May 30, 2006 #2,593 Editor-Barry Block, DPM, JD

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With this issue of PM News, we introduce our new photo feature. This will allow readers to submit photos and x-rays along with queries. We remind readers that HIPAA privacy regulations require you to remove the patient's name before submitting any photos. .

Those receiving the text version can view the photo on our website in the current issue section.

LA DPM Offers Summer Foot Care Tips

The summertime isn't just about slimming down, it's also about focusing on your feet. Especially if you're fond of flip-flops. They may be cheap and look good, but doctors say they're not good for your feet! Foot Institute podiatrist Dr. Angelo Morreale says dry cracked feet can lead to a serious health problem. Dr. Morreale also sees a lot of people with foot strain and heel pain. He says flip flops are fine for a few hours, but don't wear them when you should be sporting something more sturdy.

Dr. Morreale says don't forget to pamper your feet. Simply getting a pedicure, using lotion and making sure youre in the right shoes can get your feet going in the right direction. Other summer tips for your feet: Dr. Morreale says if you have problems with athlete's foot use baby powder everyday in your socks and shoes to help keep your feet dry. He also suggests wearing those water socks or water-type shoes if you're going to be out at the lake this weekend.

Source: KTBS , Shreveport, LA [5/27/05]

Lavery, Armstrong, and Wunderlich Published in Diabetes Care

Lawrence A. Lavery, DPM, MPH, David G. Armstrong, DPM, and Robert P. Wunderlich, DPM, et al. have just had an article titled Risk Factors for Foot Infections in Individuals With Diabetes in Diabetes Care (29:1288-1293, 2006)

They evaluated then followed 1,666 consecutive diabetic patients enrolled in a managed carebased outpatient clinic in a 2-year longitudinal outcomes study. At enrollment, patients underwent a standardized general medical examination and detailed foot assessment and were educated about proper foot care. They were then re-screened at scheduled intervals and also seen promptly if they developed any foot problem.

They concluded that foot infections which occur relatively frequently in individuals with diabetes, almost always follow trauma, and dramatically increase the risk of hospitalization and amputation. Efforts to prevent infections should be targeted at people with traumatic foot wounds, especially those that are chronic, deep, recurrent, or associated with peripheral vascular disease.

WA DPM Fined, Ordered to Take Education Course

In May 2006 the Podiatric Medical Board entered into an Agreed Order with John H. Brunsman, a doctor of podiatric medicine (PO00000246). He agrees to terms and conditions, including paying a $5,000 and taking education courses. Brunsman performed surgery on a patient's foot; the patient required several corrective surgeries and has not regained complete use of her foot.

Source: Washington State Department of Health

Query: Congenital Familial Keratoderma

A 13 year old female complains of painful calluses on both feet present since age 5 and getting worse. Her father has the same problem, in the same pattern, as does a younger brother. There is no involvement of the palms. This photo shows growth six weeks after previous debridement.

Congenital Familial Keratoderma

Debridement of hyperkerotosis relieves the discomfort for a few weeks. Orthotics did not help either her or her father much. This appears to be a case of congenital familial keratoderma. Any ideas for treatment? I thought about using Accutane, but this patient is too young for it, and her father has elevated liver enzymes.

Al Musella, DPM, Hewlett, NY, musella@aol.com

RE: Sharp Shape Scanner (David Gurvis, DPM)
From: Larry Huppin, DPM

Dr. Gurvis asks a question that many of us will be considering in the near future. Digital imaging for production of foot orthoses is new to most practitioners but will be having dramatic effect on many of our practices. Several new technologies are either currently on the market or will soon be appearing. It is the responsibility of any podiatrist who plans to use these technologies to understand what they are, how they work and how they compare to each other. I have been studying the available technologies in preparing for an upcoming lecture and paper and hope I can give some insight. There are two primary questions the practitioner must consider when deciding whether to implement digital casting:

1. Does the digital casting unit provide an image of the foot from which can be made an orthosis that provides the best possible clinical outcomes?
2. Is the unit more efficient and cost effective than what you are currently using?

Before evaluating any digital casting technology, you first have to determine what information about the foot must be captured to make an orthotic that provides the best clinical outcomes.

The point here is that any digital casting unit should allow the following in order to capture the basic information necessary to produce a functional foot orthosis:

1. The digital casting unit should allow capture of a true 3D non-weight-bearing image of the foot
2. The unit should allow the practitioner to hold the foot in neutral and to plantar-flex the first ray when casting.
3. The unit must allow capture of the forefoot-to-rearfoot relationship
4. The unit must capture the posterior heel sufficiently to bisect the heel
5. The unit must capture the true height of the longitudinal arch

Editor's note The complete text of this shortened letter can be read at: http://www.podiatrym.com/letters2.cfm?id=9614&start=1

Larry Huppin, DPM, Medical Director, ProLab Orthotics / USA, Lhuppin@prolab-usa.com

RE: MBT Footwear for Neuroma (Steven Fessel, DPM)
From: Robert S. Schwartz, C. Ped

1. Since MBT is a relatively new shoe in America, I think it is important to describe it in a biomechanical way before discussing what it is good for. Eneslow has been selling MBT footwear for over two years. I have been wearing it even longer than that. From our experience and the feedback from the people who wear them, here is the following about MBT footwear.
2. They are available in women's and men's sizes.
3. Their closed shoes are available in primarily two lasts, and one size per last. Their sandals are available in one width that has adjustable straps and buckles to fit most foot sizes and types.
4. The closed shoes have a reasonably high and wide toe box to accommodate the medium to wider foot. For the neuromas, this may reduce forefoot compression forces.
5. The midsole design is a 20+ degree semi-rigid rocker sole. This is designed to accelerate propulsion while reducing the dorsiflexion demand on the MPJ's. Some neuromas include a synovitis at the MPJ's. Reducing the sagittal plane force during propulsion is often helpful.
6. The distally pitched heel reduces impact forces and delays heel contact. The heel sensoris made of 40 durometer polyurethane that creates frontal plane instability. This purposeful feature is theorized to engage proximal muscles and joints to reduce foot and ankle stress (pronatory forces that may have an influence on neuromas.)
7. For the name of a dealer near you go to their website at www.swissmasaius.com
MBT footwear changes posture, alignment, balance, gait and circulation.

Each person who wears it needs to be properly tutored and overseen to optimize its use. It has proven to help neuromas and many other conditions. I urge all healthcare professionals to learn more about how they function and the appropriate protocols to achieve favorable patient outcomes.

Robert S. Schwartz, C. Ped., New York, N Y, rss@eneslow.com

RE: EMR (Frederick R. Fischer)
From: Marc Katz, DPM, Mark J. Tuccio, DPM

I have found that the best solution is wired as a backup and wireless for everyday EMR. If your wireless goes down just hook it up to a wired connection. There are absolutely no issues with wireless for any data, including digital images. There is plenty of speed.

Everyone that has been posting about this topic should check out TexTalk MD a great EMR, a lot of power, easy to customize and very cost-effective. I've been using it for several years (I have no connection to the company, I'm just a client).

I use a fluoroscan. You may want to consider that as an option. Amazing zoom capability and you can use it for foreign body removal, difficult injections etc. This can all be captured into your EMR. Patients also see the image on the screen immediately and you can give them a copy!

Marc Katz, DPM, Tampa, FL, dr_mkatz@yahoo.com

Mr. Fisher makes a good point with regard to EMR software and larger data files in a wired vs. wireless environment. I would also like to add that there is significant cost, in terms of hardware dollars and support dollars, when going wireless as it relates to our omnipresent friend HIPAA. We should not forget that the HIPAA security standards mandate that we protect our patient's PHI through physical and administrative measures.

I am not aware of a current standard in place with regard to encryption strength (48, 128 or 256 bit keys; DES, triple DES or AES) when sending PHI through the air HOWEVER sending a patients PHI through the air without first authenticating the user and then encrypting the data before transmission would be a clear violation of this security mandate as I see it.

In a wireless environment, closing the wireless access point (SSID disabled) and MAC filtering of a client's NIC card can not and will not prevent a determined intruder from gaining access to your network or sniffing data packets. WEP (with shared 48 bit keys) is an old standard and "crackable." WPA1 or WPA2 (the current standards)are large and costly tasks to undertake and implement. They require significant hardware and software upgrades as well as significant technical support to get them up and keep them running.

I would caution any PM News readers to consult with someone that is well-versed in network and wireless security as well as HIPAA security standards before implementing EMR and especially before deploying EMR in a wireless environment.

Do you have the confidence in your network security and your compliance with the HIPAA security standards to dismiss someone trying to shake you down?

Editor's NoteThe complete text of this shortened letter can be read at:
http://www.podiatrym.com/letters2.cfm?id=9615&start=1

Mark J. Tuccio, DPM, Jamestown, NY, mtuccio1@stny.rr.com

ASSOCIATE WANTED - NEW YORK

Associate Wanted - Rockland County, Rockland County. Associate with minimum 5 years experience, high volume established general practice. Reply with CV to nypodiatry111@aim.com

ASSOCIATE WANTED - MINNESOTA – MINNEAPOLIS SUBURB

Busy, well-established, full-scope podiatry practice, seeking highly motivated podiatrist for a full-time position with buy-in opportunity. Looking for PSR 24/36 trained individual, to help increase surgical volume. Excellent opportunity for long-term growth with unlimited income potential. E-mail CV to employment@associatedpodiatrists.com or fax to (612) 866-5875 Attn. Jennifer.

1st YEAR RESIDENT SLOT AVAILABLE - CALIFORNIA

Sherman Oaks Hospital, in Sherman Oaks CA, has a (PM&S-24 I 1st. year) program available, beginning 7/1/06. Our program offers the Residents a wide variety of cases from ankle fractures, subtalar joint, fusions, & tendon transfers as well as all other podiatric forefoot & rearfoot cases, with very impressive procedure activity numbers at a "C" level. The Residents meet & exceed the requirements for surgical case loads, usually by the first 6 months. Residents will also see an average of 250 to 300 wound patients per month.

The stipend for the 1st year Resident is Thirty Thousand dollars ($30,000) and 2nd year Resident; Thirty- Four Thousand dollars ($34,000). For more information please call Dr. Boghossian at (818) 905-2222 or e-mail him at gbogi@sbcglobal.net

PRACTICE FOR SALE – ARKANSAS

Thriving Ozark Mountains practice in prime retirement area seeks to sell on long term note. Two locations: Mountain Home and satellite office in Harrison, Arkansas, both with established patient base with full range of services and nursing homes available. Hospital privileges. Wonderful Staff. Fully equipped. Priced to sell. (870) 425-1466 orchristinag@centurytel.net

POSITION WANTED - NEW YORK

Non surgical podiatrist with 20 years experience is seeking practice opportunity 1-2 days/wk. ABPOPPM board certified, own malpractice insurance, many insurance plans. Please call (516) 557-6862 or e-mail Joelme@aol.com.

ASSOCIATE POSITION- NEW ENGLAND

Terrific Opportunity Now Available in growing New England practice. Well established and respected practice with new, large office space, latest technology, very helpful staff, loyal patients and solid referral base. Close proximity to hospitals with modern surgical suites. Opportunity for shared ownership. Prefer 24 month PSR with clinical practice experience or an experienced doctor looking to improve their situation. E-mail CV and particulars to NEAFC3@aol.com

EQUIPMENT FOR SALE - ESWT

If you are using or thinking of using ESWT, I have a new machine that has only been used twice. There is no Orbasone in the country priced like this one. Will provide training and installation. Take a look at http://www.orbasone.com Call 1-856-229-2939.

ASSOCIATE WANTED - NORTH CAROLINA

Growing practice in beautiful western North Carolina seeking qualified DPM. Great mix of office and surgery center care. Must have NC license and ABPS qualified/certified. Send cover letter and CV to dpmcareer@aol.com

POSITON AVAILABLE - WASHINGTON, DC

The George Washington University Medical Faculty Associates, a large multi-specialty practice affiliated with a teaching hospital, is seeking a full-time podiatrist. The practice has a diverse population encompassing inpatient and outpatient surgery, as well as a thriving outpatient clinical practice. Must be board certified/board eligible and have experience in diabetic limb salvage. Send CV to cdugan@mfa.gwu.edu or fax to (202) 741-2241.

ESWT MACHINE FOR SALE

I have a DolorClast shockwave machine for sale 60% of cost, call 416-545-1166 or mailto:dracula65@hotmail.com Thank you

PRACTICE FOR SALE - NEW YORK

FOR SALE - Rockland County. Well established, high-volume practice, general and surgical. Gross $500K, hospital privileges; excellent lease. All interested parties reply to: metroNYCpodiatry@aim.com

SURGICAL INSTRUMENTS FOR SALE

Complete Surgical Instruments, Hundreds; Stryker Power Set Electric motor; Reciprocating & Oscillating saw, Roto-osteotomes, also two major bone sets including DePuy osteotomes, several soft tissue sets, etc. Office instruments also. Call for exact items. Art Korbel DPM, (MD) 954 753 7621

Partnership possible after two years. Two office practice. Palliation; biomechanics/orthotics; woundcare; office/hospital surgery. Must have Virginia license. Associate will do most of the practice’s surgery. PSR24/36/Board qualified/certified in surgery preferred. Available SAP. Send CV to: Dr. Marc Jay Pinsky; 9550 Midlothian Turnpike; Suite 104; Richmond, VA 23235; mjpinsky@juno.com.; FAX: 804-320-6627.

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