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July 21, 2008 #3,303 Editor-Barry Block, DPM, JD

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Marathon Runners Need at Least 2 Years of Training: IL Podiatrist

The weather is warm and the race is on to get in shape for one of the many charity runs or marathons in your area. But if you haven't been training on a regular basis, you've got to walk before you can run, say the experts. "The attrition rate is fantastic because people go out too fast and get injured. Once people get injured, they drop out," says Stephen Weinberg, Doctor of Podiatric Medicine (D.P.M.) at Evanston Northwestern Healthcare, Evanston, IL.

Dr. Stephen Weinberg

In fact, you should be running at least two years before you tackle a marathon (26.2 miles), says Dr. Weinberg, who is a marathon runner and has served as medical director for the Chicago Marathon. Dr. Weinberg's advice is to take a brisk 15- to 20-minute walk on a regular basis."From an injury prevention standpoint, you have to start loading your muscular-skeletal system. You want to build up gradually for stress," he says.

Once you're comfortable, add jogging to the routine, taking a mile in 10 to 15 minutes. "Take the talk test. Start jogging. If you're breathing so heavily you can't carry on a conversation you're running too fast," says Dr. Weinberg. As an alternative, begin with run/walk exercise. Time yourself to run for three minutes and walk for one.

Source: Bev Bennett, Philly.com [7/18/08]

OH Podiatrist Selected as Physician Trustee at Parma Hospital

The Parma Community General Hospital Board of Trustees recently welcomed several new members.

Dr. Salvatore Sidoti

Salvatore Sidoti, a podiatrist who has been a member of Parma Hospital's medical staff for 18 years, was selected as one of two physician trustees on the board. Dr. Sidoti, who is board-certified by the American Board of Podiatric Surgery, has had a private medical practice in Parma since 1991.

Source: Sun Courier [7/17/08]

CMS to Allow Alternatives To Tamper-Proof Paper

A looming debacle appears to have been averted involving a Medicaid mandate requiring the use of tamper-proof paper in printing prescriptions with electronic prescribing systems. The CMS has accepted recommendations that soon should be released by the National Council for Prescription Drug Programs to create anti-fraud measures using computerized printing technology deployable in electronic health-record systems and standalone e-prescribing tools as a substitute for expensive tamper-proof paper, which the CMS originally stipulated.

The mandate, set to go into effect Oct. 1, now has an alternative. At least two print technologies have been deemed acceptable by the CMS, he said. One of them involves a patented process from Toronto-based AdlerTech International. The other security technology is called micro printing, which uses a strip of tiny type that appears to be smeared when photocopied by most copying machines.

Source: Joseph Conn, Modern Healthcare [7/18/08]

A Novel Way to Check Job References

Gain insight from job candidate references when you ask this question:

“If the applicant were to fail in this job, what would be the reason?”

You are likely to get an unguarded opinion in response to this non-standard question.

Source: Recruit Your Way to The Top! By John Boe

Query: Dictation Software

I am considering Dragon Naturally Speaking Software and am looking for recommendations for or against it.. Any other dictation recommendations? If you do use Dragon, which software package do you use?

Joshua Prero, DPM, Rockville Centre, NY

RE: To Biopsy or Not? (Larry Aronberg, DPM)
From: Multiple Respondents

As a generic rule of thumb, when in doubt, it's prudent to biopsy cutaneous lesions that suddenly change size, shape, color, border irregularity, bleed, ulcerate, etc. The key word here is suddenly. In this setting, you mentioned a slow, progressive course. Based on the photo and that info alone, my first clinical impression is psoriasis (classic toenail changes) with an excoriated psoriatic plaque. Ask if he scratched it recently, hence the increase in size (Koebner phenomonenon). Check other cutaneous extensor surfaces on his body. Re-question about any dandruff history, and family history of autoimmune skin disorders. Lichen planus is a solid 2nd choice differential; tinea pedis a distant 3rd.

Consider performing a PAS on the toenails because skin and nail changes are likely from the same etiology. If negative for tinea, as I suspect it would be, see if the toenail's histopathology is consistent with an autoimmune skin disorder. If so, then I believe you've corroborated that suspicion. In that setting, empirically, I'd likely try a moderate-strength steroid ointment and monitor how the lesion responds before skin biopsy, because the more psoriasis is irritated, the worse it becomes (again, Koebner phenomenon)

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

Yes. Who cares what the dermatologist thinks? He doesn't know what it is, you don't know what it is - no one knows what it is. A biopsy is one of the simpler, low risk procedures we do that pays well. Even better, everyone will know what it is and can sleep well that night. Perform two 2 mm. biopsies or a shave biopsy, whatever you're comfortable with, and send it in. Use a dermatopathologist ALWAYS, and not a general path lab. No sutures are needed and I've never had one not heal. In the last three years our lab has diagnosed two malignant melanomas. You have nothing to lose other than a law suit or a patient's life by not biopsying.

I must disclose that I am a trustee with the American Academy of Podiatric Practice Management. I say this only because I don't know offhand, any other seminar you can attend to learn hands on biopsy techniques and see one of the most eye opening lectures on dermatopathology by one of the greats, Bradley Bakotic, DPM, DO. It will change the way you practice.

Jon Purdy, DPM, New Iberia, LA, podiatrist@mindspring.com

This posting reflects the unfortunate state of a portion of our profession that refuses to cross the line when it comes to making biopsies, skin shaves and nail samples second nature when it comes to skin and nail disorders. Some of our own like Brad Bakotic and Bryan Markinson have spent endless energy and resources extending a forum for teaching these simple, effective and gold standard diagnostic tests.

When faced with a wound with an ulcerated, pus filled base, 95% of us or more take a culture and sensitivity. I wonder what percentage biopsies a non-responsive rash, skin growth, or toenail dystrophy routinely. This current rash should be accompanied by a photomicrograph of the biopsy and a diagnostic report. When in doubt not after trying 3-6 weeks of "rule outs", I biopsy the lesion. If your answer to the question How many 11100's or 11755's did I bill last year is not hundreds, I suggest investing time, energy and money elevating yourself by adding this important diagnostic acumen to your armamentarium.

Dennis Shavelson, DPM, New York, NY, drotc@aol.com

RE: Post-op Pitting Edema (Nicholas Taweel, DPM, PT, DPM)
From: Barry Mullen, DPM

I completely agree with Dr. Taweel. Obtain a stat venous duplex scan to rule out DVT. Pitting edema within the first 2 post-op days above and beyond one's usual post-op presentation should be considered a DVT until proven otherwise.

In hindsight, review this particular patient's DVT risk factors to see how many were present pre and peri-operatively (e.g., obesity, smoking, BCP's, past personal and family hx, polycythemia, thigh tourniquet use, etc) so that your future surgical candidates with similar risk factors might be DVT prophyllaxed pre-op. Is there any history of post-op trauma?

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

RE: Viagra as a Vasodilator?

Recently an 81 year old male presented to the office for his normal nail care. This time he did not want his wife to come back with him, even though in the past he can be confused. I entered the room, smiled and asked him, "how are you doing?" He looked at me with a very serious face and said, "I am out of Viagra." Not wanting to embarrass him for forgetting maybe which doctor's office he was at, I looked at him and said, "Well, we better leave that to Dr. Nickel, your PCP. I could get in trouble for prescribing that as there isn't much of an indication for its use in the foot." Without missing a beat, he looked at me and said, "doesn't it increase your circulation?"

Patrick J. Nunan, DPM, West Chester, OH

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