The Voice of Podiatrists

Serving Over 9,500 Podiatrists Daily

June 23, 2007 #2,969 Editor-Barry Block, DPM, JD

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GA Podiatrist Provides Tips on Nail Care

There are three causes of ingrown toenails: Poorly fitting shoes, poorly cut nails and mom and dad, said Columbus podiatrist Georgina Asante. "If the person has just cut their nails improperly, topical antibiotic and sandals may be all that is required to get back on track," Asante said. "If it's more serious, you need medical assistance."

Dr. Georgina Asante

Asante said fashionable pointy shoes are also hazardous to good toenail health. Pointy shoes and pointy toenails are a bad combination. Long toenails moving about in close pointy spaces result in rubbing and forcing the nail into the skin, she said.

"Cut your toenails straight across," Asante said. "Everybody wants to dig in around the corners like they are looking for gold. Believe me if there was gold in there, I would have found it long ago. If you have sharp edges, just smooth them with an emery board."

Source: Kaffie Sledge, Ledger Enquirer [6/21/07]

Former PA Podiatrist Arrested on Drug Charges

A former podiatrist from Sayre, PA was arrested yesterday by agents with the Pennsylvania Attorney General's Bureau of Narcotics Investigation (BNI) for obtaining and ordering excessive amounts of prescription medication for his personal use. Attorney General Tom Corbett identified the defendant as Dr. Brian Halton, 48. Dr. Halton is not currently practicing as a podiatrist.

Corbett said that in May 2007 BNI agents were notified by the Drug Enforcement Administration (DEA) that Dr. Halton had ordered 2,200 dosage units of Vicodin from January 2006 through June 2006. According to a chart provided by the Automated Reporting and Consolidated Order Systems (ARCOS), Dr. Halton is listed as the fourth largest purchaser of Vicodin in Pennsylvania.

Corbett said an investigation into Dr. Halton's activity revealed that he had allegedly been ordering Vicodin and having the medication shipped to his personal address in Sayre. The criminal complaint states that from July 2006 to March 2007, Dr. Halton had allegedly ordered 10,200 Vicodin tablets. On May 23, a BNI and DEA agent visited Dr. Halton at his residence and confiscated 410 Vicodin pills, 168 four-milligram Xanax bars, and 871 10-milligram Diazepam pills. Corbett said Dr. Halton surrendered his DEA registration and his state medical license.

Source: Pennsylvania Attorney General [6/21//07]

CMS Launches Internet-Based Patient Information Tracking System

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CMS has launched a new project to encourage Medicare beneficiaries to take advantage of Internet-based tools to track their healthcare services to better communicate with their medical providers. This pilot program, says CMS, will allow certain beneficiaries to access and use a personal health record provided through participating health plans, and accessible through www.mymedicare.gov.

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The data that will be made available to the beneficiaries include registration information such as name, address and policy number as well as lists of their medications and medical conditions, according to the agency. "By collaborating with Medicare Advantage and Part D Drug Plans which already offer personal health record tools to their commercial members, people with Medicare will have access to information that will enable them to be more involved with their health care services." says Leslie Norwalk, acting administrator of CMS. The pilot will run for 18 months and will include HIP USA, Humana, Kaiser Permanente and the University of Pittsburgh Medical Center.

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Source: Today in E-Health Business [6/21/07]

Query: Alternatives to Anti-Fungal Cream

I have a patient who cannot reach her feet and therefore cannot apply an anti-fungal cream to treat her tinea pedis. She also is alone and has no-one to assist her. I am wondering if either acetic acid or bleach and water soaks are helpful in treating tinea pedis. If so, does anyone know the correct ratio of either acetic acid or bleach to water.

Norm Wortzman, DPM, North Quincy, MA

Query: Venous Ulcer ICD-9 Code

My doctor has noted that a diagnosis is "venous ulcer." When I looked through the ICD-9 book for a code for venous ulcer, I can't find one. What ICD-9 code would I use?

Vicki Hicks, Office of Daniel Brown, DPM

Response: Skin ulcers, other than decubitus ulcers all are coded in the 707.1x series of ICD-9 codes (see below). The 5th digit is determined by the site of the ulcer.

ICD-9 707.1 Ulcer of lower limbs, except decubitus Ulcer, chronic, of lower limb: neurogenic of lower limb, trophic of lower limb

The fifth digits are:
0 - Unspecified part of lower limb
1 - Thigh
2 - Calf
3 - Ankle
4 - Heel and midfoot, including plantar surface of midfoot
5 - Other part of foot including toes
9 - Other part of lower limb

The ICD-9 instructs to code underlying causal conditions first (i.e., #1 diagnosis) if they exist and are documented:
- Atherosclerosis of the extremities with ulceration (440.23)
- Chronic venous hypertension with ulcer (459.31)
- Chronic venous hypertension with ulcer and inflammation (459.33)
- Diabetes mellitus (250.80-250.83)
- Postphlebitic syndrome with ulcer (459.11)
- Postphlebitic syndrome with ulcer and inflammation (459.13)

Stacey Hernandez, Placentia, CA

Codingline subscription information can be found at
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RE: Differential Diagnosis for Mycotic Nails (Mark Gresser, DPM)
From: Multiple Respondents

Dr. Gresser asks “What should I be considering in the differential, and what treatments have been successful?” due to having received “many” negative PAS stains AND cultures of “mycotic appearing nails.” He does not quantify what “many” means, but if it is 15% or less of the total, he is about right where he should be. Unlike dermatologists, who believe that 50% of dystrophic nails are something other than mycotic, I believe that podiatrists can diagnose onychomycosis with 85% accuracy. My own personal positive laboratory confirmation rate is very high, but my hospital lab encourages the culture growth with various techniques for up to four weeks. This is not typical of commercial labs. I believe Dr. Gresser’s results may improve if deep subungual nail bed skin specimens are sent for examination, as opposed to nail clippings. PAS samples containing subungual skin will also give a better yield.

Bryan C. Markinson, DPM, NY, NY, Bryan.Markinson@msnyuhealth.org

First, before abandoning your initial mycotic toenail suspicion, PAS stains contain some false negatives. The PCR is a confirmatory test when a negative PAS stain exists. If both are negative = no mycosis

Differential diagnosis for onychomycosis includes but is not totally limited to: 1) psoriasis, 2) lichen planus, 3) nail dystrophy (post traumatic, post chemotherapy), 4) thyroid disease and 5) hepatic disease 6) anemia. Check the patient's medical history for underlying systemic/dermatologic disease.

Barry Mullen, DPM, Hackettstown, NJ, YAZY630@aol.com

Perhaps some thought may be given to the possibility of psoriasis. Discussing with the patient any lesions elsewhere on his/her body and any family history may be helpful. In addition appropriate labs, ANA, etc may be beneficial.

Harold Gruber, DPM, Wilmington, DE, halgruber1@aol.com

Consider a nail and nailbed biopsy. Are you biopsying the nail(poor source) or under the nail where there is this white casseous material. Rule out psoriatic nail changes, onychobacteriosis, dystrophic nails from weight-bearing on nail, and nailbed tissue.

Simon Young, DPM, NY, NY, SimonYoung@juno.com

There are many types of nail pathology which cause symptoms that are similar to the symptoms caused by dermatophytes. Drs. Richard Scher and Ralph Daniel wrote a book titled "Nails: Therapy Diagnosis surgery" which has numerous photos of conditions causing discolored, thickened nails which are not caused by fungi.

The obvious question is how to treat a thick, yellow, painful toe nail which is not caused by a dermatophyte.In some cases such as psoriatic nails, Drs. Scher and Daniel advocate intralesional injections of steroid administered every three to four weeks. This may help however many patients may not want these injections and in some cases the treatment may not work. Another option is to use a method that we as podiatrists are well trained to administer - good surgical debridement of the thickened nail with follow up prescriptions of topical applications of keratolytic topical agents. Keralac nail gel is an excellent product. Another product that you can dispense from your office is Nonyx nail gel. Onychol is a citrus based product and we have found that it softens the nails. Some of our patients report great results with these products. What they offer is a cosmetic solution and for most patients that is what they are primarily interested in achieving.

Lastly, just because a microscopic study of a nail specimen comes back negative, there might still be a fungal cause. Some of our colleagues advocate repeating the test several times because the portion of specimen analyzed by the lab may not have had hyphae but other parts of the nail may indeed be infected.

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

RE: Forefoot Pain (Greg Cohen, DPM)
From: Barry Mullen, DPM

Dr. Cohen raises some good points regarding some possibilities. What I would suggest is a careful review of the patient's history. Use of the NLDOCAT formula is an excellent way to help determine which general system the chief complaint lies in. The nature in which the patient describes their pain is one of the most reliable pieces of information assisting in that venture. Ask open-ended questions to allow the patient to describe what they feel, i.e., What does your pain feel like? What aggravates it? Makes it better? When do you get it? Good closed-ended questions (yes/no response) include, do you have to be on your feet to experience the pain? Once you think you have isolated a system, then using the physical exam should confirm your suspicion(s). Ask yourself, based on the history of the chief complaint, if this is what I suspect, then what else should be there in my physical findings? Sounds simplistic...yet works almost universally.

In this case, does the patient describe the pain in neuritic terms (burning, sharp, tingling, electrical, traveling, shooting etc), orthopedic terms (dull ache, post static dyskinesia), rheumatologic (achy, stiff, weather-related, post static dyskinesia etc)? Keep in mind, MRI's contain false negatives. They, like all diagnostic imaging studies, lab tests, electronic diagnostic studies, etc. are merely confirmatory. Clinical impression rules. In MRI's especially, they are only as helpful as the accuracy of the interpretation. Who read the MRI? Did you see them, review them w/ colleagues, obtain another opinion, discuss the findings with the radiologist? Personally, I'd question the validity of a negative read when prior surgery was performed. Regardless of the quality of surgery performed, ask yourself, shouldn't some fibrosis be present in the plantar 3rd interspace?

Barry Mullen, DPM, Hackettstown, NJ, YAZY630@aol.com

Editor's note: This topic is now closed.

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We are looking for a highly trained, personable, ethical, and caring podiatrist, to work in a two doctor, three office practice, of thirty years. Send CV to sfpodiatry@ aol.com

PRACTICE FOR SALE - RIVERSIDE, CA

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Practice grossing over 250K/yr three days/wk. room to expand, large physician referral, good mix of sx., wound care, DME's, routine care. no rest homes. Medicare cert. surgery center on site. Will consider associate-to-purchase. may carry paper. Consider all offers. Office and sx. center also for sale. e-mail tentoes001@hotmail.com or call 951 7804782.

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ASSOCIATE POSITION FLORIDA - NORTHEAST REGION

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Busy, well established, full scope podiatry practice seeking highly motivated, hard-working, reliable, responsible and especially likeable to the average human, Associate. Surgical training a plus. Prefer PSR 24+. This is an Associate position with lots of potential. Team players only. Email CV to: healthparkmgr@bellsouth.net or fax CV to: 904-826-1586, Attn: Amy

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POSITION AVAILABLE - SOUTHEAST TENNESSEE/ NORTH GEORGIA

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Immediate position available or will wait for the right individual. Unique practice opportunity in growing multi-physician/multi-office practice. Well established/cutting edge within the medical community. Close proximity to hospitals as well as opportunity to become involved with a free standing podiatric surgical center. Must be BQ/BC. Minimum PSR/24. Competitive salary, bonus structure and benefits. E-mail CV to afcjen@hotmail.com

OFFICE TO SHARE AND RENT LONG ISLAND & MANHATTAN

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PRACTICE FOR SALE - CENTRAL FLORIDA

Practice, all phases, including wound care and hyperbaric, with excellent building and location in central Florida, in 21st fastest growing county in U.S. Outstanding place to live and work; low penetration by managed care. Excellent exposure, and parking at 2000 sq. ft building near hospital and on busy highway. Great price and opportunity to grow large practice. windnwave@earthlink.net

POSITION AVAILABLE- MIDTOWN MANHATTAN, NY

Immediate position for a part time leading to a full time associate. Long established practice with a mix of surgery, general podiatry and orthopedics as well a hospital affiliated nursing home. Office based OR suite with nitrous and power. Ground level Park ave. entrance with a total of four treatment rooms and a private office. Option to purchase in the next six months likely to become available. Candidate must have PSR/24 with some experience, Interested parties call (201)403-7685, E- Mail CV to ThakerMike@aol.com

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