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February 21, 2008 #3,173 Editor-Barry Block, DPM, JD

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In Extreme Weather Use a Treadmill: TUSPM Podiatrist

When traveling on Kelly Drive, you're certain to see people running and walking, getting their daily fix of exercise. You begin to wonder -- is there any weather too extreme for outside activity? But when the wind chills dip to single digits, it's smart to get out of the cold.

Dr. Howard Palamarchuk

Dr. Howard Palamarchuk, director of sports medicine at the Temple University School of Podiatric Medicine: "Indoor training, in fact in my days I'd go to the mall. Use a treadmill -- now we have sophisticated treadmills. Even take a day off. It wouldn't hurt you to take a day off and say tomorrow will be a better day.”

Source: Lynne Adkins, KYW-AM Philadelphia (PA) [2/18/08]

NY Podiatrist Finds Airport Hotel Convenient Solution For Delays

Airport hotels are enjoying a renaissance of sorts as business travelers, frustrated by mounting delays and canceled flights, are leaving the terminal in search of the wider array of amenities available nearby.

Dr. Tracey Toback

Offering reduced day rates for stranded travelers is even catching on among hotels that are not full service. Tracey Toback, a podiatrist, was scheduled to be on an early-morning flight to a medical conference last year, only to face a five-hour delay when he arrived at the airport in Newburgh, N.Y.

“I had a lot of work to do. I was up really late the night before and just figured I’d sleep on the plane,” he said. Dr. Toback said he ruled out napping in the fluorescent-lighted terminal and instead took a shuttle bus to the Ramada Newburgh-West Point where, for a $50 daytime access rate, he was able to get a room and some sleep.

Source: Martha C. White, New York Times [2/19/08]

FDA Rethinks Policy On 'Off-Label' Article Distribution

The Food and Drug Administration is redrafting its guidance that allows manufacturers to distribute journal articles that discuss unapproved uses of FDA-approved drugs and medical devices. The draft guidance recommends principles that manufacturers should follow when distributing scientific or medical journal reprints, articles or reference publications. The guidance specifically recommends against distribution of special supplements or publications that have been funded by one or more of the manufacturers of the product in the article.

When a drug manufacturer gets approval from the FDA, it must sell the drug with a label that lists only its approved uses. Any other use is referred to as “off-label.” The FDA in a previous guidance—which was enacted in 1997 and expired in 2006—had required companies to submit medical journal articles in advance to the FDA and agree to file within three years a supplemental new drug application for the off-label use it wanted to promote.

The FDA will be accepting comments on the draft guidance 60 days after its publication in the Federal Register.

Source: Jennifer Lubell, Modern Healthcare [2/19/08]

Query: Multiple Recurring Ingrown Toenails in Child

I have a 7 yr old female patient who seems to be having ingrown toenails in multiple toes. She started out having an ingrown toenail in her left hallux which was treated successfully, then 3 weeks later her 3rd toenail had same issue. I treated both of these successfully, but now two of her other toes are showing similar symptoms. We have tried change in footgear to make sure there was no external impingement. She does have mildly hypertrophied nail folds but nothing unusual for a pediatric foot. The issue with her as well, is that she is deathly afraid of needles and both times we had to perform procedure under local sedation. I would hate to keep re-exposing her to anesthesia. Any ideas/thoughts?

Syed Ahmed, DPM, Louisville, KY

RE: Tear of Peroneal Longus (Stuart W. Honick, DPM, PT)
From: Multiple Respondents

A 3 cm. gap will never get better. Take this patient to surgery and repair it. Cast the patient NWB with the foot plantar-flexed and everted for at least 3 weeks. I often keep these type of patients on at least 2 mg. Valium bid (to prevent muscle spasms).

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

A peroneal stop procedure may be the most viable option. Of course, pending what and where the patients symptoms are located after failed conservative management of an adequate/appropriate duration. I wouldn't currently attempt primary anatomical repair based on the scenario you described - it would be an exposure/accesses nightmare. I suppose, one could even consider letting it fly, pending the 1st ray position, foot position, heel position and presence/absence of concomitant ankle instability. Though, it begs the question of performing a concomitant Lapidus to stabilize the first ray (in the absence of a peroneus longus), and may "somewhat" be considered an area of controversy. But, surely all this depends on the clinical scenario. Was this an overtly traumatic rupture, if not, I think the bigger question is why did the tendon fail in the first place (i.e., cavovarus).

I've published two articles that are "related" and discuss some of the issues surrounding the case you describe:

1) Blitz, NM. Nemes KK. Bilateral peroneus longus tendon rupture through a bipartite os peroneum. J Foot Ankle Surg. 2007. July-Aug; 46(4): 270-7.

2) Podiatry Today, Article: How to address failed Peroneal Tendon Surgery. http://podiatrytoday.com/article/7491

Neal M Blitz, DPM, Santa Rosa, CA, nealblitz@yahoo.com

RE: Recurrent Enthesopathy of Heel (David Wolf, DPM)
From: Dan Klein, DPM

I would certainly order a MRI of the area. The aggravated cause for soft tissue reaction at the surgical site should be considered i.e. the ROM of the foot and ankle and the gait may give you hint as to the source of re-occurring shoe rub of the area. Certainly, scar tissue and chronic sub-Q fibroma may be a consideration. I would await the results of an MRI before any aggressive invasive management, but I would first try an orthotic with balance padding.

Dan Klein, DPM, Fort Smith, AR, toefixer@aol.com

RE: Discharging a Patient (Robert Lagman, DPM)
From: Robert Wunderlich, DPM

The American Medical Association website has a nice article on "Ending the Patient-Physician Relationship." It doesn't have a 'form' letter, but it details appropriate steps to follow.

The article can be found at the link below:
http://www.ama-assn.org/ama/pub/category/4609.html

Robert Wunderlich, DPM, San Antonio, TX, rwunder@gmail.com

RE: DME Accreditation
From: Mark M Levine, DPM

There seems to be something looming around the corner that will affect any podiatrist that deals with Medicare DME. We're going to have to be certified by an agency outside Medicare that according to current estimates will cost at least a few thousand dollars. The current atmosphere requires us to dispense DME items, both as a courtesy to our patients and also to augment an income that has continually been attacked by insurance companies.

I don't understand why this is not a current topic and what really boggles my mind is why are we as physicians under the Medicare program are required to be "accredited" after going through a lengthy certification and for quite a few of us re-certifications by the Medicare DME carriers.

This is just not affecting podiatry. MD's and DO's who dispense items from their offices will need to do the same. As far as I'm concerned, this to me is the last straw and I'm sick of being trampled on by our policy makers in their ivory towers. We see our politicians lying thru their teeth to get elected and promising everyone national health care which will only take more away.

Does Uncle Sam really want to continue to have the best and brightest become doctors or will they force a two tier medical system on us as so many of the socialistic countries in Europe have.It's time to write our politicians. Don't you think we've taken far too much already? No certification needed here!

Mark M Levine, DPM, Middle Village, NY, MarkLevineDPM@Verizon.net

Accepting Credit Cards (Peter Smith, DPM)
From: Multiple Respondents

We have been accepting credit card payments for several years and find that the benefit far outweighs the small amount that it costs. The money is in the bank the next day and it is certainly cheaper than having to send a bill. Also don't forget that the bank charges something when you deposit checks. In fact I am surprised that more people don't pay me with a credit card for whatever perks the credit card is offering. In any event my advice is yes to accepting credit card payments.

Sam Bell, DPM, Schenectady, NY, dpmbell@aol.com

You cannot afford not to accept them. Almost no one carries cash or checks anymore so I have found that you can collect any co-pays, deductibles, etc., at the time of service. If you think about it the 1-2% you pay to the credit card company is far less than what it costs you to send repeated statements. Also my office manager collects over the phone on any past due amounts. Once every quarter I have a "dialing for dollars" day in which the office staff shares in 10% of what is collected that day on any balance over 60 days. This past week because of the new year there were a lot of unmet deductibles that were collected. Using the credit cards we collected $5,000. The two girls doing the phone calls each received an additional $250. To me it was worth it since the value of your money goes down for each month it is uncollected.

Neal Frankel, DPM, Chicago, IL, drnrf@aol.com

I (gladly) accepted credit cards in my office practice and surgical center. We had the credit card logos displayed prominently, on tables in the waiting areas, as well as in the business office area. Most banks will gladly help you set up your account. Ours provided us with specific software we could use on our office computers...for free.

It was trivial to use. One just entered the name of the patient, their credit card number and expiration date. Some banks ask for the 3 digit ID code on the card for further security. A place for the patient's address and telephone number would automatically appear. After those entries, a menu would be offered to create a charge, remove a charge, amend a charge, etc. The software would remember the patient's name and address for future use.

After you clicked "accept," an authorization number would appear on the screen, which you could print and put in the patent's financial records. The money would appear in your designated bank account in about 2-3 days, minus handling charges, which you sign to accept when you register. You may be able to download the software off of your bank’s Internet site. There are some variations in different Point of Service Software from different banks, but after 5 minutes your staff will become experts at it.

Even as patients, our family routinely charges deductibles and other medical costs to our credit card, for airline mileage and other benefits.

Michael M. Rosenblatt, DPM, San Jose, CA, rosey1@prodigy.net

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