The Voice of Podiatrists

Serving Over 9,500 Podiatrists Daily

August 23, 2007 #3,021 Editor-Barry Block, DPM, JD

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Amputations For Severe Diabetics Not a Foregone Conclusion: IA Podiatrist

Des Moines-area podiatrists are taking increasingly aggressive measures to save the feet of severe diabetics, who can face amputation if the disease leads to deadly infections. Dean Taylor of Des Moines knows the risk. He was diagnosed with diabetes in 1993, and he has little feeling in his feet. He has repeatedly cracked foot bones and continued to walk on them, creating more damage. The latest incident came in July, when he felt a pop in his left foot. Taylor, 51, went to Broadlawns Medical Center, where he met Dr. Lee Rogers, a podiatrist who is helping establish what the hospital calls an "amputation prevention center." He explains to patients that diabetes causes a chain of events that can lead to amputations.

Dr. Lee Rogers (Bill Neibergall/The Register)

He stresses that the chain offers multiple ways to head off the tragic result. "It's not a foregone conclusion that if you have diabetes, you'll wind up with an amputation," he said. Rogers explained that healthy people unconsciously adjust their gait whenever an area of their feet becomes a little tender. Those adjustments shift weight to other parts of the foot, allowing the irritated area to heal. But diabetics can lose this natural defense mechanism as they lose feeling.

Rogers and his colleagues are using new devices, including surgical instruments that help remove dead tissue while preserving healthy tissue. He also touts an electronic, hand-held thermometer, which he asks patients to use daily on their feet. The instrument detects temperature spikes, which can pinpoint injured areas the patients can't feel. Rogers operated on Taylor, making incisions in the Achilles tendon above the heel, allowing the tendon to stretch. That should help Taylor walk more normally and prevent injuries. When he heals from the surgery, he expects to have the same procedure done on his other leg.

Source: Tony Leys, Des Moines Register, [8/22/07]

NYCPM Honors Three at International Academic Convocation

The New York College of Podiatric Medicine (NYCPM) today conferred honorary degrees on three international practitioners who have helped foster podiatry in Canada and Spain.

Drs. Francos Allart , Ricardo Becerro de Bengoa, Marta Losa Iglesias

Francois Allart, DPM, a 1993 NYCPM graduate, was instrumental (along with the late Bruce Frankel, DPM) in founding the first DPM program in Canada (at Quebec’s Trois-Rivieres University). He has served as president of the Quebec Order of Podiatric Medicine.

Ricardo Becerro de Bengoa, DPM, PhD, a 1995 graduate of NYCPM is the only podologist in Europe to have earned the DPM degree. He is a professor at the Univerdidad Complutense, an institution which collaborates to offer NYCPM courses and training to Spanish and other European professionals.

Marta Losa Iglesias, RN, PhD is a professor in the Faculty of Health Sciences at the Rey Juan Carlos Public University in Madrid. In 1992, she completed a one-month clinical program under the tutelage of the late Anthony Hernandez, DPM.

Markers Shown to Identify Diabetes in Still-Healthy People

In the first large scale, multi-ethnic study of its kind, researchers at UCLA have confirmed the role played by three particular molecules known as cytokines as a cause of type-2 diabetes, and further, have identified these molecules as early biological markers that may be used to more accurately predict future incidences of diabetes among apparently healthy individuals.

Simin Liu, professor of epidemiology and medicine and colleagues have identified three inflammatory cytokines (cytokines are messenger molecules) tumor necrosis factor-alpha (TNF-alpha); interleukin-6 (IL-6); and high-sensitivity C-reactive protein (hs-CRP) that may be one of the causes of type 2 diabetes which afflicts roughly seven percent of the U.S. population.

A blood test that looks for high levels of inflammatory cytokines could serve as an accurate predictor of diabetes in still-healthy people, years ahead of the traditional risk factors of obesity or insulin resistance. The finding also has implication for cancer research as well, said Liu, since people with diabetes are at greater risk of developing breast and colon cancers.

Source: Archives of Internal Medicine via Diabetes in Control [ August 15, 2007]

Query: Stirrup Foot Pain

I have a 70 yo male who is diabetic in good control. At least twice per year, he goes out West and is on a horse for 6-7 hours a day. After about an hour of riding, the area around the 5th metatarsal head gets very sore. There is little to no swelling noted, and only a very small callus sub 5th metatarsal. There is no redness or any unusual signs, even when it hurts. This condition started on the right foot and is now affecting the left. The only relief he gets is taking his foot out of the stirrup for a few minutes. When he steps back into it, within a matter of moments, the pain returns. He has tried different shoes, inserts, and padding with no help. He has good sensation in both feet, and he denies any obvious back pain. The stirrups are wide and they don’t cut in. Any advice would be appreciated.

Doug Mason, DPM, Freeport, IL

RE: Billing For E-mail Consultations
From: Lloyd S. Smith, DPM

CPT and RUC have established new E/M type visits that are totally done over the telephone or via email. Values have been established for these codes. I believe they will show up in CPT 2008. Whether or not an insurer will pay for these services is another story. I suspect most insurers will eventually pay. Documentation will need to be detailed to justify the codes billed.

Lloyd S. Smith, DPM, Newton, MA, E: lloydpod@yahoo.com

RE: Wired Network Vs. Wireless Tablet PCs (Mark K. Johnson DPM)
From: Multiple Respondents

Some Pros and Cons for Wired and Wireless networks:
Wired: Cheaper, Extremely Reliable, Superior Performance (Faster), Secure, installation is cumbersome (you will need to install wiring from every room to the central HUB).

Wireless: Expensive (~3-4X the cost of wired), Reliability problems (since newer technology, may interfere with office equipment and vice versa), Comparatively slower, Less secure, installation is a breeze (You may encounter problems with Windows in configuring you WiFi adapters).

Best solution would be a mix of the two, it would be best to get a wireless router and a HUB, this will allow your tablet PC to be wireless and also have wired connections in each room as a backup in case of Wifi troubles. ALWAYS encrypt your wireless connection!

Omair Zafar, DPM, Chicago, IL, omair.zafar@gmail.com

I recently moved and built a new office in "raw" space. I consulted with a few computer consultants and we all agreed to run wires for a wired network. It was felt to be more reliable. In addition to computerized notes, we have digital x-rays and patients love to see their x-rays on the computer screen. I have found that a 19 inch Samsung monitor gives excellent clarity, carrying a 19 inch tablet PC from room to room can be cumbersome. It is also much easier for you and the patient to sit and look at a monitor than hold a tablet so that both of you can see it. I can magnify and annotate the x-ray as I talk to the patient and look at the image. It would be difficult for work on the program and have the patient look at the same time unless you can type upside down. In addition, we usually have 2 or 3 doctors working at a time and the cost of PC's is much less than tablets.

Kenneth Meisler, DPM, New York, NY, Kenmeisler@aol.com

I have both. I use the desktops in each room and have the option of carrying around my wireless devices if I want. This gives you full flexibility and minimal added cost. You may find that walking around with a device gets cumbersome even if small. And yes, you must have a server. Don't let anyone tell you otherwise. This is much more secure and your data integrity is much greater. It’s easier to do backups, and the key to networking. It’s worth the money. As far as EMR systems, I've checked many and found Medinotes to be less intuitive and extremely time consuming even after time. I like TexTalk MD with voice. It’s an amazing product. Spend the money up-front and get a solid network, you will be much happier.

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

RE: Danger of Bone Biopsy? (David B. Williams, DPM)
From: Randall Brower, DPM

This is a great question with no clear answer in my opinion. Literature suggests taking a biopsy from a skin site outside the wound. However, any puncture you make in the cortex regardless of the site could potentially seed an osteomyelitis. I recommend that you FIRST get a Tech-labeled (or gadolinium) white blood cell scan. It is much more specific and sensitive than a 3-phase bone scan or x-ray. If the WBC scan is positive, you have medical-legal recourse if in fact you later decide to biopsy the bone intra-operatively and seed an osteomyelitis.

Randall Brower, DPM, Roswell, NM, randoman33@yahoo.com

There is a definite possibility that by cutting through an infected area into bone, you could extend the infection. It is possible but not definite. So why extend the incision from infected soft tissue nto underlying bone if the infection is fairly new? Why not treat the infection with appropriate antibiotics and local forms of treatment? is the question rooted in a point of view that Osteo should always be treated surgically and hence the faster you know the faster you take the patient to the OR?

There are two different ways of treating osteomyelitis and both methods have the support of the some of the worlds most esteemed vascular and wound care specialists. One approach advocates for antibiotic therapy for six to eight weeks and local care. The other calls for early surgical intervention. The "don't cut" antibiotic approach is dominant in Europe where there is no premium on surgery. The surgical approach is dominant but not exclusive among US doctors. I lean toward the more conservative, antibiotic only approach and over the past quarter of a century of practice, my patients with bone infections have done well. I do,,however, respect the opinions of colleagues who adhere to the surgical approach.

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

Editor’s note: This topic is now closed.

ASSOCIATE POSITION – LOUISVILLE, KY

Immediate opening for multi-office podiatric practice specializing in general podiatry, high volume orthotics, surgery, and advanced wound care. Looking for a motivated, surgically trained podiatrist. Partnership opportunity. Competitive starting salary, benefits, and pension. Please submit: CV, letter of intent and references to: jbroyles23@yahoo.com

ASSOCIATE POSITION – CENTRAL VIRGINIA

Two office practice, fully automated, strong referral base, hospital and surgery center privileges. Full scope of foot and ankle care. ABPS –certified/eligible. Competitive salary/percentage structure and benefits. Email letter of intent and curriculum vitae to jdisabato@virginiafootandankle.net

ASSOCIATE WANTED – NEW YORK IMMEDIATE OPENING

Busy multi-dimensional practice; 70 miles north of New York City. Currently five (5)-doctor practice. looking to expand – all phases of podiatric medicine. contact: (845) 454-8308 EXT: 106

IN-NETWORK ASSOCIATE POSITION – BROOKLYN, NY

Seeking In-Network podiatric physician in downtown Brooklyn, NY. Part-time and or full-time with flexible hours and all aspects of podiatry, including surgery in a modern office setting with EMR, Sonography, and Digital X rays. Please email resume, including list of participating plans to jr11231@yahoo.com

PODIATRISTS NEEDED - CHICAGO --NORTHWEST INDIANA

Home Physicians, a medical group specializing in house calls is looking to hire podiatrists. We are located in Chicago and Northwest Indiana. Full and part time positions are available. Competitive Compensation including malpractice. Contact Scott Schneider. Phone-773-292-4800. Fax 773-342-4201 -E-Mail sschneider@homephysicians.com -- www.homephysicians.com

MANHATTAN, NY GENERAL PRACTICE FOR SALE

Great Midtown East location near Grand Central Station. 614-918-3000 or email sell_my_practice@yahoo.com"

SIERRA VISTA, ARIZONA PRACTICE FOR SALE

Doctor retiring and willing to stay for long transition to assure the new doctor does very well. Call American Doctor Sales 614-918-3000 or email sell_my_practice@yahoo.com

PORTLAND, OREGON 2-PRACTICE LOCATION FOR SALE

Doctor retiring soon and leaving country. This opportunity is 70 miles east of Portland with little to no competition! Check out gorge.net for the area. Call American Doctor Sales 614-918-3000 or email sell_my_practice@yahoo.com

ASSOCIATE POSITION- NORTH LOS ANGELES COUNTY

Full scope of podiatry. Requires usual skills in surgery, medicine and biomechanics. Must be self-starter and highly motivated. Two full days per week. May soon increase to three days per week. All billing and administrative aspects handled by staff. Can practice autonomously. footguy1@pacbell.net

Staff Privileges at Certified Surgical Facility Available- NY & LI

Certified operating rooms which qualify under the new NY Patient Protection Law (which will require accreditation for in-office procedures) are available in Manhattan East 60th Street and Plainview, LI. Staff privileges still available. Space for rent, turn-key operation no investment available.Call 516 433-4447 for information or e-mail podo2345@aol.com

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