The Voice of Podiatrists

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June 17, 2008 #3,274 Editor-Barry Block, DPM, JD

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Pedicures at Salons Can Be Dangerous: TUSPM Podiatrist

It might make your feet look attractive, but a pedicure can actually do more harm than good, suggests an expert. According to Tracey Vlahovic, D.P.M., associate professor of podiatric medicine and orthopedics at Temple University's School of Podiatric Medicine, women often believe that pedicure salons use sterile instruments.

Dr. Tracey Vlahovic

"Unfortunately, this is not the case with all nail salons. As a result, the instruments can spread germs that can cause nail fungus and bacterial infections," said Vlahovic. She suggests that it's best to invest in your own nail files, clippers and cuticle sticks. Still if you choose to use shop instruments, make sure they are sterilized after each use.

Source: ANI [6/15/08]

Canadian Foot Doctor Runs Great Wall Marathon

It wasn’t until earlier this year that Scarborough, Ontario native Randy Moore, 52, decided to lace up his Saucony sneakers and test his endurance in a marathon. Moore, who owns Randy Moore Foot Care Clinic in West Hill, chose the grand-daddy of the marathons, the Great Wall Of China Marathon, held this year in Tianjin Province, China on May 17. A record 1,700 runners from 49 countries were represented.

Dr. Randy Moore

Moore ran in the 50 to 54 age group and finished ninth in his category, 105th in male category and 132nd overall. He crossed second among the 43 Canadians who ran. The 42-kilometre Great Wall course, which Moore described as more of an adventure race because of its steep grades and endless stairs, entailed a grueling five-km run toward the Great Wall followed by an eight-km stretch along the wall. “There were points near the end where it was completely uphill... knee to chest, almost the same pitch as ladder,” he said.

Source: Sean Durack, Scarborough Mirror

Alleged Negligent Treatment of Diabetic Ulcer (Indiana)

Facts: A podiatrist, treated Ronald Vice from November 1996 to February 2000 in connection with diabetic foot ulcers. Vice and his wife, Diana, contended defendant’s lack of aggressive treatment, patient education and lack of diagnostic studies led the doctor to underestimate Vice's lower extremity problems, which ultimately led to bilateral, below-the-knee amputations.

The plaintiffs alleged that defendant failed to recognize the seriousness of a diabetic foot ulcer, refer the patient to a vascular surgeon, order vascular and arterial pressure studies and make proper assessments of right foot wounds while attempting to treat the left foot. Other allegations included failures to order antibiotics, blood work, x-rays, MRIs, bone scan, CBC, metabolic panel, sedimentation rate and serum protein with albumin; moreover, the plaintiffs asserted that defendant had failed to hospitalize Ronald Vice, as well as inform him of the seriousness of potential leg loss. The plaintiffs further argued defendant failed to perform incision and drainage procedures with deep debridement and order bone and soft tissue biopsies and wound cultures.

According to a medical review panel opinion dated Feb. 10, 2003, the medical review panel found evidence supported the conclusion that defendant had failed to meet the appropriate standard of care as charged in the plaintiffs' complaint. However, the panel found defendant's conduct was not a factor in the plaintiffs' resulting damages. Moreover, the panel determined evidence did not support the conclusion defendant had failed to meet the appropriate standard of care.

In their answer, the defendants generally denied the plaintiffs' allegations. By way of affirmative defense, the defendants argued Vice had been contributorily negligent and had incurred the risk of a known danger. The podiatrist, in denying negligence, asserted Vice had suffered from several other medical conditions besides foot ulcers, including uncontrolled diabetes, congestive heart failure, coronary artery disease, hypertension, renal insufficiency and peripheral vascular disease. Defendant contended her care and treatment met or exceeded the applicable standard of care in all respects.

Result: Defendant’s verdict

Plaintiff’s Experts: Stephen G. Lalka, MD; Michael A. Salcedo, DPM, South Bend, IN; Robert E. Clemency, MD, South Bend, IN.; Sheree L. Peglow, MD, South Bend, IN; Stephen F. Mitros, MD, South Bend, IN; Charles E. Petersen, MD, South Bend, IN; R. Gregory Credi, MD, South Bend, IN.

Defendant’s Experts: Maria F. Curfman, MD, Fort Wayne, IN; Bruce L. Gewertz, MD, Los Angeles, CA; Michelle Cervin, DO, South Bend, IN; Daniel E. Scherb, MD, South Bend, IN; Frank C. Toepp, DPM, South Bend, IN; Jeff Niespodziany, DPM, Mishawaka, IN; Theodore A. Vorenkamp, DPM, South Bend, IN; Brian Rolfe, DPM, South Bend, IN; William Fox, DPM, Niles, MI; Nelson Worden, DPM, Mishawaka, IN; John Grady, DPM, Oak Lawn, IL, Thomas Wicks, DPM, New Castle, IN; Richard M. Hilker, DPM, Fort Wayne, IN.; Randolph J. Ferlic, MD, South Bend, IN; Bruce J. Brincko, DPM, Knox, IN.

Source: West's Jury Verdicts - Indiana Reports

How to Get More Suggestions From Staff

A good way to encourage suggestions from employees about how to improve the practice is to provide a simple form that asks them to finish this statement: “If I owned this practice…”

To tap employees’ ideas, announce that one of the suggestions will be randomly selected for a worthwhile prize. Other suggestions that are carried out will reap financial rewards.

Source: Adapted from Martin Wright, writing in Personnel.

Query: Candida Injections for Verruca

I would appreciate my colleague’s experiences with Candida injections for verruca. What is your success rate, and how does one get started?

Neil Levin, DPM, Sycamore, IL

RE: Acrocyanosis with Blisters (Sandy Schustek, DPM)
From: Elliot Udell, DPM

A positive ANA with a titer 1:640 is a very high titer and suggests that something is going on of an inflammatory nature somewhere in this patient's body which might be more than acrocyanosis. We have had patients with acrocyanosis who have had negative ANAs. The top of the differential diagnosis is generally collagen vascular diseases with lupus, scleroderma and rheumatoid arthritis. Other pathology that can cause a high ANA could even be certain malignancies, lung diseases and even certain gastro-intestinal diseases. What was the pattern of the ANA? The pattern might be helpful in suggesting a diagnosis. The fact that the TSH was slightly abnormal suggests something as well. An abnormal thyroid stimulating hormone test, which today is a highly sensitive test suggests that whatever pathology is involved, it may be affecting the patient’s endocrine system.

With such a high titer ANA and an abnormal TSH, it would best for the patient to be referred to a good rheumatologist who works in an academic setting and having him or her do a more extensive work-up which would include more specific blood tests as well as a more intense full body physical examination with appropriate full body diagnostic testing, where necessary. This patient needs to be followed up by an appropriate medical specialist not only short term but on an ongoing basis. Even if they cannot make an immediate diagnosis, a highly positive ANA and an abnormal TSH needs to be followed up with periodic retesting. A team approach in the care of this patient is best.

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

RE: Acrocyanosis with Blisters (Sandy Schustek, DPM)
From: Barry Mullen, DPM

More specifics are needed about your patient's past medical history, history of chief complaint and family medical history. It would be helpful to learn if your patient's a) skin discoloration is a constant color irrespective of cold exposure b) had past history of prolonged cold exposure i.e., chilblains c) smokes d) has family history of collagen vascular or other autoimmune disease e) any additional symptoms present (arthralgias, constitutional, visual, etc.) f) results of lab work taken thus far, especially whether anemia exists.

While a presumptive diagnosis of acrocyanosis has been made, its color changes tend to be fairly constant, often irrespective of temperature w/ a general benign clinical course. It's used more as a descriptive term of the color changes to the distal parts of the extremities rather than an actual disease entity. You mentioned your patient's color changes worsen w/ cold exposure. This clearly implies vasospasm. Raynaud's phenomenon is always aggravated by cold exposure and often mirrors its primary disease course. Though you witnessed these color changes in 100 degree heat, was the patient exposed to an air-conditioned treatment room or car on the way to your office? That would certainly explain why she went into vasospasm despite such hot weather. Her positive ANA suggests a collagen vascular disorder as primary etiology. In an 18 year old female, SLE heads that list, though vasculitis is seen in autoimmune thyroid disorders like Hasimoto's thyroiditis. Her elevated TSH certainly mandates further thyroid investigation.

Raynaud's phenomenon (secondary) is associated with collagen vascular disorders that include SLE, scleroderma, RA, juvenile RA (Still's disease), dermatomyositis, mixed connective tissue disease, Sjogren's syndrome and cryoglobulinemia (associated with lymphoma and myeloma). I'd recommend a) a hematology consult for extensive blood work up b) rheumatology and/or internal medicine consult.

Despite the limited history given thus far, my differential includes all of the aforementioned diseases and I'd order them 1) SLE 2) mixed CT 3) Hashimoto's thyroiditis 4) JRA 5) cryoglobulinemia.

Barry Mullen, DPM, Hackettstown, NJ, yazy630@aol.com

RE: Diagnostic Ultrasound (Michael A. DeVito, DPM)
From: Bruce Krell, DPM

I have been using a Siui CTS-5500 diagnostic ultrasound from Fisher Biomedical. I purchased the US/accessories, and have performed the training. The ultrasound equipment operation is fairly easy to use and proficiency will increase over time. The picture quality is very good and as I encounter pathology, on a repetitive basis, I see more clearly than before. Patients like and accept it as part of your exam process.

Insurance companies pay for it and have not as yet asked for pre-cert or documentation (HealthNet does not allow). I perform exams only as necessary but the opportunity presents itself many times a day as a needed assist in a diagnostic exam. I am very happy with it and look forward to increasing my scope of use and knowledge base.

Bruce Krell, DPM Chandler, AZ, footdoc352@cox.net

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ASSOCIATE POSITION – LONG ISLAND

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