The Voice of Podiatrists

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February 15, 2007 #2,810 Editor-Barry Block, DPM, JD

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AK Podiatrist is Traveling Foot Doctor

Lynn Stevens shuffled into the crafts room at Chester Park Senior Housing, which she calls home. She set her walker aside, sat down and pulled off her blue sneakers, baring feet worn from walking for nine decades. Dr. Donna Klecka picked both up in her hands and tended to Stevens' nails and skin. Even though this isn't a doctor's office, it's definitely a doctor visit. Just as in the old days, this is a house call -- Klecka's specialty.

Dr. Donna Klecka (Photo by Erik Hill)

Ten years ago, Klecka moved her podiatry practice north from Seattle. In Alaska, she did something unconventional: She opened a medical practice in Eagle River but not an office. Patients don't come to her; she goes to them. The little sign on her black Toyota Prius reads: "Traveling Foot Doctor."

Klecka is a single mother of three children. A doctor who focuses on house calls can be more flexible about family, she said. She schedules her patients around her children's needs. Klecka doesn't hire a billing staff anymore. She does that on her own and has slimmed down the paperwork because she doesn't participate in the Medicare program and hands patients documents with which they can bill private insurance companies themselves. At the end of a visit, her patients reach for their pocketbooks. They pay in cash or check, not credit cards.

Source: Ann Potempa, Anchorage Daily News, [2/13/07]

CA Podiatrist Hired as Executive Director of Diabetes Society

The Diabetes Society has announced the hiring of Dr. Douglas Metz as its executive director. He brings a wealth of knowledge about health care and non-profit administration to the 43-year-old organization.

Dr. Douglas Metz

After practicing Podiatric Medicine & Surgery in the Almaden Valley for 16 years, he obtained his Masters in Public Health (MPH) degree and pursued a career in public health and human services management. Prior to joining the Society, Metz served six years as vice president and chief operating officer at Asian Americans for Community Involvement (AACI), overseeing many of their human services programs including Health Services, Family Violence, Seniors and Youth

Metz comes to the Society at a critical time. The Centers for Disease Control and Prevention (CDC) and the American Diabetes Association have both identified diabetes as a major health crisis. “My passion is to assure health access to all,” Metz says. “And my vision for the Society includes increasing awareness and visibility of our agency in the community as well as expanding services to include populations we are not already serving.”

Metz received his medical degree at the California College of Podiatric Medicine in San Francisco, his Masters in Public Health at San Jose State University, and his B.A. in Communications at Michigan State University.

Part B Premiums Could Increase by 17% in 2008

Medicare Part B premiums in 2008 could increase by 17% or $15.90 monthly, to $109.40 monthly, according to a report released on Tuesday by the TREA Senior Citizens League, the Palm Beach Post reports. The federal government covers about 75% of the cost of Medicare Part B -- which pays for outpatient care such as physician services, durable medical equipment, home health visits and preventive services -- and beneficiaries cover about 25% through premiums. Individuals with annual incomes that exceed $80,000 and married couples with annual incomes that exceed $160,000 pay higher premiums.

According to the Post, the estimates in the report are "based on the rapidly growing deficit between what the program was expected to cost and the actual costs." For example, although Medicare trustees must include a scheduled 10% reduction in physician reimbursements in estimates of Part B premiums for 2008, the report assumes that Congress will reverse the scheduled reduction. Medicare Part B premiums have increased by 60% over the past five years, compared with 14% for Social Security COLA.

Source: Palm Beach Post via American Health Line [2/14/07]

Query: Post-op Allergic Reaction?

I have a patient who underwent three PIPJ arthroplasties (toes 3 and 4 on the right and 4 on the left) four weeks ago. She now has edema and terrible itching at the operative sites. There is no sign of infection (afebrile and wounds completely coapted). I believe she may be having an allergic reaction to the Vicryl sutures I used to repair the extensor tendon. I have placed her on Naprosyn 500mg bid and have started her on a Medrol dose pack. She has had little relief and of course is quite upset. Does anyone have any other suggestions?

David Gutierrez, DPM, Bronx, NY

RE: Refractory Hyperhidrosis (Evan Meltzer, DPM)
From: Multiple Respondents

Dr. Meltzer described a patient with persistent primary hyperhidrosis of the feet. I find topical Formalin (Lazerformalyde) helpful in these patients. Application begins once daily and is titrated to individual needs. Caution your patient about over drying the feet.

When topical treatments fail I prescribe Robinul (glycopyrolate) 1 mg bid to start, and again titrate as necessary. Patients must be advised of possible side effects with anticholinergics (especially dry mouth, and headaches). I have had several young female patients tell me this treatment has been a wonderful way for them to participate in social events without the embarrassment of anxiety induced palmar-plantar hyperhidrosis.

Patients should always be evaluated for secondary hyperhidrosis (i.e., hyperthyroidism, etc.) if the clicial picture indicates more generalized hyperhidrosis.

David Arkin, DPM, Big Flats, NY, docarkin@stny.rr.com

First determine if there is an emotional component. Does the patient appear to be "high strung" or nervous? Ask the patient if he or she is anxious? If you uncover an emotional component you can address it or send the patient to a mental health professional. If this is ruled out as a cause, then consider some of the pharmaceutical and /or natural products available.

One natural product that comes to mind which is quite effective is having the patient soak his or her foot in a concentrate of tea. The tannic acid closes the pores and reduces sweating. The downside is that the mixture will stain the patient’s feet orange. A good pharmaceutical product that I have used with great success over the years is Pedinol's Lazerformalyde. It is a prescription item. It can also be dispensed from your office. I have the patient apply it to both feet three times a week. There might be other protocols.

Iontophoresis using tap water has also been used and there are some companies that make iontophoresis modalities just to control excessive sweating. One is called the Idromed 4 and the other is called Drionic. Both are available on the Internet. When I was a resident I was amazed how each attending had his own formula to treat hyperhydrosis.

Elliot Udell, DPM, Hicksville, NY, elliotu@aol.com

In these situations I have been successful with using Botox. http://www.botoxseveresweating.com/index.aspx is a good place to start learning. I have had insurance companies pay for it. Give the patient an Rx for 100 units of Botox. The patient brings in the bottle and I would perform the procedure.

Bret M. Ribotsky, DPM, Boca Raton, FL Ribotsky@doctorbret.com

I used [with reservation], Erythromycin 250 mg. q.i.d. for a 3 week course. I always tried the topical gel first. The p.o. delivery is highly effective if the etiology is an overgrowth of microbacterium and not neurlogical.

Mitchell R. Mosher, DPM, Belmont, NC, bowenfootdoc@yahoo.com

There are several options still left to try:

1. Black Tea Soaks: This is used for the tannic acid content. Simmer three or 4 tea bags (black tea only) for 20 min. Add one quart of cold water to dilute and cool and soak each foot for 30 min once a day for about a week. In many cases, this may stop or decrease the hyperhidrosis for nearly 4-6 weeks and can be repeated.

2. Drionics: Please see the link below. This is a battery-operated home unit for iontophoresis and can also work very well.
http://www.drionic.com/dermatologist_findings.html

David E. Gurvis, DPM, Avon, IN, deg1@comcast.net

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