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12/31/2020
RESPONSES/COMMENTS (PM NEWS QUICK POLLS)
From: Allen Jacobs, DPM
There is no dispute that a PT block provides anesthesia and thereby pain relief in the management of PAIN associated with any painful acute monarticular disorders, including gout. However, to conclude that the PT block alters the pathophysiology of gout is without any scientific evidence. The so-called sympathectomy effect may or may not be true. However, your suggestion that a PT block alters the natural history of this disorder (other than pain relief and theoretically vasodilation) is without evidence. If you have such studies to the contrary, “show me the money”.
A PT block will reduce pain from septic arthritis, pseudogout, fracture, malignancy. Pain relief and “sympathectomy” do not alter the disease process. Is the administration of a PT block associated with a shortened course of the disease? Less need for steroids, NSAIDs, colchicine, or irate lowering therapy? Is there evidence that a PT block reduces the intra-articular urate burden, inflammatory cytokines, joint pH, or leukocyte/macrophage? The answer is no, you have no such evidence. There is a difference between theory and proven fact. It is called the scientific method. Absent confirmatory studies, the suggestion that a PT block “dilutes out” the uric acid (which effect would be expected to last only for the duration of the anesthetic used) is mumbo-jumbo until proven otherwise.
Allen Jacobs, DPM, St. Louis, MO
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05/03/2024
RESPONSES/COMMENTS (PM NEWS QUICK POLLS)
From: Ivar E. Roth, DPM, MPH
I read Dr. Kesselman’s response. While I understand his thinking, here are my old school thoughts concerning student loans. Any student can easily reduce their loan dependence by working part time during their schooling or on summer breaks. Also decreasing debt is easy; spend less and scrimp during school and residency. Too many students today think nothing of drinking $6 Starbucks whenever they want and living above their means. Maybe you must reduce rent by sharing an apartment.
There are lots of ways to spend less and or supplement your income. There is nothing wrong with a little struggle but today’s students to me seem to be entitled to a certain lifestyle that maybe they can’t afford. What I am trying to say is that where there is a will there is a way. The same goes for wanting to just get a 9 to 5 job. If you want to really excel, try the concierge/ direct pay model, and make as much as you feel you deserve. Yes, it will be difficult at first but in the long run, you are the boss of your future not just an employee happy to get yourself a cost of living increase each year.
Ivar E. Roth, DPM, MPH, Newport Beach, CA
05/02/2024
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1B
From: Paul Kesselman, DPM
Recently, I met a young intern doing his PGY-1 prior to starting his five-year residency in general surgery. He is faced with almost $400K in debt from medical school and more from undergraduate school. Between the two, he can easily amass $600K or more in debt. A neighbor graduating from high school will amass $500K in debt from his undergraduate degree and then more from his anticipated pursuit of a legal degree.
It is no wonder that more and more young students are moving away from traditional degrees in healthcare and moving to shorter degree paths with easier career paths. PA and NP are far shorter than MD/DO and DPM degrees with much less stress, easier lifestyles, and nice salaries. Nurse anesthestists command $150+ salaries after a four year BSN and a year or two of...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
05/02/2024
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1A
From: Shashank Srivastava, DPM
I understand the points that Dr. Hofacker is making and all are very good. That said, I personally feel that it is not reasonable to expect 17 year old high school kids to want to know they want to be podiatric surgeons at such a young age. I remember how I was at that age, and no way could I have made such a commitment. I think a certain level of maturity and some life experiences are required before making this commitment.
The problem is if they decide at 22 years of age that they want to do something different (common sentiment among that age group), there is no turning back and lots of debt and possible resentment. Unlike allopathic or osteopathic physicians, we cannot just simply change specialties and do different residencies and fellowships. There is no turning the ship around.
Shashank Srivastava, DPM, Rockville, MD
06/14/2023
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1B
From: Patrick J. Nunan, DPM, Steven Kravitz, DPM
I find it interesting that a person commenting that the profession itself is its own biggest threat, once testified against ankle privileges for podiatrists on behalf of orthopedic surgeons in his state. At that time, I was vice president of that state association and heard his testimony firsthand. Was not the question asking for forces outside of the profession?
Patrick J. Nunan, DPM, Beaufort, SC
Dr. Tomczak points to an age old question that faces not just podiatry, but all fields of medicine. There's too often a disconnect between the pride of being in medical practice, the economics that drive that practice, and the realization that all of us have a limitation of education. At the end of the day the primary focus must be whatever is best for the patient.
I just had a paper accepted by The Journal of Wound Care (due October 2023) that addresses this very issue. It describes a simple vascular procedure that went wrong, causing...
Editor's note: Dr. Kravitz's extended-length letter can be read here.
06/14/2023
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1A
From: William A. Wood, DPM, MPH, Robert Kornfeld, DPM
The greatest existential threat to our profession is the lack of a national practice act license uniting the profession.
William A. Wood, DPM, MPH (retired), Chicago, IL
Other than the fact that podiatry has never been a cohesive unit, I believe the biggest existential threat is participating with health insurance. There will be no end to the erosion of income over time. Podiatrists work like dogs and are being exploited by insurance companies. So who is to blame? Clearly, insurance companies because they figuratively rape doctors. BUT, this is not a new story. It is the continued participation/cooperation/acceptance of this madness that is also to blame. And that is something every podiatrist can change. Otherwise, they can continue working as the underpaid employees of the insurance companies that they are.
Robert Kornfeld, DPM, NY, NY
05/19/2022
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1C
From: Elliot Udell, DPM
Dr. DiResta is correct in noting that two surveys taken on how many people have contracted COVID-19 may be totally inconsistent with each other. Expect more of this. When COVID-19 first became a pandemic, the strain caused severe morbidity and mortality. The only way of knowing if a person had the disease was to go to a public testing site, hospital, or urgent care facility. The results were documented and made public. Today, things have changed.
The strain today is more contagious but less virulent. Many are also vaccinated. People are, thankfully, not dying or winding up on ventilators as frequently. The symptoms for many people may mimic a mild cold. There is also an ample supply of home testing, the results of which, remain private and undocumented. Hence, today, we can only get rough estimates from government agencies and other surveys and the results from multiple studies may indeed vary.
Elliot Udell, DPM, Hicksville, NY
05/19/2022
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1b
From: Alan Sherman, DPM
There are some very good reasons why we podiatrists should have a lower incidence of COVID than the general population. Doctors, in general, are among the most vaccinated population. We podiatrists are so well educated in infectious disease and the precautions that we need to take to keep our staff and patients safe. We spend so much time in operating suites where the principles of antisepsis have been followed long before COVID.
I don’t find it surprising that our incidence of COVID as a group is lower than average, but rather, that it is a testament to the policies that were put into place and the practices that were diligently followed in our offices and clinics, as well as in our personal lives.
Alan Sherman, DPM, Boca Raton, FL
05/19/2022
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1A
From: Gary S Smith, DPM, Al Musella, DPM
James DiResta wondered why the PM News polling showed a negative 65% for having had COVID-19. I would remind him the question was "Have you ever tested positive for Covid?", not have you ever had COVID-19?
Gary S Smith, DPM, Bradford, PA
That shows that podiatrists understand and implement infection control. Most of the MDs I know also never caught it.
Al Musella, DPM, Hewlett, NY
05/18/2022
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 2
From: Paul Betschart, DPM
I tried to dissuade my son from a career in medicine for many of the same reasons presented. I guess the calling was too great as he is graduating from medical school next weekend. As a DO, he may well be an employee and not have the business challenges of solo practice.
Paul Betschart, DPM, Danbury, CT
05/18/2022
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1
From: James J DiResta, DPM, MPH
The results to this week’s polling is puzzling. CDC recognizes that some 60% of the U.S. population has had COVID-19 which would appear to me a conservative number, yet the poll results show 65% of respondents stating they have not had COVID-19, which begs the question why is being a podiatrist "protective"? It would seem to me with our level of exposure, we would be as high if not higher than the CDC data.
James J DiResta, DPM, MPH, Newburyport, MA
05/17/2022
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1B
From: Dennis Shavelson, DPM
The biggest mistake we made as a profession continues to be to ask “Is it covered?” as a prerequisite to care. The second biggest mistake has been the simultaneous abandoning and minimizing of lower extremity biomechanics. We have neglected our inherited claim to be the best orthotic and closed chain professionals that Drs. Root, Langer, and Dananberg gifted us by instead becoming amateurish, uneducated, and unskilled.
This year, I tearfully retired as a DPM. How did we let this happen?
Dennis Shavelson, DPM (retired), CPed, Tampa, FL
05/12/2022
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1B
From: Steven Finer, DPM
I applaud Dr. Kornfeld’s personal journey. I did not have the guts to do what he did and accepted Medicare. I always made a living .However, those 1978 fees adjusted for inflation are the same as 2022. My son could easily have gone into medicine but is in the business world. None of my friends' children chose medicine. My personal physician is leaving the big group as more and more patients are pushed on him. My excellent dermatologist looks tired and harried as the big group pushes him to do more. None of their children have gone into medicine and both sets are husband and wife MDs.
Steven Finer, DPM, Philadelphia, PA
03/23/2022
RESPONSES/COMMENTS (PM NEWS QUICK POLLS)
From: Vince Marino, DPM
Although I have used them in the past, they are no longer available as the FDA quashed their use since they are injectable biologics. The FDA is requiring the companies go through more hoops. Here is an excerpt from the FDA notice sent to the public:“…warning to consumers in FDA’s July 2020 Consumer Alert:
•Regenerative medicine therapies have not been approved for the treatment or prevention of COVID-19, acute respiratory distress syndrome, or any other complication related to COVID-19.
• Regenerative medicine therapies have not been approved to treat autism, macular degeneration, blindness, chronic pain, or fatigue.
• Regenerative medicine therapies have not been approved to treat any neurological disorder, such as multiple sclerosis, amyotrophic lateral sclerosis (ALS; Lou Gehrig’s disease), Alzheimer’s disease, Parkinson’s disease, epilepsy, or stroke.
• Regenerative medicine therapies have not been approved for the treatment of any cardiovascular or pulmonary (lung) diseases, such as heart disease, emphysema, or COPD.
• Regenerative medicine therapies have not been approved for the treatment of any orthopedic condition, such as osteoarthritis, tendonitis, disc disease, tennis elbow, back pain, hip pain, knee pain, neck pain, or shoulder pain [emphasis added by poster].
FDA has repeatedly notified manufacturers, clinics, and healthcare practitioners of the need for Investigational New Drug applications (INDs) to legally administer these products and to ensure safety measures are in place prior to administration.” So the results of the poll may be skewed.
Vince Marino, DPM, San Francisco, CA
04/05/2021
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1B
From: Kenneth Meisler, DPM
Dr. Kass stated "like Dr. Meisler does with ultrasound guidance," he injects "into the region of the neuroma...is a pretty easy location to find without ultrasound." I agree that to be in "the region" is pretty easy. I do not inject into "the region of the neuroma." I inject directly into the body of the neuroma. I have done this for about 15 years after reading a study performed this way at the Hospital for Special Surgery. I have found injecting directly into the neuroma under ultrasound guidance is more effective than injecting in the region of the neuroma, which I did for 25 years. It is difficult to do even with ultrasound guidance. There is a definite learning curve.
I think you will be surprised where you are injecting as you watch yourself under ultrasound. Eventually, it becomes quite easy. Injecting directly into the neuroma also reduces complications such as fat necrosis and skin discoloration because the firm body of the neuroma holds the steroid or alcohol within it after the injection. A comprehensive review of the literature on ultrasound guided vs. non-ultrasound-guided injections in the Orthopedic Journal of Sports Medicine concluded that ultrasound-guided injections are overall more accurate than landmark-guided injections. I perform all neuroma injections under ultrasound guidance even if the insurance company will not pay for it. I cannot ethically do an injection without it if I know I am capable of being more accurate with ultrasound; that's just me.
Kenneth Meisler, DPM, NY, NY
04/05/2021
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1A
From: Steve Tager, DPM
Maybe these posts about neuroma treatment are not truly representative of what the nation’s podiatrists do for this condition. I am reasonably certain that as physicians, we all try to achieve positive outcomes and do what we feel is mutually beneficial for our patients when it comes to treatment regardless of the problem. Fifty plus years of doing all that has been discussed, from steroid injections, dehydrated alcohol, DTL sectioning, excisions from both above and below, etc. Nothing compares to the success rate I’ve experienced by simply reversing the pathomechanics of lateral column overload. My experience continues to tell me that restoring rearfoot function anywhere close to anatomic neutral gives the foot optimal opportunity to heal itself.
How many times have we sat in front of a pair of feet and identified good upper and lower leg alignment, with the plantar surface of both feet trying to face each other? Is it not possible that...
Editor's note: Dr. Tager's extended-length letter can be read here.
01/20/2021
RESPONSES/COMMENTS (PM NEWS QUICK POLLS)
From: Michael J Marcus, DPM
A year ago, we dealt with the uncertainty of this virus. Some thought it would be no different than the common flu, others considered it more potentially problematic. Now a year later, over 400,000 lives have been lost in the U.S. as a result of this virus. In my area of the country-LA- 95% of our inpatients are covid positive. Every day, I hear about a death from COVID. Our ICUs are flooded. Three or four patients seem to code very day.
The development of this mRNA vaccine is nothing short of a miracle. Many hospitals are making it mandatory for new employees. The PM News survey is very discouraging to me. I could think of no reason not to be...
Editor's note: Dr. Marcus' extended-length letter can be read here.
01/07/2021
RESPONSES/COMMENTS (PM NEWS QUICK POLLS)
From: Leonard A. Levy, DPM, MPH
Carl Solomon, DPM, indicates that the foot is warm during a gouty attack. However, it is actually the area surrounding the inflammation that is warm. This is due to what are among the cardinal signs of inflammation which the ancients characterized as redness (rubor), swelling (tumour), heat (calor;), pain (dolor), and loss of function (functio laesa). The first four of these signs were named by Celsus in ancient Rome (30–38 B.C.) and the last by Galen (A.D 130–200) (source: Hurley JV. Acute inflammation. Edinburgh, London: Churchill Livingstone; 1972).
These are local responses to cellular injury marked by capillary dilation, not the larger vessel dilation caused by blocking sympathetic nerve fibers of the posterior tibial nerve. The block causes an increase blood flow to areas distal to the nerve block, which is a much more significant increase in fluid (i.e., blood) than there may be in an area of inflammation. Indeed, the block (and the vasodilation) lasts significantly longer when the anesthetic agent includes epinephrine. Thus, the patient gets immediate pain relief during the time it takes for the traditional anti-gout agents to be used.
Leonard A. Levy, DPM, MPH, Ft. Lauderdale, FL
01/05/2021
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1B
From: Henry Stark, DPM
Almost by definition, temperature in the human foot is normally less than core body temperature. I think we can all agree that there is no need for double-blinded studies to determine this to be a fact. During a hyperuricemic episode, it is believed that urate crystals coming out of solution from a “saturated” plasma concentration, precipitate in these naturally cooler, distal articular regions which initiate the gouty attack. In conjunction with other therapeutic measures, many podiatrists utilize posterior tibial blocks to induce a temporary, localized sympathectomy for increased perfusion as well as the analgesic effect. Yet, the Arthritis Foundation, most all rheumatologists, as well as most of my colleagues would argue that ice (rather than mildly increasing the temperature of the site) is appropriate therapy for the ACUTE phase of the attack.
Dr. Levy appears to suggest (as do I) that consideration towards increasing perfusion (and perhaps warming of the affected area of the gouty attack) rather than ice may be more appropriate. Yes, ice is an analgesic in this situation, yet its use seems counterintuitive since it decreases temperature, perfusion, and would tend to prolong and enhance localized urate crystal formation. I am aware that once a gouty attack has begun, uric acid concentration in the plasma often has already decreased. Why would ice be the recommended therapy simply for analgesic purposes, when it may cause further, localized urate crystal formation?
Henry Stark, DPM, Lake Park, FL
01/04/2021
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 2
From: Leonard A Levy, DPM, MPH
After a successful posterior tibial block, simply by touching the plantar aspect of the foot, the patient feels anesthesia and also, a significant rise in temperature occurs. This is prolonged by including 1:1000 epinephrine in the anesthetic agent. Statistically significant increases in cutaneous temperature after nerve blocks compared to the same skin area before the procedure have been reported in the literature (Anesth Analg. 2009 Mar;108(3).
An article by Lima A, et al. in Critical Care (2009; 13 (Suppl 1): p 237) also indicates that after successful regional anesthetic blocks, local vasodilatation and increased blood flow occur as a result of blockade of sympathetic nerve fibers. Of course, the posterior tibial nerve block for acute gout is not the primary treatment of the condition. It markedly reduces pain but also begins the therapeutic process of bringing more fluid to the area as a result of vasodilation. This is followed by any of the oral medications that are used during the attack as well as after the attack resolves. In addition, injection of the affected joint with a corticosteroid may also be used.
Leonard A. Levy, DPM, MPH, Ft. Lauderdale, FL
01/04/2021
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1
RE: Have you received your COVID-19 vaccination yet? (Adam M Budny, DPM)
From: Robert Scott Steinberg, DPM
I am not sure of Dr. Budny's point. Is he rationalizing his decision? Here is what I do know. "The general recommendation is to get the vaccine, even if you were previously infected," said Dr. David Thomas, a professor of medicine and director of the infectious diseases division at the Johns Hopkins University School of Medicine. "There are some nuanced questions that we don't have the answer to yet, but from what we know now, it's the right call to get the vaccine."
Everyone be as safe as you can. You owe it to your family, your patients, and yourself.
Robert Scott Steinberg, DPM, Schaumburg, IL
12/30/2020
RESPONSES/COMMENTS (PM NEWS QUICK POLLS)
From: Leonard A Levy, DPM, MPH
Allen Jacobs, DPM, claims that the use of a posterior tibial block in acute gout is an unproven theory. There is nothing theoretical about the use of sympathetic nerve blocks (e.g., posterior tibial nerve block) to cause vasodilatation in acute gouty attacks. Not only does the block typically result in immediate relief of pain, but also vasodilatation created brings more blood to the innervated areas. This also results in a significant rise in temperature.
The chemistry of saturated solutions is clear, based on long known concepts, not merely a theory. That is, by increasing temperature and fluid volume, the sharp crystals of the supersaturated solution of sodium urate dissolve and, in addition, Ph increases. A low Ph (i.e., acid) results in the increase of crystals of sodium urate. The reason a PT block is not popular in other medical specialties is likely that the average physician does not know how to administer it, including rheumatologists. No one can administer a PT block better than a podiatric physician.
Leonard A. Levy, DPM, MPH, Ft. Lauderdale, FL
12/29/2020
RESPONSES/COMMENTS (PM NEWS QUICK POLLS)
From: Joe Agostinelli, DPM
I have read various responses as to this question from well learned colleagues. So far, however, I have not read about some "classic treatment". First of all, a good history, regular radiographs, and physical evaluation of the great toe joint should lead you to believe you have an acute gouty attack.
A local or PT block, then an “aspiration” of the joint fluid is then accomplished. You should see either a gouty synovial fluid aspirate or in the rare case of a septic joint, the synovial fluid murky with purulence. After aspiration of the contents of the joint leaving the aspiration needle in the joint, swap out with another syringe for a...
Editor's note: Dr. Agostinellis' extended-length letter can be read here.
12/28/2020
RESPONSES/COMMENTS (PM NEWS QUICK POLLS)
From: Jeffrey Klirsfeld, DPM, Allen Jacobs, DPM
A PT block works very well for a gout attack. We must tell our patients that their foot and ankle is numb for a period of time depending on type of anesthesia used (lidocaine, bupivacaine, etc.) and they must essentially do no activities until there is full sensation. It sounds obvious but we still have to tell them.
Jeffrey Klirsfeld, DPM, Levittown, NY
I have long heard the unproven theorem that PT blocks are useful for the treatment of acute gout by inducing vasodilation and helping to "wash away" the uric acid. Funny how I believe the edema, hyperthermia, and erythema observed in acute gout represented hyperemia. The inflamed joint hardly appears to require additional vascular perfusion. PT blocks provide limited temporal effects. They are helpful for immediate pain relief. However, to suggest other theoretical effects is without a scientific basis and remains theoretical.
Speaking of theoretical, I utilize a focal anesthetic block with epinephrine to reduce the hyperemia and pain. My observation has been that epinephrine provides a more prolonged and profound analgesic effect. I want vasoconstriction. As I previously described, I perform a wide dorsal V block apex proximal. I do not encircle the 1st ray. Obviously epinephrine containing anesthetics are not utilized when inappropriate. PT block, dorsal block, no block. This is again the art of medicine, making reasonable efforts to reduce patient suffering.
Allen Jacobs, DPM, St. Louis, MO
12/25/2020
RESPONSES/COMMENTS (PM NEWS QUICK POLLS)
From: Leonard A. Levy, DPM, MPH
Drs. Allen Jacobs and Elliot Udell comment about the use of PT blocks in acute gout. Dr. Udell also remarks about the late Dr. Marvin Steinberg who employed PT blocks in treating acute gouty attacks. I spent a number of years in his office at least once a week which literally resulted in my love for podiatric medicine. The use of PT blocks was not only for anesthesia for virtually immediate relief from the acute pain, but also because it was a sympathetic nerve block.
This resulted in vasodilatation which created a dramatic increase in temperature as well as an increase in the flow of blood by blocking the autonomic nerve component. The increase in blood flow increased the volume of fluid to the area and since much of this fluid is water and a solvent, resulted in dilution of the supersaturated solution of monosodium urate. Reducing the sharp crystals of monosodium urate also results in increasing the pH (reducing acidity). Thus, these combined effects of a PT block make such an intervention quite effective.
Leonard A. Levy, DPM, MPH, Ft. Lauderdale, FL
12/23/2020
RESPONSES/COMMENTS (PM NEWS QUICK POLLS) - PART 1B
From: Elliot Udell, DPM
Dr. Tritto questions the use of posterior tibial nerve blocks in light of the fact that there are no published studies supporting their efficacy. The point he is making is well taken. Even though the late Dr. Marvin Steinberg, who was regarded as the father of modern podiatric medicine, showed that by blocking the posterior tibial nerve, a patient could be rendered almost asymptomatic within minutes, there are no studies published in any peer-reviewed journals supporting it. Why?
Studies cost megabucks and no pharmaceutical company will invest millions of dollars into showing that PT blocks are helpful, when there is no way they will make money off of the procedure. What makes it worse is that most insurance companies will not pay for PT blocks because there is no research. Could there be research and publications on PT blocks? Sure! Our professional associations along with our colleges of podiatric medicine would have to fund the research without corporate sponsorship. If enough of us want it to happen, maybe it will.
Elliot Udell, DPM, Hicksville, NY
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