery is delayed to 12-14 rather than 6-8 weeks.

Study of immunological factors in non-inflammatory bowel disease enterocutaneous fistulae

Lead applicant: Mr Goher Rahbour, Clinical Research Fellow

Institution: St Marks Hospital, London

Cost: £7,400

Aim: An enterocutaneous fistula is a connection between the bowel and the skin. Almost all form after surgery and lead to a number of serious and debilitating complications. These include the need for patients to have a temporary or permanent feeding line placed into a neck vein through which formulae feed is passed on a daily basis.

They often cannot be cured by standard medical management which is attempted for several months to years. Further surgery is very demanding, prolonged and requires vast skill. It has several significant risks including death.

Currently the patient’s options are either to have surgery with its extensive risks or to live with this debilitating condition for the rest of their life.

A cytokine is a substance secreted by specific cells of the immune system which carry signals locally between cells, and thus have an effect on other cells. Infliximab is a drug which works by counteracting a cytokine which causes inflammation called tumour necrosis factor alpha (TNF- α).

A case series has reported that patients with persistent enterocutaneous fistulae associated with non-inflammatory bowel disease have healed following use of Infliximab. We believe TNF-α is present in these fistulae. To date no studies have been undertaken to assess therapies such as Infliximab or to measure TNF- α.

We want to see if TNF- α is present in non-inflammatory bowel disease enterocutneous fistulae. If it is, there will be potential for patients to receive Infliximab to heal their fistulae and hence avoid the risks of major surgery.

Sentinel lymph node detection in anal cancer: A feasibility study of indocyanine green fluorescence and conventional blue dye/radiocolloid mapping

Lead applicant: Mr Justin Davies, Consultant Colorectal Surgeon

Institution: Addenbrookes Hospital, Cambridge

Cost: £29,700

Aim: Anal cancer is a painful, debilitating and potentially fatal disease. About 850 new cases are diagnosed in the UK each year. The treatment of choice is chemotherapy and

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radiotherapy; surgery is reserved for when the disease recurs or does not fully respond.

In a minority of anal cancer patients cancer cells spread to the lymph glands of the groin, but we currently have no accurate way to test for this. Therefore, all patients have to receive radiotherapy treatment to the groin although the majority of them do not need it. Groin radiotherapy can cause a variety of serious complications and side-effects.

In patients with recurrent disease being considered for surgery, if it was known at that time that cancer cells were present, then relevant glands in the groin could be removed during surgery to give a better chance of cure.

This study will first assess how accurate a method (sentinel lymph node detection – SLND) traditional in other cancers of detecting whether cancer cells have spread to the lymph glands is in patients with anal cancer. Second it will compare the traditional method with a newer, easier and potentially safer technique that does not involve exposure to radiation.

We will assess how well each of the techniques works in patients with anal cancer. This will allow a more focused and individualised treatment for newly diagnosed patients who do have spread of cancer cells to the lymph glands in the groin. The majority of patients currently overtreated can then be spared the significant potential complications of groin radiotherapy.

Further, in patients with recurrent disease, we will be able to offer a better chance of cure if all residual cancer is removed at the time of surgery, including the groin lymph glands if SLND shows them to be involved. Finally, comparison of different SLND techniques may allow a more reliable, safer and easier method to be developed.

Current projects – progress reports

How do sensory nerves work in the human bowel, and can we improve pain relief for people suffering from two chronic bowel diseases?

Lead applicant: Dr Wen Jiang, Research Associate

Institution: University of Sheffield

Cost: £52,242

The human bowel receives extensive sensory information, crucial for reflex control and perception of abdominal discomfort and pain. Our understanding of abdominal sensory signalling is based almost exclusively on animal studies. The poor translation of knowledge from animal models has

motivated the team’s attempt to record in vitro electrical signals from nerves supplying the human bowel. The study has demonstrated the feasibility of this novel approach.

Establishing this human model paves the way for mechanical investigation of human gut sensory signal transduction, and also provides a screening tool for discovery of new visceral pain-relief. So the potential rewards of this study are enormous.

New projects continued

Lead applicant: Dr Gina Brown

Institution: Royal Marsden Hospital

Cost: £10,000

The present study aimed to investigate the diagnostic accuracy and clinical value of Magnetic Resonance Imaging (MRI), Diffusion-Weighted MRI(DW-MRI) and Positron Emission Tomography (PET)/MRI, a novel diagnostic technique.

MRI has been shown to be highly accurate in predicting tumour invasion

and survival following exenterative pelvic surgery. The added value of DW-MRI was at the range of 3%. PET/MRI has been demonstrated to be very accurate in the local staging of tumour within the pelvis.

The outcomes of this study have been presented to national and international conferences with appropriate acknowledgement to BDRF and four manuscripts are ready to submit for publication. The results for the 3d anatomical model are currently being evaluated.

The role of new scanning methods in improving surgical technique and outcomes in more extensive pelvic surgery for recurrent and locally advanced primary rectal cancer

Dr Wen Jiang, Professor David Grundy, Dr Kathryn Hodgkins, Dr Jim Tiernan, Mr Ian Adam (Consultant Colorectal Surgeon), Professor Andrew Shorthouse (Consultant Colorectal Surgeon) and Dr Panagiota Kitsanta (Consultant Pathologist).

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Current projects – progress reports

Lead applicant: Richard Brady

Institution: University of Edinburgh

Cost: £28,077

Aim: The team in Edinburgh have established a new model of human colorectal mucosal tissue maintained under stable experimental conditions. This enabled dissection of the human colonic response to aspirin in a relevant and controlled human tissue platform. Early results confirm that aspirin-induced responses observed in colon cancer cell line models are recapitulated in this ex-vivo model.

They have also identified the presence of colonic stem cells and induced cells to proliferate and differentiate into alternative cell lineages. These

developments are very relevant to the further understanding and dissection of the complex molecular mechanisms involved in both aspirin-induced chemo-preventative pathways and the regulation and control of colonic tissue growth and differentiation.

“BDRF support was fundamental to this progress, allowing production of exciting experimental data, expansion of our research team, including new collaborations, and enabled scientific discovery and knowledge acquisition of major relevance to the understanding of human colonic regulation, response and disease.” Dr Brady

Regularly taking aspirin over a long period decreases the risk of developing bowel cancer: why?

Miss Sonia Novo (PhD Student), Mr Richard Brady (Principal Investigator), Mr Neil Waslidge (BDRF-funded Research Technician).

Dr Ramesh Arasaradnam (Senior Lecturer/Consultant

Gastroenterologist at UHCW), Mr Peter Gold, Clinical Research Fellow, Mr Nigel Williams, Consultant Surgeon.

Lead Applicant: Nigel Williams

Institution: University Hospitals Coventry and Warwickshire

Cost: £7,000

Aim: Following some initial difficulties common to clinical research in surgery the team are now making steps towards

Characterisation of crypt cell changes as signifiers of risk of colorectal tumours (benign and malignant)

Assessing the predictive accuracy of MRI scans in determining which low-rectal cancers require enhanced surgery

Lead applicant: Mr Peter How

Institution: Pelican Centre, Basingstoke

Cost: £5,000

So far the team have completed 21 MRI scans of rectal specimens following anterior resection, APE, and pelvic exenteration. They have been taking precise measurements using specialized software within individual axial MRI images with regards to tissue available for resection.

Preliminary analysis of the data shows that MRI can accurately predict the amount of tissue available for surgical removal (resection) at various levels and provides quantitative support for its use in identifying safe planes for surgery.

Metabonomic profiling of recurrent colonic adenomas using faecal water extracts

Lead applicant: Anthony Antoniou

Institution: Chelsea and Westminster Hospital, London

Cost: £10,000

Using nuclear magnetic resonance (NMR) spectroscopy we analysed faecal water extracts from 26 patients with colonic adenomas (benign tumours)but without a family history. Nine patients had recurrent adenomas.

We identified 35 metabolites. The patients with recurrent adenomas had significantly higher levels of succinate, a metabolite in the Kreb’s cycle, compared to the patients without recurrence. Further studies with more patients will be used to validate this finding and to see if it can be extrapolated for use as a screening tool for colorectal carcinoma.

further defining biomarkers for risk of colorectal adenomas and cancer.

They have been experimenting with and developing techniques for quantifying crypt cell kinetics. Patient recruitment should be complete early in 2011 and they hope this will allow time to strengthen their work by carrying out additional studies on the same patient group.

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Great Wall of China Trek 15-23 October 2010, continued from page 1

Day 2: The wall at Gubeikou was very different, not having been restored. The walk up to the wall was long and steep through scrub and with some extremely narrow vertiginous sections which proved very challenging for some of the group. When we reached the wall it was only 1-2 metres wide and overgrown with a central path and no side walls.

Day 3: We were walking in Black Dragon Paw Park. We climbed over the mountain on a steep path alongside water. There were many waterfalls, stepping stones and bridges across the fast flowing river. Our afternoon challenge was a climb to the top of the tallest tower on the wall. We were the only group allowed up on that day and were privileged to see the spectacular views.

Day 4: We walked up through terraces of pear, walnut and chestnut trees on a steep path to the wall at Mutianyu. This section attracts lots of tourists; we encountered wedding couples wearing both red (traditional Chinese) and white dresses to have their photos taken. We walked to the 20th Tower with an option, taken by all, to climb 473 steps for a view from a tower before lunch. After lunch, we trekked back to the toboggan top station. It was a fast and furious way to get back down to the coach!

Day 5: The final day. There were 1200 steps to climb before breakfast. The steps varied in height from 1 to 4 bricks and were truly awesome to

complete. I thought that I had become pretty good at steps but these were something else. We had the wall to ourselves until we reached the middle stretch of the wall, when we came across a path that was full of Chinese tourists in their customary red baseball hats. The hats are a colourful addition to the scene but I wouldn’t want to be walking in their high fashion stiletto-heeled footwear! Back to our hotel for celebratory photos, Chinese champagne and a well earned shower. We followed up the trek with well earned foot massages and trips to the Silk Market and Forbidden City, including a lunch in a family home.

It is amazing how quickly the 5 days flew by and what a sense of achievement there has been both individually and for the group. I succeeded in completing the challenge and although my calves and knees ached I hadn’t needed any of my huge stock of blister plasters. Hopefully this will have brought significant sponsorship to BDRF.

Words by Jane Linsell Photos from Judy Allen

Trusts and companiesMost of BDRF’s income is raised from charitable trusts and private companies. Every penny raised goes to research, with no deduction for administration, as the charity’s running costs are met by the Association of Coloproctology and other sources.

BDRF is very grateful to all its trust and company donors. We list below recent gifts. (In each category donors are listed alphabetically.)£80,000 Robert Luff Foundation (F)

Limited (3)

£10,000 The Charles Wolfson Charitable Trust (CT)

£6,000 Ensix CT£5,000 The Holbeck CT £3,000 The Tay CT (4)£2,000 The Anson CT (2)£1,200 Schroder Charity Trust£1,000 The Lord Faringdon CT;

The Row Fogo CT; The Eric Kay CT; Leach No. 14 Trust; The George A Moore F; The J K Young Endowment Fund

£700 The Sir James Roll CT (4)£500 An Anonymous CT (2);

Armourers & Brasiers’ Gauntlet

Trust (2); The Ian Askew CT (4); Bank of England; The Liebenrood CT (2); The Mackintosh Foundation (3); The Norman Family CT; The Wilkinson CT

<£500 The James Dyson F; Harris CT (4); Charles Hughesdon F; Roger Raymond CT (3); Reuben F; The F G Roberts CT; The Michael and Anna Wix CT; WPP 2005 Ltd

We greatly value regular support. Numbers in brackets above indicate where the gift is e.g. the 2nd or 3rd from the donor.

Editor’s note: at the time of writing the 8 walkers had raised over £21,000 in sponsorship. Over £15,000 was donated via BDRF’s JustGiving site. JustGiving is a secure way to donate online to charity; they also collect Gift Aid, increasing the gift’s value by 28%.