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02/23/2021    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: Opioids Prescribed for Diabetic Neuropathy Pain Not Advised 


From: Leonard A. Levy, DPM, MPH


 


A retrospective study by Rozalina G. McCoy, MD, an endocrinologist and primary care clinician at the Mayo Clinic in Rochester, Minnesota, funded by the National Institute of Diabetes and Digestive and Kidney Diseases, indicated that opioids as a first-line treatment for painful diabetic peripheral neuropathy (DPN) are not recommended and are not safe, even for severe DPN pain or painful exacerbations. Dr. McCoy reports that it is a myth that opioids are the strongest pain medications possible, and can cause harm to DPN patients. She explains that for painful neuropathic pain, duloxegtine [Cymbalta], pregabalin [Lyrica], and gabapentin [Neurontin] are the most effective pain medications based on multiple studies and extensive experience using them. 


 


The American Diabetes Association DPN guidelines essentially also advise opioids only as a tertiary option for refractory pain. Not only do opioids have the potential for dependency and potential overdose, but also the potential for opioid-induced hyperalgesia. Non-pharmacologic measures such as cognitive behavioral therapy, acupuncture, or physical therapy may also help some patients as well. (Clinical Endocrinology News, February 17, 2021


 


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

Other messages in this thread:


02/25/2021    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: FDA Panel Cites Non-Efficacy of Drug-Coated Balloon Catheter for Lower-Leg Ischemia 


From: Leonard A. Levy, DPM, MPH


 


The FDA’s Circulatory System Devices Panel concluded that the benefits of the investigational angioplasty catheter (Lutonix DCB) do not outweigh its risks as a treatment for patients with critical limb ischemia (CLI) who have obstructive de novo or non-stented restenotic lesions in below-the-knee (BTK) arteries. The DCB was also associated with no added benefit in terms of quality of life. Among the panel members was Robert Yeh, MD, MSc, of Harvard Medical School, who acknowledged the strong clinical need for such a device on the market but said that "public health is best served when we have more certainty that the device works, and I felt we didn't get that today."


 


The Lutonix DCB features a proprietary coating containing paclitaxel. Had it been approved by the FDA, it would be the first device indicated for below-the-knee, drug-coated balloon ischemia (BTK CLI) beyond percutaneous transluminal angioplasty (PTA) and atherectomy. FDA is not required to follow the advice of the panel, but it often does. (MedPage Today, February 18, 2021


 


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

02/24/2021    

RESPONSES/COMMENTS (RELEVANT RESEARCH)



From: Steven Finer, DPM


 


When I was in practice, I found the best treatment for my patients was gabapentin. When they first presented, many were on sub-optimal doses such as 300mg per day. When I moved them up, they felt much better at about 1200mg per day. Most had other issues such as severe obesity alcohol use and numerous injuries. I also checked the Pennsylvania drug database to make sure they were not pill shopping.  


 


Steven Finer, DPM, Philadelphia, PA

02/09/2021    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: Social Deprivation and Diabetes-Related Foot Disease in Patients with Type 2 DM 


From: Leonard A. Levy, DPM, MPH


 


Reiley J, et al. concluded in a population-based retrospective cohort study published in Diabetes Care (January 2021) that social deprivation is an independent risk factor for the development of diabetes-related foot disease (DFD), peripheral neuropathy, foot ulcers, peripheral vascular disease, lower limb amputation, and gangrene in newly diagnosed patients with type 2 diabetes.


 


Considering the high individual and economic burdens of DFD, strategies targeting patients in socially deprived areas are needed to reduce health inequalities. The most deprived patients had the highest risk compared with those who had the least. DFD incidentally developed in 12.1% of the study population of more than 150,000 patients over 3.27 years. 


 


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

12/25/2020    

RESPONSES/COMMENTS (RELEVANT RESEARCH)



From: Ivar E. Roth DPM, MPH


 


Thanks, Dr. Levy for your insight. I never really gave much thought how we as podiatrists should interact with cardiologists. Bravo as usual. I think you should do a weekly column for PM News with your pearls of practice.


  


Ivar E. Roth DPM, MPH, Newport Beach, CA


 


Editor's note: Regular readers of PM News are aware that Dr. Levy is a regular contributor to this newsletter, for which we are greatly appreciative.

12/24/2020    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: Unna Boot Efficacy in Dermatologic Diseases (Steven R Kravitz, DPM)


From: Michael M. Rosenblatt, DPM


 


This is just a brief note to confirm Dr. Kravitz’s very high credentials in giving wound care treatment advice. He is too modest to describe those credentials in detail, but they are extensive. I take his advice about Unna boots as absolutely authoritative. When he discusses wound care issues, I always closely listen.


 


Michael M. Rosenblatt, DPM, Henderson, NV

12/24/2020    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: Podiatric Medicine in Health Promotion - Not Podiatric Health Promotion 


From: Leonard A. Levy, DPM, MPH


 


It is time for members of the podiatric medical profession to begin to change the way they think about public health (and the way the profession is perceived by other health professions and the public). We do not or at least should not treat feet. We treat people who may have problems affecting the pedal extremity. This is not a play on words but a shift in how we participate as part of the army of health professionals. Without getting into a long discourse about what I mean, let me provide an example of an area of healthcare as well as health promotion that demonstrates the importance of podiatric medical practitioners in public health. 


 


This example is the patient who visits the primary care physician (e.g., family practice physician or internist) or the cardiologist and is told that they need to exercise and/or should walk 20 minutes daily. Almost never (if ever) do these practitioners ask if the patient has painful feet. Have we in podiatric medicine ever studied how many people do not engage in daily exercise because of podiatric problems? Has anyone ever determined the effect of the condition of the pedal extremities on cardiovascular health? 


 


How much of cardiovascular morbidity (or even mortality) is affected by the condition of the feet and ankles? How many deaths from cardiovascular disease could be prevented if these victims had the benefit of podiatric medical care? Remember, cardiovascular disease is the single most common cause of death in the Western world. Let us begin to think about our comprehensive role in health not just foot health. 


 


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

12/22/2020    

RESPONSES/COMMENTS (RELEVANT RESEARCH)



From: Steven R Kravitz, DPM


 


A news item in PM News showed the efficacy of Unna boots in a number of dermatologic conditions. The dermatologic beneficial effects of the topical agents within an Unna boot can best be obtained with direct skin application. However, Unna boots are also used for a number of other conditions including orthopedic support for ankle sprains and other injuries. They're also used for wound care due to the dermatology changes that occur with chronic wounds, and also from the compression applied from the Unna boot.


 


There is a good bit of misunderstanding when Unna boots are used for compression therapy to decrease edema which is common, especially in wound care. Literature substantiates that, in general, Unna boots do not increase wound healing. The reason for this is that they do not...


 


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

12/21/2020    

RESPONSES/COMMENTS (RELEVANT RESEARCH)



From: Elliot Udell, DPM


 


We have used Unna boots for various foot conditions but there are differences in the way these are applied. Some practitioners place a layer of Webril on the foot first. Others will apply the Unna boot directly to the skin and cover it with Webril and/or an Ace bandage. How are most of you applying your Unna boots?


 


Elliot Udell, DPM, Hicksville, NY

12/18/2020    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: The Fauci Effect: An Increase in Medical School Applicants—Is This Occurring in Podiatric Medicine?  


From: Leonard A. Levy, DPM, MPH


 



Even as college and university enrollment overall dropped this fall, officials say there is a record number of applicants to medical school. The number of applicants is up 18% this year over last year, according to the Association of American Medical Colleges (AAMC), driven by the example of medical workers and public health figures such as Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases.


 


For example, Stanford University School of Medicine reports a 50% jump in the number of applications, or 11,000 applications for 90 seats and Boston University School of Medicine says applications are up 27%. Medical school admissions officers have started calling this the Fauci Effect. The question: is there also a spike in applicants to schools of podiatric medicine?  If not, why not? (Source: Public broadcasting- WNPR 91.3 FM, Dec. 7, 2020)



 


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

12/01/2020    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: Apremilast Used as Treatment for Psoriatic Nails


From:Leonard A. Levy, DPM, MPH


 


Allen S.W. Oak, MD, of the department of dermatology at the University of Alabama at Birmingham, et al. reported at a European Academy of Dermatology and Venereology Congress on an investigator-initiated, open-label, single-arm study, that apremilast 30 mg twice daily in 11 adults was effective for the treatment of nail psoriasis. Improvement in nail psoriasis was observed with apremilast at week 36 when assessed via the primary endpoint of the Nail Psoriasis Severity Index (NAPSI). 


 


Visibly, nail improvement was observed as early as week 8. Oak and colleagues wrote, “Gastrointestinal adverse events were common as expected and should be discussed with patients." These included nausea, abdominal pain, and increased bowel movements; upper respiratory infections and headache were other possibly related adverse events. According to a presentation at the European Academy of Dermatology and Venereology Congress apremilast, a phosphodiesterase 4 inhibitor, is approved for treatment of moderate to severe plaque psoriasis and psoriatic arthritis. European Academy of Dermatology and Venereology Congress, November 20, 2020.


 


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

11/13/2020    

RESPONSES/COMMENTS (RELEVANT RESEARCH)



From: Leonard A, Levy, DPM, MPH


 


Encouraging results for painful diabetic neuropathy patients using low-frequency spinal cord stimulation (SCS) and who are refractory to conventional care were reported by Erika Petersen, MD, of the University of Arkansas for Medical Sciences in Fayetteville, and colleagues. There was a significant difference between the treatment groups with respect to achieving ≥50 percent pain relief and without a worsening baseline neurological deficit. At a three-month follow-up, there were also differences noted in lower-limb pain scores, responder rates, and investigator-assessed sensory improvements. (American Diabetes Association, ProSmart Brief, November 12, 2020) 


 


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

10/15/2020    

RESPONSES/COMMENTS (RELEVANT RESEARCH)



From: Elliot Udell, DPM


 


Kudos to Dr. Fryberg, et al. for their research showing that topical oxygen therapy is effective in healing diabetic wounds. We have used this modality for over twenty years in our practice and have had excellent results. The only problem is that in my state, the only insurance that will cover this for home use therapy is Medicaid. Since most of the patients we see with diabetic foot wounds tend to have Medicare, when it comes to this modality, they are out of luck.



 


Perhaps now that Dr. Frykberg's paper is in existence, pressure can be brought on Medicare as well as other insurance companies to cover this modality. 



 


Elliot Udell, DPM, Hicksville, NY

09/25/2020    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: COVID-19 and Nail Manifestations 


From:  Leonard A. Levy, DPM, MPH


 


Multiple cutaneous dermatologic manifestations have been reported in patients infected with SARS-CoV-2, especially pernio-like lesions. However, nail apparatus manifestations of SARS-CoV-2 have been scarcely reported. A case was reported in a patient with SARS-CoV-2 infection of transversal red bands of the nail located above the lanule also referred to as the “red half-moon nail sign”.


 


The pathophysiology of this nail manifestation remains to be elusive; however, it was hypothesized that this transient phenomenon could be secondary to vascular inflammation. International Journal of Dermatology, Mendez-Flores, S., et al. Aug. 29, 2020. 


 


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

09/24/2020    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: Co-morbidities in Patients with Palmoplantar Plaque Psoriasis 


From: Leonard A. Levy, DPM, MPH 


 


A study by Greenberg, R, et al. in the Journal of the American Academy of Dermatology reported that several co-morbidities were prevalent in a series of patients with plaque palmoplantar psoriasis. Individuals affected with plaque palmoplantar psoriasis showed a particularly high risk for mood disorders. Dyslipidemia, hypertension, and psoriatic arthritis were also frequent among patients with palmoplantar plaque psoriasis. 


 


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

09/18/2020    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: Treating Plantar Warts with 5-FU Solution Combined with Microneedling 


From: Leonard A. Levy, DPM, MPH


 


In 86.7% of patients having plantar warts a complete resolution resulted in a study employing a combination of 5-fluorouracil (5-FU) solution and microneedling. Treatment was provided for a maximum of six sessions two weeks apart. There was no recurrence reported. The use of microneedling was well tolerated when evaluating therapeutic efficacy, safety, and tolerability. When 5-FU was administered intralesionally, its use was limited because of intense pain. (Ghonemy P, et al. Dermatologic Therapy, Aug 12, 2020) 


 


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

09/16/2020    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: Urate-Lowering Therapy May Reduce Type 2 Diabetes Risk in Patients with Gout 


From: Leonard A. Levy, DPM, MPH


 


A large retrospective cohort study (i.e., 69,326 patients with gout and 69,326 matched control participants) suggest that urate–lowering therapy (ULT) may mitigate the risk for Type 2 diabetes in patients with gout. The mean age of both groups was about 50 years and 70% were male. A total of 69.3% of patients with gout were receiving ULT. 


 


Source: Association between gout, urate-lowering therapy, and risk of developing type 2 diabetes mellitus: a nationwide population-based retrospective cohort study. Published online July 28, 2020. Biomed Res Int. 


 


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

09/10/2020    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: Infrared Thermography as an Adjunct for PVD Diagnosis 


From: Leonard A. Levy, DPM, MPH


 


With the rising cost of healthcare, the economic and social burdens of peripheral arterial disease (PAD) are likely to become considerable. This is being driven mainly by the aging world population and increased exposure to chronic disease risk factors. Among the non-invasive tools used in determining the severity of PAD is a reduced ankle-brachial index (ABI) of less than 0.9. PAD has occasionally been observed even in young adults, with an incidence that is similar in both males and females. Other non-invasive diagnostic methods include toe-pressure measurement (TP), toe-brachial index, pulse volume recording, duplex ultrasound, and a tissue partial oxygen pressure measurement. However, all these have their limitations. 


 


A study has shown that infrared thermography (IRT) is a novel safe, reliable, and non-invasive diagnostic method for quick evaluation of radiating energy related to skin temperature especially useful for evaluating PAD in diabetic feet. This study shows that IRT could effectively distinguish differences in temperature among different foot areas. It can be useful as an additional diagnostic tool combined with other diagnostic non-invasive methods. (Ilo, A, et al. Advances in Skin & Wound Care, pp 482-488. Sept 2020.  


 


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

09/03/2020    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: Black Diabetics Lose Limbs at Triple the Rate of Others


From: Leonard A. Levy, DPM, MPH


  


Clinical Endocrinology News reported (August 31, 2020) that Black Americans with diabetes lose limbs at a rate triple that of others. The American Diabetes Association (ADA) has promoted an initiative to prevent unnecessary amputations as part of an unprecedented campaign to reduce racial disparities in diabetes care. The CEO of the ADA reports, “Every four minutes, someone is losing a limb from diabetes.” Obstacles to equitable care for diabetic patients at risk of amputation include the government’s decision not to endorse screening at-risk patients for vascular disease in the legs, to the inadequate incentives for certain specialists to move to underserved areas, to the health system’s failure to consider limb-saving options before surgeons apply a blade.


 


The ADA’s Health Equity Now campaign addresses the cost of diabetes care, nutrition, discrimination, and more. It was motivated by the racial health disparities that have been exposed by COVID-19, which has hit Black Americans with diabetes particularly hard. As part of the project, the association has built a Health Equity Bill of Rights, asserting that all diabetes patients are entitled to affordable drugs, healthy food, and the latest medical advances. The right to avoid preventable amputations is the only complication of uncontrolled diabetes that is included in the list. The ADA is encouraging practitioners, patients, and members of the public to ask their governors to support the project. 


 


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

08/26/2020    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: Increase in Diabetic Foot Amputations Seen During COVID-19 Lockdown 


From: Leonard A. Levy, DPM, MPH


 


The role of podiatric medicine in the COVID-19 pandemic has been further emphasized. Patients with diabetes admitted to a tertiary care center for diabetic foot ulceration (DFU) during the COVID-19 lockdown in Italy had a more than three-fold risk for amputation versus patients seen in 2019, according to a report published online July 23 in Diabetes Care conducted at the University of Campania in Italy. There was no significant differences in clinical and biochemical measures, except  for urinary albumin-to-creatinine ratio, which was significantly higher in the 2020 group. 


 


In addition, there were no differences seen in ulcer duration; prevalence  rate  of peripheral artery disease, neuropathy, and osteomyelitis; or the percentage of patients reporting a previous history of DFU. In the 2020 group there was a significantly higher prevalence of gangrene (64 versus 29 percent) and a higher proportion of patients requiring amputation (60 versus 18 percent). The researchers indicated that there was a higher risk of amputation observed during the COVID-19 lockdown confirming the need for proper and timely management of DFU patients to prevent a reduction of quality of life and increased morbidity and mortality.


 


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

08/06/2020    

RESPONSES/COMMENTS (RELEVANT RESEARCH)



From: Jean Chen-Vitulli, DPM, MS


 


I absolutely concur with Dr. Levy’s comments about timely management of diabetic foot ulcers during a pandemic. We know it’s not just a matter of when; a pandemic can occur at any time. A group of us are working on this matter with APMA currently and are developing proper data gathering for publication. We hope to use the data to not only show the value of podiatry but also to change healthcare policy of the United States.


 


As we all know too well, delay in diabetic foot ulcer treatment will lead to higher levels of amputation with increased morbidity and mortality. Furthermore, the economic cost to the patient and society will be astronomical.  


 


Jean Chen-Vitulli, DPM, MS, Wappingers Falls, NY

08/05/2020    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: Vitamin D Deficiency Linked to Painful Diabetic Neuropathy


From: Leonard A. Levy, DPM, MPH


 


Vitamin D supplements may significantly improve neuropathic symptoms, including pain and quality of life. A study indicates that vitamin D deficiency is associated with increased risk for painful diabetic neuropathy. Previous studies have reported an association between vitamin D deficiency and painless diabetic neuropathy. Additional studies also have suggested a potential association between vitamin D deficiency and painful diabetic neuropathy.


 


However, this study had several limitations, including small sample size, no data on sunlight exposure or daily activity, and lack of a control group of patients with diabetes without neuropathy. (Source: Alam U, Petropoulos IN, Ponirakis G, et al. Vitamin D deficiency is associated with painful diabetic neuropathy [published online  June 7, 2020]. Diabetes Metab Res Rev


 


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

08/04/2020    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: Foot Amputations in Diabetes Rise During COVID-19 Pandemic 


From: Leonard A. Levy, DPM, MPH


 


During the COVID-19 lockdown in Italy from March 9 to May 18, 2020 compared with those seen in January through May 2019, there was a more than threefold increased amputation risk among diabetes patients who were admitted to a tertiary care center for diabetic foot ulceration. The higher risk of amputation observed during COVID-19 lockdown confirms the need for proper and timely management of diabetic foot ulcer patients to prevent such dramatic outcomes responsible for a reduction of quality of life, and increased morbidity and mortality, researchers indicated. (Source: Diabetes Care, July 23, 2020) 


 


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

07/31/2020    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: Research Continues on “COVID Toes” and What Causes Them  


From: Leonard A. Levy, DPM, MPH


 


In 7 children with painful chilblain-like symptoms on their toes, British investigators found what looks like coronavirus particles within the tiny blood vessel cells of the feet. This may explain the phenomenon known as “COVID toes”,  providing some of the strongest evidence that the virus may be directly responsible for this condition. All tested children were respiratory PCR-negative even though the SARS-CoV-2 virus was visualized on the biopsy specimens.


 


An interesting question would be whether these children end up developing antibodies. While this was a small case series, it is a start in understanding the chilblains-like skin eruption and its relationship with SARS-CoV-2. It was suggested earlier that COVID toes was just in children, but has been seen across the whole age spectrum. (Source: Dermatology Daily, July 28, 2020) 


 


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

07/31/2020    

RESPONSES/COMMENTS (RELEVANT RESEARCH)



From: Simon Young, DPM


 


"Its use is for treating neuropathic pain associated with diabetic peripheral neuropathy (DPN) of the feet in adults but should not be dispensed to patients for self-administration or handling." Who then is going to apply it on the affected areas?


 


Simon Young, DPM, NY, NY

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
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