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09/11/2017    

RESPONSES/COMMENTS (CLINICAL)


RE: Alcian Blue Stains as an Alternative to Genetic Testing 


From Daniel Chaskin, DPM, Ridgewood, NY 


 


PCR assays or genetic testing are more expensive than Alcian Blue Stains. Many podiatrists do not order genetic testing because of cost. Alcian Blue Stains may not be as expensive and may with PAS yield a higher positive result. Alcian Blue stains combined with PAS is likely to result in more positive onychomycotic results. Thus, if you are concerned about cost and do not want to order genetic testing, consider Alcian Blue Stains. If cost is not a factor, my personal opinion is that genetic testing is the optimum choice for detecting onychomycosis. 


 


Daniel Chaskin, DPM, Ridgewood, NY

Other messages in this thread:


09/17/2018    

RESPONSES/COMMENTS (CLINICAL)



From: Paul Clint Jones, DPM


 


I have had this issue as well. I found that using topical Silvadene cream 2-3 times daily is very effective to getting rid of them. Let us know how it works for your patient. 


 


Paul Clint Jones, DPM, Portland, OR

09/17/2018    

RESPONSES/COMMENTS (CLINICAL)



From: Martin V. Sloan, DPM


 


It is difficult to tell, but those lesions look like pitted keratolysis. Have the specimens been analyzed for bacterial identification and sensitivity? Is Corynobacterium a possibility? Is the patient diabetic?


 


Martin V. Sloan, DPM, Abilene, TX

08/31/2018    

RESPONSES/COMMENTS (CLINICAL)


RE: Body Identity Integrity Disorder (BIID) 


From: George Jacobson, DPM


 


This is a rare disorder where the patient wants to get rid of a body part. In this case, amputate the foot. The patient gets happiness at the loss of a body part. To read more about this, look it up or click this link. Could you imagine having a patient that has this disorder and does everything they can to lose their foot or leg. 


 


George Jacobson, DPM, Hollywood, FL

08/29/2018    

RESPONSES/COMMENTS (CLINICAL)



From: Joel Morse, DPM


 


This appears to be purpura due to a hypersensitive vasculitis due to the antibiotics. One can also see a transient rash from endocarditis. This does not appear to be embolic, which usually occurs at the tips of the toes. Ask the internist if they can put the patient on another antibiotic.


 


Joel Morse, DPM, Washington, DC

08/21/2018    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: Lawrence Rubin, DPM


 


The characteristic radiographic appearance of chronic gouty arthritis in the foot is the presence of clearcut, “punched-out” erosions with dense, sclerotic margins in a juxta-articular distribution, often with overhanging edges. What's going on in the proximal interphalangeal joint of the second toe and the distal-medial tuft of the distal phalanx in the great toe is highly suspicious.


 


Arthrocentesis with even just a couple of drops of synovial fluid enables microscopic examination which can make the diagnosis. If crystals are seen, their shape and appearance under polarized light are diagnostic. Way back when I taught in the classrooms and clinics of the Illinois College of Podiatric Medicine, when we saw this kind of arthropathy on an x-ray, we used to say, "When in doubt, think of gout."  


 


Lawrence Rubin, DPM, Las Vegas, NV

08/21/2018    

RESPONSES/COMMENTS (CLINICAL) - PART 1B



From: Steven Kravitz, DPM


 



There have been a number of posts dealing with gout and diabetic patients, most recently that by Dr. Udell on the differential between gout and infection.


 


Strange as it may seem, gout has been misdiagnosed when the actual pathology is early onset of Charcot foot disease. This is more common than might otherwise be recognized and most often [misdiagnosed] by family practice type physicians who are not educated enough for the index of suspicion needed to diagnose early onset of this osteoarthropathy.


 


In particular is a case that was seen by a family practice physician for several months, referred back to radiology, then to orthopedics, all of which has confirmed gout without supportive serological testing, etc. With the patient apparently not improving, the family practice physician... 


 


Editor's note: Dr. Kravitz's extended-length letter can be read here.  


08/17/2018    

RESPONSES/COMMENTS (CLINICAL)



From: Stephen Musser, DPM


 


It is not that uncommon for diabetics to experience gout attacks. After all, diabetes does/can affect the renal function in diabetics causing increase in uric acid. Regarding the radiographs submitted, there is not enough evidence in the pictures to suggest chronic attacks of gout in that particular toe. Obtaining labs is recommended. 


 


Stephen Musser, DPM, Cleveland, OH

08/16/2018    

RESPONSES/COMMENTS (CLINICAL)



From: Elliot Udell, DPM


 


Two conditions that share clinical appearances are acute gout and acute bacterial infection. A sixty five year old diabetic patient could have acute gout or an infection, and missing the correct diagnosis could be problematic. It is not out of the question that the patient could even be presenting with acute gout combined with a bacterial infection.


 


This case calls for a needle biopsy of the affected joint and ask the lab to not only look for urate crystals but have them do a culture and gram stain. You will have to send the fluid tapped in two different types of media (Call your lab). In the interim, place the patient on a broad spectrum antibiotic and monitor the patient carefully for any signs of ascending cellulitis.


 


Elliot Udell, DPM, Hicksville, NY

08/15/2018    

RESPONSES/COMMENTS (CLINICAL)



From: Elliot Udell, DPM


 


I had a similar case many years ago. What was most annoying is that the patient would come in every four weeks to have the lesions debrided and enucleated. Can you imagine what it was like debriding and enucleating 30 or 40 punctate lesions every four weeks. What finally worked was that I casted the patient for fully functional rigid foot orthotics. After using the orthotics, the lesions all went away. That was 25 years ago. Today, I would have done a punch biopsy first and sent the specimen to the Derm Path lab. 


 


Elliot Udell, DPM, Hicksville, NY

08/06/2018    

RESPONSES/COMMENTS (CLINICAL)



From: Steven J. Kaniadakis, DPM


 


EMLA works best placing it under occlusion. I tried it in practice on young apprehensive teens, some younger children, and apprehensive older patients. My experience is it takes too long to work. Also, the patch or occlusion preparation seems to work on certain areas better than others. When I tried it on the plantar foot, forget it. The flexor side (anterior) surfaces are somewhat better. EMLA takes too long in any case. Use the freezing sprays instead.


 


Steven J. Kaniadakis, DPM, St. Petersburg, FL

08/03/2018    

RESPONSES/COMMENTS (CLINICAL)



From: Mark K Johnson, DPM 


 


In clinical practice, I have in the past recommended EMLA cream topically BID over small surface areas of the tarsal tunnel, sural, or deep peroneal nerve trunks for neuropathic pain reduction, especially in diabetic patients or those with radiculopathy. Pre-treatment topically of younger patients, or the use of vibration devices, often lessens apprehensive fear of local nerve blocks. Finally, we have had patients with hypersensitive feet or reduced pain thresholds benefit from topical EMLA under occlusion 45 minutes prior to the office visit for sharp debridement of IPKs.


 


Mark K Johnson, DPM, Bakersfield, CA

07/31/2018    

RESPONSES/COMMENTS (CLINICAL) - PART 2



From: Donald J. Adamov, DPM


 


In my 13 years of clinical practice, I estimate that 2-3 people out of every 100 experience the metallic taste in the mouth with oral terbinafine. Most of these patients were able to deal with it. I do recall one patient several years ago to whom it became very bothersome. It took a couple of weeks to resolve after stopping the medication. 


 


At the time, I did a Google search on this and found a case of a gentleman, in I believe the UK, who was actually hospitalized because he didn't want to eat due to the taste disturbance. In my experience, the taste disturbance with oral terbinafine is rare and to become a big problem is incredibly rare. 


 


Donald J. Adamov, DPM, Spring Hill, FL 

07/31/2018    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: Steven Finer, DPM


 


I have used EMLA on some patients with diabetic neuropathy. Mainly, I used it on patients' toes, with some improvement. I have never used it as a pre-injection nor procedure anesthetic. 


 


Steven Finer, DPM, Philadelphia, PA.

07/31/2018    

RESPONSES/COMMENTS (CLINICAL) - PART 1B



From: Amira Mantoura, DPM


 



I have used EMLA for my kids when they were young, prior to injections and blood draws. I then used it for electrolysis. If used as directed from a fresh tube, it is very effective and leaves the skin completely numb. I suggest applying a liberal amount under occlusion for 30 to 45 minutes. This is all my personal experience. I have never used it on patients prior to nail debridement.


 


Amira Mantoura, DPM, Stamford, CT

07/30/2018    

RESPONSES/COMMENTS (CLINICAL) - PART 1



From: Robert L. Baron, DPM


 


I see this type of lesion on occasion. It appears to be ossification of a bursa, most likely due to repetitive, low grade trauma to the area.


 


Robert L. Baron, DPM, Willowbrook IL

07/30/2018    

RESPONSES/COMMENTS (CLINICAL) - PART 2



From: Allen Jacobs, DPM, Neil Barney, DPM


 


I must admit to “shock and awe" at the recent discussion regarding loss of taste with oral terbinafine. Loss of taste is one on the most common adverse sequels of this medication, occurring in greater than 1/50 patients. Although typically reversed with discontinuation of terbinafine, loss of taste may be permanent. I suggest that in the future, practitioners might familiarize themselves with the FDA package insert before prescribing medications, or offering commentary regarding potential medication side-effects.


 


Allen Jacobs, DPM, St. Louis, MO


 



After over writing 200 scripts for terbinafine, I have seen 3 cases of taste disorder that caused the patient to stop its use. Taste came back within days of stopping. No ill effects were noted thereafter. As an aside, not one case of elevated liver functions was found in those patients tested.


.


Neil Barney, DPM, Brewster, MA


07/27/2018    

RESPONSES/COMMENTS (CLINICAL)



From: David Secord, DPM, S. Jeffrey Ali, DPM


 


Dysgeusia with Lamisil is not common as far as I know, but I have always let my patients know that it is a possibility. In the large number of prescriptions I’ve written for this medication, I’ve had one patient suffer from dysgeusia. I’ve also had one patient suffer from fulminant hepatic failure, so you get an idea of how my luck runs. This one patient suffered for about half a year before regaining normal taste. Until then, he stated that “everything states like cardboard.” Because I warned him of the possibility, he wasn’t upset with me. His wife likes it because he stopped eating so much and eventually went on to lose 45 pounds. 


 


David Secord, DPM, Houston, TX


 



That is about the only side-effect that I have never had a patient complain about in my 20 years since podiatry school. Nausea, sight disturbances, and even anxiety after reading about the drug, yes, but no taste disturbances. I have had to limit Lamisil use due to elevated hepatic enzyme levels.


 


S. Jeffrey Ali, DPM, Broadview Heights, OH


07/12/2018    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: George Flanagan, FCPodS


 


I am very interested to hear the replies following this query. In the UK, despite common usage of Xiaflex by hand surgeons, we have still only just had NICE (National Institute for Health and Care Excellence) approval for its use in hands. Effective use for Ledderhose disease would be off-license. I have used it once, with minimal benefit. In the hand, it largely improves contracture. As the contracture rarely develops in the foot, I wonder if collagen breakdown alone is sufficient to reduce the mass.


 


Luck’s (1959) work on pathogensis of Dupuytren’s would suggest it will only be beneficial for ‘mature’ lesions. I am only aware of Ziyad Hammoudeh’s brief 2014 article in Plastic & Reconstructive Surgery which highlights its use in one patient, without success. I look forward to hearing readers' experiences.


 


George Flanagan, FCPodS, Podiatric Surgeon & Medical Advisor to the British Dupuytren’s Society, UK

07/12/2018    

RESPONSES/COMMENTS (CLINICAL) - PART 1B



From: Donald Blum, DPM, JD, Simon Tabchi, DPM


 



According to GoodRx.com, a "fair price for the drug (2 injections) is $8618.11. This is approved (on label) for Dupuytren's contracture.


 


Donald Blum, DPM, JD, Dallas, TX


 


Dr. Jeffrey Lehrman and I have done a case study on Xiaflex for a patient with recurrent plantar fibroma. It was very successful for the patient, and she is still pain-free with no recurrence. We were able to obtain a donated vial from the manufacturer. We are currently in the process of getting our article published.


 


Simon Tabchi, DPM, Allentown, PA


06/27/2018    

RESPONSES/COMMENTS (CLINICAL)



From: Ira Baum, DPM, Cindy Resnick, DPM


 


I refer you to the dissection technique of Luke D Cicchinelli, DPM: Another Approach to the Posterior Heel Surgery. Podiatry Update 2002. His approach, if done meticulously, many times spares the majority of the AT insertion. It may give you the option of simply reinforcing the AT insertion, if necessary.


 


Ira Baum, DPM  Miami, FL


 


I have successfully used plantar fascial night splints for the treatment of chronic Achilles tendonitis. It effectively stretches the Achilles and its usage often precludes the necessity for surgical intervention.


 


Cindy Resnick, DPM, Staten Island, NY

06/26/2018    

RESPONSES/COMMENTS (CLINICAL) - PART 1B



From: David Zuckerman, DPM 



 


I am surprised that ESWT hasn’t been mentioned as a  treatment for Achilles tendinosis with or without posterior calcification. Typically, the pain is caused by degenerative fibers of the insertional Achilles tendon. John Furia, MD published a peer-reviewed article in the American Journal of Sports Medicine titled, "High-Energy Shock Therapy as a Treatment For Insertional Achilles Tendonpathy." ESWT is non-invasive, office-based, with none of the disability and complications typically known with surgical approaches to this difficult clinical problem. 


 


David Zuckerman, DPM,  Cherry Hill, NJ


06/25/2018    

RESPONSES/COMMENTS (CLINICAL) - PART 1



From: Steven J. Kaniadakis, DPM


 


On this weight-bearing lateral view, there appears to be the very subtle anterior break in the Cyma line, because the sinus tarsi is essentially obliterated, and there is a decreased calaneal inclination angle. These findings give rise to a decreased metatarsal declination angle, perhaps the etiology of the clinical presentation of a tyloma. Is it bilateral, because she may be compensating from one foot/ankle and a contralateral condition? Does she have flexible pes cavus foot or feet?


 


Try conservative measures, including carefully aligning and placing a "dancer's" pad or metatarsal pad in the shoe, placed slightly proximal to the metatarsal heads. Better yet, have any padding built into the forefoot extension of an orthotic. Make the extensions and padding bilateral. There appears to be an incidental finding of an accumulation of fat rather than a "bursa sac". I noticed what appears to be some early stages of anterior spurring in the talar beak or some variation of the typical beak. She may need a peg in the sinus tarsi.


 


Steven J. Kaniadakis, DPM, St. Petersburg, FL

06/25/2018    

RESPONSES/COMMENTS (CLINICAL) - PART 2



From: Bryan C. Markinson, DPM


 


In the case presented on dermal sarcoma, it would have been better to first do a biopsy on a portion of the lesion. As presented, primary excision before knowing the biology of the lesion is not optimal. Histologic findings not only identify that the neoplasm is malignant, but a biopsy can give important information as to the aggressiveness of the tumor. As such, it is better left in the patient until that info is known. When excised primarily, only to find out it was malignant afterwards, this presents problems for wide excision planning. What may have been a conservative but complete excision now has to be expanded to a much wider surgical field as the tumor margins are now not reliably identifiable. On feet, this may create the need for an otherwise unnecessary amputation or need for free flap.


 


Additionally, patients need to be staged before complete excision. Definitive local surgery planning will often change if the patient has been found to have metastases. Lastly, some tumors require local radiation and/or chemo before definitive surgery is performed. The best way to go in a case like this is an initial biopsy. If benign, planning for excision is easy and straightforward. If malignant, referral to a university/hospital-based sarcoma treatment team with tumor intact is optimal.


 


Bryan C. Markinson, DPM, NY, NY

06/25/2018    

RESPONSES/COMMENTS (CLINICAL) - PART 3



From: Brian Kiel, DPM, Dave Williams, DPM


 


I have had good results using Topaz on the Achilles as well as plantar fascia. Over a period of time, I have devised a technique that works well. 


 


Brian Kiel, DPM, Memphis, TN


 


Surgery may still be an option, and you do not have to transect the Achilles tendon for good results. O.A. Mercado, DPM made a series of surgical instructional DVDs entitled, “The Art of Surgery.” He has 2 specific DVDs dedicated to Haglund’s deformity and calcified tendo-Achilles. I  recommend the series. He is a wonderful teacher.


 


Dave Williams, DPM, El Paso, TX

06/23/2018    

RESPONSES/COMMENTS (CLINICAL) - PART 1A



From: Andrew Cassidy, DPM


 


I have found that not all physical therapy is the same. For a small spur like this, I suggest PT do aggressive soft tissue mobilization (it’s supposed to hurt but not be worse the next day) combined with phonophoresis (ultrasound with 10% hydrocortisone in the ultrasonic gel that can be compounded), as well as stretching protocols and eccentric loading exercises, maybe combined with a CAM walker.


 


If this fails, I would surely consider trying a growth factor, or stem cell injection in lieu of surgery. I have had many patients that failed conservative measures get complete resolution of pain with the use of biologics, which I would use in the form of PRP intra-operatively as well. The spur has been around longer than the pain. Be sure to treat the patient, not the x-ray.   


 


Andrew Cassidy, DPM, Austin, TX
Thera Band