The Voice of Podiatrists

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December 04, 2006 #2,755 Editor-Barry Block, DPM, JD

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Schofield Supports NY Hospital Merger

The Berger Commission -- created last year by state lawmakers to revamp the state's healthcare system -- was looking to eliminate such service duplications when it recommended the two Elmira hospitals resume discussions about joining forces. And many local physicians, both active and retired, stand behind the commission's proposal.

Dr. David Schofield, a podiatrist who retired from clinical practice in 1992 and is now the executive director of the Chemung County Medical Society, took part in the original St. Joseph's-Arnot Ogden merger talks about 20 years ago.

Dr. David Schofield, APMA President

The goals of the two institutions were not closely enough aligned then to complete the merger, he said. Both had good intentions, Schofield said, but the boards of directors didn't let it happen. "But from a physician's leadership position, it's clear to me that without some kind of working relationship between the two hospitals, we waste resources on the medical arms race that results in an inefficient use of resources," Schofield said. "Competition in making television sets makes sense, but sometimes in healthcare, direct competition for the same patients and services is not good. You can control costs other ways," he said.

Source: G. Jeffrey Aaron, Star-Gazette (Elmira, NY) [11/30/06]

Gerard Yu, DPM Receives APMSA’s Kenison Award Posthumorously

The American Podiatric Medical Students’ Association (APMSA) 2006 Kenison Award was awarded posthumously to Gerard Yu, DPM (1954-2005) on behalf of the APMSA by John Steinberg, DPM, assistant professor, department of plastic surgery at Georgetown University, Washington, D.C. during a recent Podiatry Institute Seminar honoring the life and accomplishments of Dr. Yu.

The APMSA Kenison Award, named for Nehemiah Kenison, a visionary and leader in the profession of chiropody in the mid 1800’s, recognizes individuals who have made outstanding efforts and contributions to podiatric medical students and the profession.

John Steinberg, DPM, (right) presents the APMSA 2006 Kenison Award to Dr. Yu's wife Barbara and son Jason.

Dr. Steinberg, a friend and colleague of Dr. Yu’s, presented the award to Dr. Yu’s wife, Barbara, in a moving presentation to a crowded lecture room of Dr. Yu’s friends and colleagues. Also in attendance were Dr. Yu’s five children, his parents and siblings, and many nieces and nephews.

APMSA president Timothy Mineo extended his appreciation. “Dr. Yu is remembered by the APMSA and students for his integrity and dedication and for his countless contributions and lasting impressions, most specifically for serving as a role model and inspiring and teaching podiatric medical students.”

GAO Recommends Lowering Payments to ASCs

The Government Accountability Office recommended that Medicare go forward with a plan to pay ambulatory surgery centers based on the hospital outpatient prospective payment system. The GAO said ambulatory surgery centers (ACS) perform procedures similar to those done at hospital outpatient departments but at a lower cost. Using one type of analysis, the GAO estimated ambulatory surgery centers’ costs at about 84% of hospital outpatient department costs. Another source of data resulted in a cost ratio of about 40%.

The CMS, meanwhile, has proposed setting payments for ambulatory surgery centers at 62% of the outpatient rate. The American Association of Ambulatory Surgery Centers said the lower GAO estimate was flawed and urged the CMS to use the higher estimate in setting payments. The move to the same basic payment system for ambulatory surgery centers and outpatient departments is part of a congressionally mandated effort to streamline Medicare.

Source: Jennifer Lubell, Modern Healthcare [12/1/06]

Query: “Floating” Toe Post-op Osteotomy

I have been doing Weil osteotomies for a while with good results. On occasion the procedure results in a "floating" toe. Any suggestions on preventing this and also a good procedure for correcting it when it happens.

F. Don Chantiles, DPM, York, PA, Jis4Fun@aol.com

RE: A Picture is Worth 1,000 Words (Kevin Kirby, DPM)
From: Elliot Udell, DPM, Dennis Shavelson, DPM

Only a podiatrist could look at those narrow, pointed shoes and be so frustrated with why the patient is not taking better care of her feet. I can liken it to my dentist getting frustrated when I come for an oral exam and he finds evidence that I did not brush my teeth as well as he would like. Those pictures are worse. Showing those shoes to a podiatrist is akin to my coming into the dentists office chewing bubble gum and wondering why a filing came loose.

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

Is there a woman who doesn't currently have her version of these dissimilar shoes in her closet? The podiatric view on this subject remains that "high heels are no good and should be avoided." The critical problem with many high fashion shoes is not heel height; it is width, length and girth of the toe box. In fact, the functional equinus that accompanies the rigid rearfoot functional foot types (TM) has a longer stride and healthier mechanics after a TAL or when in a 1.5"+ heel. These feet have exaggerated Achilles tendonitis, plantar fascitis and forefoot breakdown syndromes in flat shoes!

DPM's should advise shoe variety, so that the feet and posture can compensate for the extreme polarity of footgear that society demands. We should educate that if a patient has problems with higher heels, they should select shoes with greater girth in the forefoot, and we should put pressure on shoe manufacturers to produce shoes that offer this advantage. We should stress the fact that when fit into high style shoes, properly cast and prescribed, custom foot orthotics that shorten feet and make them more narrow reduce high heeled sequelae. We should inform the public that we perform elective surgery that can alter the structure of feet internally making them better equipped to win the battle of high heeled life. Finally, we should be seeking a paradigm change in biomechanics that exists outside of the Root box because we spend more of our time standing still, moving side to side, moving backwards, and moving up and down then we spend going from point A to point B (gait) and therefore, subtalar joint neutral evaluation, casting, and rearfoot control fail to maximize what we can do for our patients biomechanically.

Dennis Shavelson, DPM, Medical Director, The FootHelpers Lab
drsha@footworldusa.com

RE: Tinea Versicolor
From: Philip Larkins, DPM

I recently placed a response regarding effective treatment being selenium sulfide 2.5% applied qd for at least one week. Readers who think that oral Lamisil is the best for everything fungal on the skin, should read on. This pesky infection tinea versicolor, sometimes called creeping infection or sun spots, and often mistaken for tinea pedis. This fungal infection of the skin is caused by the organism Malassezia furfur. It is estimated to colonize over 90% of the population. This organism only occupies the most superficial or "dead layer" of the skin, the most superficial stratum corneum, not the epidermis, hair or nail structures.

This being the case, oral Lamisil taken for this particular problem must transit to this layer of skin infection over the course of a normal skin growth 28-day average growth cycle. This could take almost a month before clinical clearing could be anticipated to be seen by only using oral Lamisil for tinea versicolor.

For further reference as to why oral Lamisil would not be a good choice for tinea versicolor go to the following link, http://www.doctorfungus.org/mycoses/human/other/Pityriasis_versicolor.htm , which will show that the fugicidal levels of oral terbinafine would most likely be too high for the patient to safely handle in order for the medicine to have an effect on the stratum corneum. Also, the most recent PDR makes no reference as to Malassezia furfur or Tinea Versicolor in the oral terbinafine facts section.

Finally, pay attention to whether the drug was actually tested against M. furfur. For instance, oxiconazole cream and lotion is efficacious treatment, as would appear to be topical terbinafine (depending on which reference you peruse), but naftifine hydrochloride does not list the drug as being efficacious against M. furfur. It is important to ascertain whether the problem you are treating is tinea pedis or tinea versicolor, as this would possibly change your topical therapies.

Philip Larkins, DPM, San Marcos, CA, larko33139@yahoo.com

RE: Non-Healing Stress Fracture (Jay C. Goldstein, DPM)
From: Kathleen J. Richards, DPM

Dr. Goldstein didn't say if he have tried these yet; CAM walker or fiberglass cast immobilization, bone growth stimulator, and increase calcium intake. I have had excellent results in the past using EBI's stimulator.

Kathleen J. Richards, DPM, Scottsdale, AZ, sallyclub@excite.com

Editor’s note: This response was incorrectly placed in the last issue of PM News. Our apologies to Dr. Richards.

RE: Closing 1st MP Pressure Ulcers (Robert Teitelbaum, DPM)
From: Pam Haig, C. Ped.

I recommend a severe-angle rocker sole. You may need to make an excavation in the shoe that leads completely through the sole of the severe angle rocker. I had a similar situation with a CMT non-diabetic, non-healing ulcer and this worked beautifully. The Tekscan inshoe pressure system showed no pressure with the patient's orthoses, but we couldn't heal fully heal it until we did the above recommendation. The severe-angle rocker need to be at an inclination angle of about two inches from the proximal MPJ's/parabolic curve and thinning down to the zero material at the distal end of the shoe.

Pam Haig, C. Ped. Elwood, IN, rmpinst@aol.com

Editor’s note: This topic now closed.

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