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July 17, 2007 #2,987 Editor-Barry Block, DPM, JD

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NV Podiatrist Warns Diabetics of Summer Hazards

Podiatrist Cyaandi Dove cautions her diabetic patients about a number of potential hazards during the summer. "One of the things I tell patients, especially here in Las Vegas, is never, never walk barefoot," she said. Nerve damage from diabetes may prevent someone from feeling the heat. "You can actually sustain second and third burns on the bottoms of your feet, which can lead to ulcers and hospitalization and actually foot loss as well," she said.

Dr. Cyaandi Dove

Dr. Dove says flip-flops offer little protection and are not a good idea for diabetics. The more solid sandal is a better choice -- but not all the time. "Foreign bodies can get into the sandal. They can step on things. Insects can have access to their feet and cause problems with bites and things like that. So the sandal... it's not an absolute that they don't wear it. They can wear it for shorter periods of times. And they need to be very vigilant when they do wear it," she said.

Source: Paula Francis, KLAS-TV CBS 8 (NV), [7/11/07]

WY Podiatrist and Daughter Stand Toe-to-Toe on Career Choice

From the beginning, Dr. Craig Capron’s daughter Charlotte appeared destined to follow in her father’s footsteps. By 8 years old, she was assisting Capron with ingrown toenail surgeries. “I just thought it was natural,” Charlotte Capron said.

Dr. Craig Capron and daughter Charlotte photo by Nathan Payne

Capron’s foot-ministering, troubadour-travels led the family to three different towns in the last five years, according to Charlotte. Even so, for the Mormon family, togetherness was always paramount. Charlotte was home-schooled until she was 15, along with her other siblings.

Charlotte, now 18 years old, is in the middle of her sophomore year at Gillette College and will graduate at the end of this fall semester with an associate’s degree in science. She’s in the middle of the application process at Brigham Young University and still thinks she’ll probably become a podiatrist, perhaps even joining a practice with Capron.

Source: Brantley Hargrove, News-Record [7/15/07]

This past June, Dr. Richard Feldman of West Haven, CT presented an abstract and poster at the American Diabetes Association Scientific Sessions in Chicago, IL. The study, titled “Improving the Quality of Diabetes Care in the Outpatient Setting” was a collaborative effort involving a team, including a physician, podiatrist, nurse practitioner, nutritionist and pharmacist. The goal of the study was to redesign the system of diabetes care in the Yale-New Haven Hospital (YNHH) Adult Primary Care Center (PCC) in order to improve control of patients’ hemoglobin A1c, lipids, blood pressure, and to ensure appropriate preventive management of complications associated with diabetes.

Dr. Feldman and Poster Presentation at ADA Meeting

A group of subjects, identified as “high risk,” were encouraged to attend a session of the Diabetic Comprehensive Clinic. Held bimonthly in the PCC, the multidisciplinary team implemented a comprehensive initiative utilizing information services (electronic medical record), patient education and clinical care to improve health status.

All measures in the initiative improved substantially. Hemoglobin A1c, blood pressure, urine protein and lipid profile all showed statistically significant improvement, exceeding national benchmarks. This study indicated that improvement in outpatient quality of care efforts can be feasible, sustainable, and implemented with minimal incremental cost.

RE: Chemotherapy as a Possible Cause of Toenail Deformity? ( Evan F. Meltzer, DPM)
From: Multiple Respondents

Chemotherapy creates many varied and sundry changes to nails. After all, hair falls out, skin often changes, and very frequently nails either fall out, discolor, or become deformed as a result of Chemo. After therapy stops there is, often, a renewed normal growth of nails.

Barry A. Wertheimer, DPM, Torrance, CA, bwertheimer@cox.net

Toenail dystrophy is a common side-effect of chemotherapy. I have observed this on several occasions. If painful, keratolytics like a Keralac nail stick with periodic debridement may be helpful in reducing toenail girth and discomfort. Depending on where the patient is in their chemotherapy course and how their body has tolerated it, you may also want to consider ordering a PAS stain for the chemotherapy's immune system compromise can potentiate formation of secondary opportunistic infections, like onychomycosis. If the patient has completed their chemotherapy course and the test is +, they may become a candidate for systemic fungicide therapy. In cases like this, however, I'd recommend conferring with their oncologist prior to treatment initiation.

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

Docetaxel, known by the brand name Taxotere, is the most common breast
cancer agent associated with nail changes in my experience. In addition to liver toxicity, decreased platelet and RBC counts, swelling of the hands and feet, and hair loss, nail issues are common problem. The most common issues are onycholysis and brittleness, color chages, and spontaneous avulsion (complete lysis). These may or may not be painful. The typical patient I see is referred after the second or third cycle of treatment. They usually present with multiple nails involved and always bilaterally. The nails are lysed, with evidence of episodic bleeding. There is also a "coagulum" of material under the nail plate which probably includes serum, blood, stratum corneum, and probably some bacteria. It can be amber colored or have a green to gray tinge.

It is common for non-specialists to rush to a diagnosis of fungal infection, which I believe is NOT common in these patients. Thickening, if present, would be an unlikely effect of the chemo as Docetaxel is an antimitotic agent. Treatment is supportive only, with removal of all lysed portions of nail and appropriate hygienic measures and footwear advice. I have not seen a case yet where these changes were not accompanied by hair loss, which you may not be aware of if the patient wears a quality hair replacement. Although these toenail complications are not very serious, they are very visible and potent reminders to the patient of the battle in which they are engaged(many of my patients cry when they learn that the nail problems are complications of the chemotherapy), and a bit of
emotional hand-holding may be the most important thing you can do.

Bryan C. Markinson, DPM, NY, NY, bryan.markinson@mountsinai.org

RE: Complex Regional Pain Syndrome (Jim Clark, DPM)
From: Larry H. Woodcox, DPM, Jay Goldstein, DPM

If you feel you’re dealing with RCPS (RSD) you need to refer the patient ASAP for a diagnostic lumbar sympathetic block (LSB)by your local pain specialist.. If the LSB is helpful, then the pt will need a series of LSB s. You can control the pain management yourself if you are comfortable with doing so. Most often narcotics are essential. One can also add an antidepressant, such as Effexor, which is very helpful for chronic pain and can even reduce the dose of narcotic. I like to add Lyrica for the pain management as well. With Chronic pain coupled with the use of narcotics this pt. will become depressed. This will need to be addressed sooner than later by a psychiatrist. You need to continue with aggressive PT Rehab .If you are starting to have color and temp changes, a limited bone scan can be ordered, and if positive, can aid in the diagnosis or at least point you in some direction if not obvious .However a negative bone scan does not rule out RSD (RCPS) .

If you are not comfortable with this treatment, then refer the patient to one of your colleagues with experience in treating this condition. This condition can get ugly and the patient can blame you . Therefore, do not lose control of this patient. My concern was that I often see my follow podiatrist refer problems patients to a pain specialist and/or an orthopedist ,never to hear from the patient again

Larry H. Woodcox DPM, DC, Oakland, CA, podsurgchi@aol.com

A note by Jay Goldstein, DPM appears at: http://www.podiatrym.com/letters2.cfm?id=14862&start=1

Editor’s Note: This topic is now closed.

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