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06/29/2020    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: “COVID Toe” Lesions are Probably Not Caused by the SARS-CoV-2 Infection


From: Leonard A. Levy, DPM, MPH


 


“COVID toe” lesions are not caused by the SARS-CoV-2 infection but by quarantine conditions, reports Dermatology Daily (June 26, 2020), a newsletter of the American Academy of Dermatology. It also indicates that Spanish researchers found that none of the patients affected by the condition tested positive for the virus, and the researchers suggested that the lesions were instead caused by people “walking around barefoot at home” for weeks while under lockdown. A Belgian study reached a similar conclusion, adding that the condition appeared to be most common in younger children.


 


Leonard A. Levy, DPM, MPH, Ft. Lauderdale, FL

Other messages in this thread:


07/09/2020    

RESPONSES/COMMENTS (RELEVANT RESEARCH)



From: Gary Dorfman, DPM


 


I have three words to say on the subject: Communication! Communication! Communication!


 


Gary Dorfman, DPM, Dana Point, CA

07/02/2020    

RESPONSES/COMMENTS (RELEVANT RESEARCH)



From: Leonard A. Levy, DPM, MPH


 


I am glad and extend thanks to Dennis Shavelson, DPM for his comment on my post regarding the alleged cause of "COVID-Toe." My comment simply brought attention to this condition. Hopefully, members of the podiatric medical profession will assess the conclusion presented by the American Academy of Dermatology, supporting or challenging the results of their studies. I think that especially in today's climate, such a study would be a major contribution to information constantly being reported on the pandemic.


 


Leonard A. Levy, DPM, MPH, Ft. Lauderdale, FL

07/01/2020    

RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 2


RE: COVID Toe” Lesions are Probably Not Caused by the SARS-CoV-2 Infection (Leonard Levy, DPM, MPH)                                                                                               From: Dennis Shavelson, DPM



Dr. Levy is a podiatric icon. He guided us as a dean of an allopathic medicine university for decades. He reports on the findings from an American Academy of Dermatology (AAD) Newsletter allowing him to conclude that “Covid Toe lesions are caused by people walking around barefoot at home for weeks while under lockdown” and not the virus. He cites two references that reject his conclusions. The “Spanish researchers” article states “All patients were included who had an eruption of recent onset and presenting with compatible symptoms or confirmed COVID-19 with laboratory confirmation of SARS-CoV-2, irrespective of clinical signs and symptoms.” The Belgian Study states “Limitations of this study include a small sample size and a population that may not be representative. There was also no control group and no long-term follow-up.”


 


A recent Journal of the European Academy of Dermatology and Venereology (JEADV) systematic review concluded that “Our review systematically presented the clinical characteristics of 507 patients and showed that skin might be the potential target of the infection according to ACE2 expression. I sit on the advisory board of “The COVID-19 Foot Registry”, composed mainly of DPMs. We are archiving the signs, symptoms, and treatments of Covid Toes cases anonymously, adding to the data of the AAD Covid Toes Dermatology Registry. I have dozens of cases that relate endovascular complications of COVID-19 to the feet and toes, suggesting that Dr. Levy’s post is a potential red herring.


 


Dennis Shavelson, DPM, NY, NY

07/01/2020    

RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1


RE: Terbinafine May be More Effective than Fluconazole and Itraconazole in Treatment of Dermatophyte Toenail Onychomycosis


From: Leonard A. Levy, DPM, MPH


 


A report in the Dermatology Advisor presented at the American Academy of Dermatology’s Virtual Meeting Experience 2020 (June 26, 2020) indicated that terbinafine may be more effective than fluconazole and itraconazole in the treatment of dermatophyte toenail onychomycosis. But all regimens appear to be safe and effective when administered for up to three to 12 months. This was the conclusion of investigators after a 4,205-patient systematic review and analysis.


 


Leonard A. Levy, DPM, MPH, Ft. Lauderdale, FL

06/22/2020    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: Older Age, Diabetes Prolong Toenail Onychomycosis Cure


From: Leonard A. Levy, DPM, MPH


 


A 10-year retrospective study presented June 17, 2020 at the American Academy of Dermatology virtual meeting, concluded that older patients and patients with diabetes had a longer duration to cure onychomycosis, “The incidence of onychomycosis is more frequent in the elderly, and the majority of cases are toenail onychomycosis,” indicated Sumanas Bunyaratavej, MD, and colleagues, Department of Dermatology, Faculty of Medicine, Siriraj Hospital at Mahidol University, Thailand.


 


They reported, “This condition tends to have more co-morbidities, which could affect treatment results.” The study included 143 patients with mixed infection toenail onychomycosis. Patients aged 70 years or older with diabetes mellitus and toenail onychomycosis required a longer time to cure.


 


Leonard A. Levy, DPM, MPH, Ft. Lauderdale, FL

06/19/2020    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: High-frequency Spinal Cord Stimulation Eases Painful Diabetic Neuropathy


From: Leonard A. Levy, DPM, MPH


 



Painful diabetic neuropathy that doesn’t resolve with standard treatment may have relief of pain and improved sensation using a 10-kHz spinal cord stimulation device (Nevro Corp.) as reported in a large randomized controlled study. Within 3 months after starting treatment, 79% of patients had substantial pain relief compared with 5% of patients managed with conventional medical treatment in the largest-ever randomized, controlled trial of spinal cord stimulation for managing painful diabetic neuropathy. The median age of patients was about 61 years and roughly two-thirds were male. All subjects had lower extremity pain. 


 


Natalie H. Strand, MD, assistant professor of pain medicine at Mayo Clinic, Scottsdale, AZ., said that while the findings of this randomized study may require corroboration, they do suggest that this neuromodulation device may provide another option for frontline diabetes providers when patients have persistent pain despite appropriately medication management. Study results were presented as a late-breaking poster presentation at the 2020 virtual annual scientific sessions of the American Diabetes Association. (Family Practice News, June 14, 2020)



 


Leonard A. Levy, DPM, MPH, Ft. Lauderdale, FL

06/18/2020    

RESPONSES/COMMENTS (RELEVANT RESEARCH)



From: Wenjay Sung, DPM


 


Excellent work, Drs. Armstrong and Tan. When podiatrists want to know what role we play in the world today, we can always turn to see how Dr. Armstrong and his collaborators are advancing society and the podiatry profession with statement research and visionary goals. Well done, brother.


 


Wenjay Sung, DPM, Los Angeles CA

06/15/2020    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: Diabetic Foot Ulceration: No Risk Change for Most Low-risk Patients After 2 Years


From: Leonard Levy, DPM, MPH


 


According to a new UK observational study of 10,421 outpatients with diabetes published in the journal Diabetic Medicine, around 5 per cent of individuals at low risk of diabetic foot ulceration had a change in their clinical risk status, with <1% experiencing foot ulceration or amputation after 2 years. 5.1% were classified as low risk at their first visit, progressing to moderate risk. The cumulative incidence of ulceration, amputation, and mortality among the low-risk individuals was 0.4%, 0.1%, and 3.4%, respectively.


 


Age was significantly associated with an increased risk of ulceration, amputation, and mortality. Male sex had a significant association with increased mortality risk. These findings could possibly influence the current UK guidelines on the frequency of foot screening. (Heggie R, et al. Diabet. Med.2020 Jun 08 [Epub ahead of print].


 


Leonard A. Levy, DPM, MPH, Ft. Lauderdale, FL

05/27/2020    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE:  Medicine to Treat Foot Ulcers in Diabetic Patients


From:  Leonard A. Levy, DPM, MPH


 


Suramin, a century-old medicine, was a typical treatment of sleep-related sickness but is being repurposed to treat foot ulcers in people with diabetes (Areeba Hussain: ASK HEALTH NEWS, May 12, 2020). First developed to treat African sleeping sickness (African trypanosomiasis) and river blindness disease, it has been tested for use against other diseases showing promising results. A breakthrough study conducted by the researchers from the University of Arizona dental school was initially to treat oral mucositis and given by injection. But it also opened a way to treat painful foot ulcers in people with diabetes. A brand new topical treatment plan for diabetic foot ulcers is under development that might be a light of hope for such patients. The researchers intend to make it commercially available in the form of gels, creams, and ointments for such ulcers.


 


 Leonard A. Levy, DPM, MPH, Ft. Lauderdale, FL

05/15/2020    

RESPONSES/COMMENTS (RELEVANT RESEARCH)



From: Martin E. Wendelken, DPM   


 


The short article on the reduction in growth of diagnostic ultrasound utilization by podiatrists is a bit misleading. Previous to 2010, podiatrists were the number one provider performing extremity ultrasound scans along with being providers having the highest rate in growth in ultrasound. At that time, there was a single CPT Code 76881 which was utilized for all extremity ultrasounds. The reimbursement was approximately $150 per scan. In 2010, there was the addition of code 76882 (limited ultrasound scan) which had a reduction in reimbursement to physicians performing limited scans (about $30 Medicare). This low fee is what I believe had caused the reduction in the rate of growth. Today, however, reimbursement has changed for the better. While CPT 76881 (complete scan) now pays about $100, payment for CPT 76882 limited code has greatly increased with a Medicare average reimbursement of about $60 per scan (depending on where you practice in the country). 


 


It is also noteworthy that next year Medicare will require pre-authorization for MRI in order to limit over-utilization. Podiatrists should reconsider to incorporate point of care ultrasound to evaluate plantar plate tears, tendon issues, masses, and soft tissue pathologies. Further, ultrasound is used for guided procedures (CPT 76942), including those involving regenerative medicine.


 


Martin E. Wendelken, DPM, Elmwood Park, NJ, Diagnostic Ultrasound Specialist, 2020 Imaging

05/12/2020    

RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 2


RE: Higher Risk of Incident Heart Failure in Older Adults with Gout


From: Leonard A. Levy, DPM, MPH


 


MedPage has (May 6, 2020) reported a study by Lisandro D. Colantonio, Kenneth G. Saag, et al., indicating that 4% of the U.S. population ('6 million men and '2 million women) are affected by gout. Furthermore, older individuals with gout were at increased risk for incident heart failure, but not for incident coronary heart disease or stroke or all-cause mortality.


 


Leonard A. Levy, DPM, MPH, Fort Lauderdale, FL

05/12/2020    

RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1


RE: COVID-19 and Guillain–Barré Syndrome


From: Richard H. Mann, DPM   


 


On April 17, 2020, the online New England Journal of Medicine published the correspondence Guillain–Barré Syndrome Associated with SARS-CoV-2. The paper was authored by a team of Italian physicians and describes a previously unreported potential association between COVID-19 and Guillain–Barré syndrome, an autoimmune disease associated with ascending paresthesia and paralysis of the lower extremities.


 


The team reported that, of an estimated 1,000 to 1,200 patients with COVID-19 admitted to three hospitals in Northern Italy from February 28 through March 21, 2020, five patients developed Guillain–Barré syndrome within 10 days of the onset of COVID-19 symptoms. In four of these patients, lower-limb weakness and paresthesia were among the first symptoms noted. 


 


Although viral infections have long been considered a possible trigger for Guillain–Barré syndrome, this is believed to be the first report indicating a potential association between the SARS-CoV-2, the virus that causes COVID-19, and Guillain–Barré syndrome. Other viruses associated with Guillain–Barré syndrome include Zika virus, Epstein–Barr virus, cytomegalovirus, human immunodeficiency virus (HIV), influenza virus, and the coronavirus responsible for Middle East Respiratory Syndrome (MERS).  


 


Richard H. Mann, DPM, Boca Raton, FL

05/08/2020    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: Most Adults Would Avoid Medical Visits During COVID-19 Pandemic: Survey


From: Leonard A. Levy, DPM, MPH


 


The newsletter Dermatology Today (May 5, 2020) reported that a majority of adults are reluctant to visit healthcare providers unless the visit is related to COVID-19. This was  a result of a survey of 2,201 adults conducted April 29-30 (margin of error, ±2 percentage points) conducted by Morning Consult. When the subjects were asked how likely they were to visit a variety of healthcare settings for treatment not related to the coronavirus, 62% of respondents said it was unlikely that they would go to a hospital, 64% would not go to a specialist, 64% would not go to a dentist, and 65% would avoid walk-in clinics. However, only 48% would not go to a primary care physician.


 


Leonard A. Levy, DPM, MPH, Fort Lauderdale, FL

05/06/2020    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: Significantly Elevated Risks for Gout Incidence in Obstructive Sleep Apnea Patients


From: Leonard A, Levy, DPM, MPH


 


Studies conducted in the U.K. found significantly elevated risk for gout incidence in obstructive sleep apnea (OSA) patients (including 9,865 patients with newly diagnosed OSA). Another including 15,879 patients with OSA, hypoxemia caused a rise in adenosine triphosphate degradation eventually increasing purine concentrations and their end product, uric acid. Also, hypercapnia and acidosis caused by OSA could influence the likelihood of monosodium urate precipitation. In addition, excretion of lactic acid, generated during the hypoxic episodes in OSA, could result in a higher renal reabsorption of uric acid. However, both studies did not adjust for the presence of heart failure, which has been linked to both gout and OSA, and relied on medical diagnoses for chronic kidney disease rather than reports of estimated glomerular filtration rates (eGFR).


 


To calculate the gout risks among OSA patients taking into account these factors, the investigators, de Vries and colleagues, analyzed medical data from the U.K. including medical records of 1.3 million individuals in primary care with a mean age of 62. A total of 1,094 of the gout cases had OSA. The risk of gout rose with worsening renal impairment among OSA patients. When renal function declines, less uric acid is excreted, which leads to hyperuricemia and eventually gout. Women with OSA also had a greater risk of gout than men did, possibly due to differences in the anatomy of the upper airway, fat distribution, and the influence of sex hormones. Reference: Van Durme C, et al. "Obstructive sleep apnea and the risk of gout: a population-based case-control study" Arthritis Res Ther 2020. 


 


Leonard A, Levy, DPM, MPH, Ft Lauderdale, FL

04/02/2020    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: Double Fifth Toe Nails in Four Female Patients


From: Leonard A. Levy, DPM, MPH


 


Pasquale, E., et al report in the Journal of the American Academy of Dermatology (April 2020) cases of what it calls “double little toenails”, or accessory nails of the fifth toe. It states that this is a rare deformity distinct from other nail dysplasias. Four cases in female patients, including a 6-year-old girl, experiencing this bilateral condition after birth are described. The article indicates that the nail anomaly shows an autosomal-dominant type of transmission affecting only female individuals.


 


All the subjects were from a family without marriages between blood relatives and without neuroectodermal hereditary diseases. There were no bone alterations of the terminal phalanges of the fifth toe or alterations of the joints of the toes or hair. In one patient, the nail deformity was associated with epilepsy. Another patient had an associated infection of an accessory nail.


 


Leonard A. Levy, DPM, MPH, Ft. Lauderdale, FL

01/31/2020    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: HBA1c Testing: A Routine Podiatric Medical Practice?


From: Leonard A. Levy, DPM, MPH


 


Osorio, et al. reported in JAMA Internal Medicine (January 27, 2020.doi:10.1001) about barbershops identifying black men with undiagnosed diabetes using community-based hemoglobin A1c testing. Since a significant number of podiatric medical patients may be undiagnosed diabetics, performing routine HBA1c testing on a routine basis in podiatric medical practices could be a major contribution to the nation’s health and to individuals with undiagnosed diabetes. Such testing also could further identify the profession as being important members of the physician community.


 


Leonard A. Levy, DPM, MPH, Ft. Lauderdale, FL

01/21/2020    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: Risk for Gout in Patients with Type 2 Diabetes Prescribed Sodium-Glucose Cotransporter-2 Inhibitors                                           


From: Leonard A. Levy, DPM, MPH


 


A study done at Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, and Sinai Health System and University of Toronto, Toronto, Ontario, Canada published in the Annals of Internal Medicine (January 14, 2020, ISSN: 003-4819) assessed the risk of gout in 295,907 adult patients with type 2 diabetes mellitus prescribed sodium-glucose cotransporter-2 inhibitors (SGLT2) and those prescribed a glucagon-like peptide-1 (GLP1) receptor antagonist.


 


Adults with type 2 diabetes prescribed a SLGT2 inhibitor may reduce their risk for gout more than those prescribed a GLP1 agonist. The study was funded by Brigham and Women's Hospital. 


 


Leonard A. Levy, DPM, MPH, Fort Lauderdale, FL

11/26/2019    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: Plantar Mechanical Stress Tied to Formation of Plantar Melanoma


From: Leonard A. Levy, DPM, MPH


 


A study in the Journal of European Academy of Dermatology and Venereology was reported by Dermatology Advisor indicating that “mechanical stress on the plantar surface of the foot, which is typical of normal weight-bearing on the foot, is associated with a higher formation of plantar melanoma compared with other non-weight-bearing areas of the body.” It indicated that “the heel was the most common region with plantar melanoma, followed by the forefoot, plantar aspect of the toes, lateral midfoot, and arch.”


 


Leonard A. Levy, DPM, MPH, Ft. Lauderdale, FL

11/11/2019    

RESPONSES/COMMENTS (RELEVANT RESEARCH)



From: Elliot Udell, DPM


 


Thank you Drs. Frykberg, et al. for completing the study on topical oxygen therapy for the treatment of diabetic foot ulcers. The study showed that that those who used the topical oxygen therapy device had 41.7% of their ulcers heal as compared to 13.5% who used a sham device. This is significant. 


 


In our practice, we have used topical oxygen therapy to treat diabetic ulcers for many years and have had great success. In two cases where there was no ability to surgically revascularize the lower extremities and the surgeons expected the patients to go on to BK amputations, we were able to save those legs using topical oxygen therapy. The only problem with it is that the only insurance company (in NY) that pays for the device is Medicaid. Patients are not given the opportunity to pay out-of-pocket, although one supplier has been willing to supply some of my patients with the modalities for free. 


 


I hope that Dr. Frykberg and his team of researchers will be able to convince Medicare and other carriers to cover this limb-saving modality. 


 


Elliot Udell, DPM, Hicksville, NY

10/28/2019    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: Rising Plasma Copeptin Level Tied to Amputation Risk in Diabetes


From: Leonard A. Levy, DPM, MPH


 


A study published in Diabetes Care (Potier, L, et al., October 2019) found that during follow-up, the cumulative lower-extremity amputation incidence was higher among patients with type 1 and type 2 diabetes with increasing levels of plasma copeptin, compared with those who had lower plasma copeptin levels. Plasma copeptin, a surrogate marker of vasopressin, is associated with the risk of cardiovascular and renal complications in diabetes. Researchers used a cohort of 5,263 diabetes patients and suggested that improved hydration could reduce the risk.


 


Leonard A. Levy, DPM, MPH, Ft. Lauderdale, FL

10/15/2019    

RESPONSES/COMMENTS (RELEVANT RESEARCH)



From: Paul Busman DPM, RN


 


It's just anecdotal, but I've used CA glue many times on my own finger hangnails and occasionally on a stubborn incurvated toenail. In every instance, the result has been almost instant relief and rapid healing. I've also used it frequently on small workshop and household cuts and scrapes with equally great results.


 


That said, if I was still in practice, I'd definitely hesitate to recommend that a patient do this. If anything went wrong, this would obviously be a huge problem. 


 


Paul Busman DPM, RN, Frederick, MD

05/16/2019    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: Diabetes Peripheral Neuropathy and Driver Error 


From: Leonard Levy, DPM


 


DiabetesPro SmartBrief (May 13, 2019) reports of a study published in Diabetic Medicine that found  patients with diabetic peripheral neuropathy were at risk for poor driving performance. This was because these patients had lower ankle proprioception function and weaker muscle strength of the plantarflexors, resulting in loss of control of the vehicle than those who did not have diabetic peripheral neuropathy. They also drove at slower speeds, compared with individuals without peripheral nerve dysfunction.


 


Podiatric physicians should use this information in their interaction with diabetic patients who are identified as having peripheral neuropathy.


 


Leonard Levy, DPM, Ft. Lauderdale, FL

05/13/2019    

RESPONSES/COMMENTS (RELEVANT RESEARCH)



From: Bret Ribotsky, DPM


 


I have been very “on top of this treatment” from the beginning. When I was in practice, I also was involved in managing a large dermatology practice with 5 derms, 3 plastic surgeons, 9 PAs/NPs, and a research division. We owned 13 lasers and rented 4. The “cure” for onychomycosis (OM) could have been bigger than BOTOX for the dermatologists. 


 


Twice in the past 10 years, we did an IRB-approved study using three different lasers. In the first study, we took patients who had more than 6 OM nails and treated every other nail with the laser, randomizing the patients by starting with the left little toe on patients with odd Social Security numbers and the right little toe for those with even Social Security numbers. We wanted to see if there were any changes noticed on visits at 2,4,8, and 16 weeks. No differences were found. The second study used the same randomization on lasers #2 & #3. No differences between the toes were found.


 


DUSA therapy (photodynamic) with blue light seemed promising, but those studies failed. My hypothesis is that if there were a way to get a colored chemical into the fungal cells only (either orally or topically), then we could have a targeted chromosphere with a known wavelength frequency and we could use a laser to heat up the cell and kill it. That’s a cure. I’m keeping my toes crossed.


 


Bret Ribotsky, DPM, Boca Raton, FL

05/10/2019    

RESPONSES/COMMENTS (RELEVANT RESEARCH)



From: Bryan C. Markinson, DPM


 


When the laser technology achieved very anemic approval for "temporary clearing of nails," as did all lasers marketed for onychomycosis, it seemed as if every five minutes in NYC a DPM was advertising on the radio about it. Unfortunately, the overwhelming majority of the ads gave the listener the impression that laser was a quick "zap" cure that was permanent, without actually saying so. Most ads pushed the limit excessively and unethically to give that impression without running afoul of the law. Some state boards actually took action against this advertising. 


 


Soon enough, the Internet was full of patient postings that laser treatment for onychomycosis was a sham. How unfortunate to ruin a potentially efficacious adjunctive treatment based on...


 


Editor's note: Dr. Markinson's extended-length letter can be read here.

05/09/2019    

RESPONSES/COMMENTS (RELEVANT RESEARCH)



From: Tip Sullivan, DPM, Allen Jacobs, DPM


 


One may debate the literature from now until the cows come home. There are those who swear by lasers and those who do not. Let me share what I did when I got all hot and bothered about the potential of lasers in onychomycosis treatment probably 7-10 years ago. I convinced two different laser manufacturers to let me use their machines for 3 months each. I treated 40-50 people for free with each laser, of course after the company had given me an in-service on use. I figured the multiple thousands of dollars in expense would be worth it if it worked like the companies claimed. The short of it--I did not buy a laser!


 


Tip Sullivan, DPM, Jackson, MS


 


Mark Twain stares that “facts are stubborn things. But statistics are pliable.” Let us look at facts.



 


Fact: Current “ approved lasers for onychonycosis “ have been cleared through the 510k process, not by virtue of proof of efficacy.


 


Fact: Treatments which affect the appearance of a nail do not imply resolution of fungal infection; 


 


Fact: We do not know if special populations (e.g.: diabetics, immunocompromised, chemotherapy) respond...


 


Editor's note: Dr. Jacobs' extended-length letter can be read here.

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