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09/07/2021    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: Novel Macrophage-Regulating Drug-Effect on Wound Healing in Patients With DFUs 


From: Leonard A. Levy, DPM, MPH


 


A study by Huang, YY, et al. reported that topical treatment with ON101 resulted in improved healing of diabetic foot ulcers (DFUs) compared to standard care. The study was a randomized phase 3 clinical trial of 236 patients with DFUs. A topical application of ON101 with gauze immediately after debridement demonstrated significant healing efficacy compared with an absorbent dressing in all patients (Hydrofiber; ConvaTec Ltd), including those with DFU-related risk factors. Delayed healing of DFUs is known to be caused by dysregulated M1/M2-type macrophages. Restoring the balance between these macrophage types plays a critical role in healing. Drugs used to regulate M1/M2 macrophages have not yet been studied in large randomized clinical trials.


 


This study was a multicenter randomized clinical trial. Eligible patients with debrided DFUs of 1 to 25 cm2 present for at least 4 weeks and with Wagner grade 1 or 2 were randomized 1:1 to receive ON101 or control absorbent dressings. ON101 exhibited better healing efficacy than absorbent dressing alone in the treatment of DFUs and showed consistent efficacy among all patients, including those with DFU-related risk factors (glycated hemoglobin level, ≥9%; ulcer area, >5 cm2; and DFU duration, ≥6 months). No treatment-related serious adverse events occurred in the ON101 group vs 1 (0.9%) in the comparative group.  


 


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

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07/21/2022    

RESPONSES/COMMENTS (RELEVANT RESEARCH)



From: Steven Kravitz, DPM


 


This is an interesting study, but not necessarily a "green light" for cortisone injection in the treatment of Achilles tendinitis. It still should be used only after conservative treatment, when heel lifts, stretching, etc. are not effective. If cortisone injection is used, it should be applied judiciously, not repeated on a regular basis for a long period of time, and short-acting steroids are preferred. Additionally, the degree of tendon disruption should be considered prior to the use of cortisone therapy.


 


Finally, what is the lifestyle and the degree of stress the individual is expected to apply to the Achilles tendon apparatus post-injection therapy? The two extremes would be a ballet dancer and a librarian. The long-term potential negative impact on the structure intended is of much more concern with a ballet dancer and others who are extremely...


 


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

07/20/2022    

RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1B



From: Keith L. Gurnick, DPM


 


This is a wonderful piece of literature to help defend doctors who end up in a lawsuit after Achilles tendon ruptures associated with repeated cortisone injections. They reported no "severe" adverse effects in their study. All patients were injected with either (1) 1 mL of methylprednisolone acetate (40 mg/mL) and 1 mL of lidocaine (10 mg/mL) (corticosteroid injection) or (2) 1 mL of lipid emulsion and 1 mL of lidocaine (10 mg/mL) (placebo injection). No severe adverse events were observed in either group, and there was no deterioration in the long term (2-year follow-up).  Patients were offered up to 3 injections with an interval of at least 4 weeks between each injection.


 


All adverse events, defined as any negative or unwanted reaction to the intervention, were recorded at each physician visit, with special focus on fat atrophy, skin depigmentation, infections, and tendon ruptures. Furthermore, during the intervention period, the patients were asked to register any adverse events in their patient diary, including pain beyond a few days after the injections.


 


A total of 215 injections were administered (87 corticosteroid and 128 placebo). Injection pain was indicated in the patients’ diaries, with a mean (SD) pain score of 12 (14) of 100 in the corticosteroid group and 14 (17) of 100 in the placebo group, with no significant differences between groups. No severe adverse events (e.g., infection, tendon rupture, subcutaneous depigmentation, or atrophy) were recorded in either of the groups.


 


Keith L. Gurnick, DPM, Los Angeles, CA

07/20/2022    

RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1A



From: Doug Richie, DPM, Elliot Udell, DPM


 


It is important to recognize that the corticosteroid injections were not administered directly into the Achilles tendon in this study.  As noted in the manuscript, the injections were "placed peritendinous anterior to the tendon in the Kager triangle as close as possible to the thickest part of the tendon, or, in the case of neovascularization, as close as possible to the intratendinous vessel(s)."


 


Doug Richie, DPM, Long Beach, CA


 


Thank you, Dr. Kass for sharing this article with all of us. What is most interesting is that the paper not only documented "immediate" relief of symptoms but studied the Achilles tendon with ultrasound, and documented that there was no deterioration over two years. 


 


This would seem to give us a green light to treat Achilles tendinopathy with one injection of a steroid. One question that this paper did not cover was whether there is danger to the Achilles tendon by giving multiple, weekly injections of a steroid. 


 


Elliot Udell, DPM, Hicksville, NY 

07/19/2022    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: Ultrasonography-Guided Corticosteroid Injection vs. Placebo Added to Exercise Therapy for Achilles Tendinopathy


From: Jeffrey Kass, DPM


 


I read this JAMA Open Access article titled, "Effect of Ultrasonography-Guided Corticosteroid Injection vs. Placebo Added to Exercise Therapy for Achilles Tendinopathy: A Randomized Clinical Trial" with interest as it seemingly went against the previous notion of injecting steroid near the watershed area of the Achilles' tendon. Not only did they inject steroid, but they opted for an acetate as opposed to a phosphate. Any comments for discussion will be appreciated.


 


Jeffrey Kass, DPM, Forest Hills, NY

06/14/2022    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: Study Shows Relationship of Diabetic Foot Ulcers to Vitamin D Deficiency


From: Leonard A. Levy, DPM, MPH


 


A retrospective study was done on 339 hospitalized patients with type 2 diabetes, aged 60-90 years (mean age 67, nearly two-thirds were men) . They were seen between January 2020 and March 2020, including 204 with and 135 without diabetic foot ulcers. Overall, 80.5% had vitamin D deficiency (defined as < 50 nmol/L or < 20 ng/mL). Factors that independently linked with an increased diabetic foot ulcer risk were prolonged diabetes duration and elevated systolic blood pressure. 


 


While the relationship between diabetic foot ulcers and vitamin D levels has been controversial, the study showed that among the people with a diabetic foot ulcer, only 3% had vitamin D levels that were sufficient (> 75 nmol/L or > 30 ng/mL), 24% had levels defined as insufficient (50-75 nmol/L or 20-30 ng/mL), and 73% were deficient. The differences between these rates and those among the people without a diabetic foot ulcer were significant. Elderly people with diabetes were recommended to have routine vitamin D screening or receive vitamin D supplementation to prevent the onset or improve the prognosis of diabetic foot ulcers. (Source: Miriam E. Tucker, Medscape, Low Vitamin D Links With Increased Diabetic Foot Ulcers, June 03, 2022)


 


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

06/09/2022    

RESPONSES/COMMENTS (RELEVANT RESEARCH)



From: Ivar E. Roth, DPM, MPH


 


Kudos to Dr. Armstrong on moving our profession ahead with his amputation statistics showing how much podiatry can help save lives and limbs.


 


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

06/09/2022    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: Tall People at Increased Risk of Peripheral Neuropathy


From: Leonard A. Levy, DPM, MPH


 


Analyses were performed using data from the U.S. Veterans Affairs (VA) Million Veteran Program in 222,300 non-Hispanic White and 58,151 non-Hispanic, Black adults in the U.S. It was concluded that tall people have an increased risk of peripheral neuropathy and skin and bone infections but a lower risk of heart disease, hypertension, and elevated cholesterol.


 



 


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

05/24/2022    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


Race, Ethnicity, and Rurality Associated With Amputation or Death with DFUs


 


Investigators from the University of Wisconsin School of Medicine and Public Health as well as the William S. Middleton Hospital, Department of Veterans Affairs, conducted a cohort study which concluded that rural patients with diabetic foot ulcers identified as Black had a greater than 10 absolute percentage increase in the rate of major amputation or death compared with the overall cohort. 


 


Of the 124,487 patients hospitalized with diabetic foot ulcers and who were Medicare beneficiaries, 17.6% underwent major (above-ankle) leg amputation or died within 30 days of hospital discharge; proportions increased to 18.3% for rural patients and 21.9% for those identifying as Black. The proportion further increased to 28.0% for patients who identified as both rural and Black, suggesting a role for intersectionality. (Meghan B. Brennan, et al., April 21, 2022.) 


 


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

03/22/2022    

RESPONSES/COMMENTS (RELEVANT RESEARCH)



From: Gary R. Bauer, DPM


 


I would agree with the commentary by Drs. Ivar Roth and David Secord regarding the recent interest/revolutionary concept of fat transplant to supplement fat pad atrophy in the infracalcaneal and sub-metatarsal regions. Although Edward Chaiman, DPM may have developed instrumentation to facilitate this procedure, he certainly did not invent the idea. Raymond J. Suppan, DPM, the Chairman of the Department of Surgery, Ohio College of Podiatric Medicine in 1975 had already contemplated the concept, performed his own clinical trials, and determined the procedure unsatisfactory due to migration and atrophy of the fat transplant.  


 


Gary R. Bauer, DPM (retired) , Franklinville, NJ

03/18/2022    

RESPONSES/COMMENTS (RELEVANT RESEARCH)



From: Ivar E. Roth, DPM, MPH


 


I read with interest about this “new” procedure. It really bothers me that this common problem that can be treated so well with conservative care would have doctors out there coming up with invasive, costly, new procedures. In my opinion, this new procedure is a gimmick. It is an attempt to treat a problem that pretty much can be easily resolved universally by podiatrists. Am I missing something?


 


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

12/21/2021    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: Bilateral Plantar Pseudo-Kaposi Sarcoma Treated with Propranolol 


From: Leonard A. Levy, DPM, MPH


 


Pseudo-Kaposi sarcoma (PKS), also known as acroangiodermatitis, is a benign cutaneous reactive angiomatosis with clinical and histopathologic characteristics resembling Kaposi sarcoma (KS). There are 2 variants, one the Mali type, associated with venous hypertension, and the Stewart-Bluefarb type, associated with an arteriovenous malformation or an acquired iatrogenic arteriovenous fistula in patients with chronic renal failure. A patient is described with bilateral plantar PKS treated with propranolol, a non-selective β-adrenergic blocker which improves vascular diseases, such as proliferating infantile hemangioma and other vascular diseases, owing to its vasoconstrictive and angiogenesis-inhibiting effects.


 


Treatment of PKS tends to be conservative. PKS is a rare disease among cutaneous reactive angiomatoses and is thought to be characterized by a vascular abnormality followed by histiocyte recruitment and endotheliocyte and pericyte hyperplasia. PKS typically presents with violaceous papules and plaques, which are usually located on the lower limbs. Source:  Takaaki, Mine, et al., JAAD Case Rep. 2021 Dec; 18: 74–78.


 


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

12/08/2021    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: Alcohol Consumption and Diabetic Peripheral Neuropathy


From: Richard Mann, DPM


 


A recently published paper in the journal Diabetes Therapy, examines the impact of alcohol use in diabetic patients with distal symmetrical polyneuropathy (DSP). In the paper, “Alcohol Consumption as a Causator and/or an Accelerator of Neuropathy in People with Diabetes is Regularly Overlooked,” the authors note that the most common cause of DSP next to diabetes is excessive alcohol intake, which is almost never evaluated, and that peripheral nerve damage from these two distinct pathologies is likely to be additive.


 


Authored by two board certified endocrinologists, the paper makes the point that alcohol use is often underreported by patients. They recommend that in addition to taking a detailed medical history, clinicians should investigate the possibility of...


 


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

12/07/2021    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: Association of Psoriasis with Venous Thromboembolism and PVD


From: Leonard A. Levy, DPM, MPH  


 


There are no known reviews examining the association of psoriasis with the incidence of venous thromboembolism (VTE) or peripheral vascular disease (PVD). Tai-Li Chen, MD, et al. conducted a systematic review and meta-analysis to address this knowledge gap. It was concluded that psoriasis is associated with an increased risk of incidence of VTE and PVD, especially in patients with psoriatic arthritis. The authors also concluded that physicians and patients with psoriasis should be aware of the risk of VTE and PVD.


 


Typical presentations (e.g., unexplained dyspnea, chest pain, and painful edematous swelling, as well as lack of pulses and sensorimotor abnormalities of leg) should not be ignored by physicians who are treating patients with psoriasis. Risk factors, such as obesity, physical inactivity, smoking, and varicose veins, should be identified and treated in patients with psoriasis, and medications like hormone-related therapies should be prescribed cautiously. 


 



 


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

12/01/2021    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: Diabetic Peripheral Neuropathy Linked to Cognitive Decline in Type 2 Diabetes


From: Leonard A. Levy, DPM, MPH


 


Diabetic peripheral neuropathy is associated with a decline in cognition for people with type 2 diabetes, according to a study by JL Barzilay from the Division of Endocrinology at Emory University School of Medicine published in the Journal of Diabetes and its Complications. In his findings from the Glycemia Reduction Approaches in Diabetes Study (GRADE), diabetic peripheral neuropathy was associated with worse results in cognitive tests, but no association was found with cardiovascular autonomic neuropathy and cognition. Barzilay indicates that “If indeed subclinical peripheral neuropathy arises together with subclinical cognitive dysfunction in people with diabetes, it suggests that people with peripheral neuropathy may be at risk later on for more serious clinical cognitive dysfunction.”


 


In fully adjusted models, highly sensitive C-reactive protein, HbA1c, systolic blood pressure, and alcohol intake were not associated with diabetic peripheral neuropathy. However, LDL cholesterol was associated with definite diabetic peripheral neuropathy, but not continuous diabetic peripheral neuropathy. Waist circumference and urine albumin creatinine ratio were the strongest covariates in the association between diabetic peripheral neuropathy and cognitive impairment. “Recently there was a scientific study demonstrating that peripheral nerve stimulation leads to MRI changes in the parts of the brain associated with cognition,” Barzilay said. “Such scientific studies can help explain how and why such associations exist.


 


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

11/19/2021    

RESPONSES/COMMENTS (RELEVANT RESEARCH)



From: Tom Hardiman, DPM


 


I was horrified and in disbelief that a professional and responsible source such as PM News would choose to publish a piece about Prof. Yasmin Ezzatvar's very questionable and misleading "study." This professor from Spain with a doctorate in physical therapy, who is a faculty member at a nursing school, performed a literature search and only included 23 studies in her final review.


 


Making a final conclusive statement such as "No differences have been found in the risk of other complications, such as amputations, among people of other racial or ethnic groups" is absolutely untrue and irresponsible. This is utterly insulting to...


 


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

11/02/2021    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: PRP Injections Ineffective in Ankle Osteoarthritis


From: Leonard A. Levy, DPM, MPH


 


Patients with ankle osteoarthritis got no relief from PRP injections, reports L. Paget, MD, and colleagues of the University of Amsterdam in the Netherlands. Paget's group indicated that the results of a study that included a placebo does not support the use of PRP injections for ankle osteoarthritis. PRP is an autologous extract from patients' blood.


 


Platelets release certain growth factors thought to modulate the intra-articular environment, potentially facilitating an anti-inflammatory, anabolic, and analgesic effect. Paget L, et al. "Effect of Platelet-Rich Plasma Injections vs. Placebo on Ankle Symptoms and Function in Patients with Ankle Osteoarthritis: a Randomized Cinical Trial" JAMA 2021. 


 


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

10/19/2021    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: Epidemiology of PAD, One of the Most Common Conditions in the World         


From:  Leonard A. Levy, DPM, MPH 


 


Peripheral artery disease (PAD) affects approximately 8.5 million people in the U.S. and approximately 230 million people worldwide. While uncommon before age 50 years, it affects up to 20% of people aged 80 years and older. PAD is associated with increased rates of cardiovascular events, lower extremity events, and functional decline compared with that of people without PAD. Compared with people without PAD, those with the disease have approximately twice the rate of all-cause mortality, cardiovascular mortality, and major coronary events at 10-year follow-up. Approximately 11% of people with PAD develop chronic limb-threatening ischemia, the most severe form of the condition. 


 


Approximately 75% of people with PAD report no change in leg symptoms over time. In addition, those with PAD have significantly greater annual declines in 6-minute walk performance compared with those without it. Polansky and McDermott report in JAMA that people with PAD should be treated with the highest dose of statin tolerated, antithrombotic and/or antiplatelet therapy, and exercise. (2021 Jun 1; 325(21):2188-2198.


 


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

10/08/2021    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: Isolates from Shoe Soles Reveals Clostridioides Difficile Inside and Outside Healthcare Settings 


From: Leonard A. Levy, DPM, MPH


 


In an NIH-funded worldwide analysis conducted at the University of Houston in Texas of 11,986 collected isolates from shoe soles, Clostridioides difficile (C. diff) positivity rates were 26% in healthcare settings and 24% in non-healthcare settings. Over 90% of samples were from the U.S. The lead author, Jinhee Jo, PharmD, indicated that the bottoms of shoes are not clean and may introduce harmful bacteria into bathrooms or kitchens and cause illness. Co-author Kevin W. Garey, PharmD, remarked "We can no longer think of C. diff as only existing in healthcare settings, and the population at risk is no longer just the very sick patient in the hospital." 


 


Identifying that person at risk anywhere in the world should become a priority regardless of whether the person is in a hospital or the community.” The CDC estimates that nearly half a million C. diff infections which may include mild diarrhea to sepsis, occur annually in the U.S. resulting in 30,000 deaths. The study was presented at the annual joint meeting of the Infectious Diseases Society of America, Society for Healthcare Epidemiology of America, Pediatric Infectious Diseases Society, HIV Medicine Association, and Society of Infectious Diseases. 


 


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

09/15/2021    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: Sedentary Behavior Increases Risk of Foot Ulcer in Diabetic Peripheral Neuropathy


From: Leonard A. Levy, DPM, MPH


 


A recent study in the journal Diabetes Research and Clinical Practice indicated that patients with diabetic peripheral neuropathy (DPN) who spend at least 12 hours of sedentary time (SED-time) are more likely to develop a foot ulcer. The study suggests that sedentary time should be monitored, and standard care for diabetes patients should include strategies aimed at reducing it. The eight-year prospective study included 175 DPN patients.


 


Nerve function was evaluated by conduction studies, vascular function by ankle-brachial index and pedal pulses, and foot deformity and skin dryness by inspection. 35.5% of the participants developed DFUs and SED-time was significantly higher in people who developed DFUs which was one of the strongest variables contributing to DFUs. The study concluded that SED-time is an independent predictor of DFU development. (Orlando G, et al., Diabetes Research and Clinical Practice)


 


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

09/13/2021    

RESPONSES/COMMENTS (RELEVANT RESEARCH)



From: Paul Kesselman, DPM


 


The recent posting in PM News regarding effectiveness of At Home Skin Temperature Monitoring in Reducing the incidence of DFUs contains, at best, misleading information and a totally wrong conclusion. Due to the limitations of a letter, only the three main objections to the conclusion will be addressed:


 


1) The conclusion and headline of the PM News post does not represent what was actually stated in the original manuscript. The letter in PM News states: At-home foot temperature monitoring does not significantly reduce...


 


Diclosure: I am a paid consultant to Siren Technologies.


 


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

09/11/2021    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: Role of Podiatric Physicians in Preventing Mortality


From: Leonard A. Levy, DPM, MPH


 


While podiatric physicians have one of the most important roles in assuring that their patients can engage in a very important aspect of human life, namely walking, little is found in the podiatric medical literature recognizing the importance of walking to prevent coronary heart disease and reducing mortality. A study estimated the association of steps per day with (age 41-65 years) all-cause mortality among Black and White men and women. This was a prospective-cohort study that was part of the coronary artery risk development in Young Adults (CARDIA) study. Participants were aged 38-50 years.


 


The study found that among White and Black men and women in middle adulthood, participants who took approximately 7,000 steps per day or more, mortality was lower than those who took fewer than 7,000 steps per day. Furthermore, there was no association of step intensity with mortality. Those taking at least 7,000 steps per day had approximately 50% to 70% reduction in risk of mortality but those taking more than 10,000 steps per day did not have a further reduction in mortality risk.


 


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

09/09/2021    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: Lower Extremity PAD and Chronic Limb-Threatening Ischemia


From: Leonard A. Levy, DPM, MPH


 


Approximately 8.5 million people in the U.S. and 230 million worldwide are affected by lower extremity peripheral artery disease (PAD). While uncommon before aged 50 years, it affects up to 20% of people aged 80 years and older. Non-invasively, it can be diagnosed with the ankle-brachial index (ABI) value of less than 0.90 which is 57% to 79% sensitive. ABI is 83% to 99% specific for arterial stenosis of at least 50%. However, 70% to 90% of people with an ABI value less than 0.90 report no exertional leg symptoms (i.e., asymptomatic) or leg symptoms with walking not consistent with classic claudication.


 



 


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

09/08/2021    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: Painful Lower Extremity Rash


From: Leonard A. Levy, DPM, MPH


 


A 25-year-old woman was admitted to the hospital with a 2-day history of leg swelling and a painful, palpable rash that started on her toes and spread up her legs. She was otherwise in good health and had no personal or family history of skin problems. The woman’s palpable purpura with edema in her lower extremities was consistent with cutaneous leukocytoclastic vasculitis (LCV). LCV is characterized by the circulation of immune complexes that promote activation of complement, leading to endothelial injury and palpable purpura. Pain, arthralgia, cutaneous ulceration, and constitutional symptoms may be observed.


 













Painful Lower Extremity Rash



 


About 50% of LCV cases are idiopathic but causes may include infection (including syphilis infection), drugs, malignancy, and...


 


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

08/30/2021    

RESPONSES/COMMENTS (RELEVANT RESEARCH)



From: Robert Schwartz, CPed


 













Our worn shoes tell a story- Click on photo to view video



 


Robert Schwartz, CPed, NY, NY

08/25/2021    

RESPONSES/COMMENTS (RELEVANT RESEARCH)


RE: Alcoholic Peripheral Neuropathy


From: Richard Mann, DPM


 


Summary: Clinicians should consider the diagnosis of alcoholic peripheral neuropathy in patients who presently use alcohol excessively and patients who, while currently sober, have a history of such behavior.


 


In 2019, according to The National Institutes of Health (NIH), there were approximately 14.5 million alcoholics in the U.S. – with estimates suggesting that nearly 10 million of them suffered from painful small fiber peripheral neuropathy – the most common neurological complication associated with...


 


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