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05/01/2025
RESPONSES/COMMENTS (RELEVANT RESEARCH)
RE: Elevated Serum Vitamin B12 Levels May be Linked to Adverse Health Outcomes
From: Richard Mann, DPM
Recent studies indicate that persistently elevated serum vitamin B12 levels–as may be the result of high dose oral B12 supplementation (≥1 mg or 1000 mcg per day)–may be linked to adverse health outcomes. A meta-analysis by Liu, et al. of 22 cohort studies (92,000 individuals) showed a positive association between a high serum vitamin B12 concentration (>813 pg/ml) and all-cause mortality. This effect was greatest in older patients and is consistent with the work of other researchers. Serum vitamin B12 levels in the range of 400-500 pg/ml appear to likely optimize neurological function while reducing the risks associated with both deficiency and excess.
Given these new findings, healthcare providers who dispense or prescribe high dose oral vitamin B12 for their patient’s neuropathic symptoms should consider regularly monitoring their patients' vitamin B12 levels and adjusting supplementation as necessary.
Richard Mann, DPM, Highland Beach, FL
Other messages in this thread:
05/05/2025
RESPONSES/COMMENTS (RELEVANT RESEARCH)
From: Elliot Udell, DPM
Thank you, Dr. Mann, for citing this study, which associates an increase in mortality in patients, especially elderly patients, with Vit B12 levels above 400. Thank you, Dr. Jacobs, for pointing out that there is a difference between "association" and "causality." Be that as it may, this paper, cited by Dr. Mann, was a meta-analysis and there are plenty of papers that cite the same association.
In my early days of practice, when we used to treat neuromas with vitamin B12 injections, I recall monitoring their vitamin B12 levels. Patients with serum levels over 800 caused by the injections did not seem to be dying from the treatments. In light of this study cited by Dr. Mann and the wealth of other studies, should we be monitoring our patients who are taking supplements containing vitamin B12? This is in light of the fact that many insurance companies strictly limit the number of times a patient's serum can be monitored for vitamin B12, and if a patient gets a large bill from the lab, he or she will not be a happy camper.
Elliot Udell, DPM, Hicksville, NY
05/02/2025
RESPONSES/COMMENTS (RELEVANT RESEARCH)
From: Allen M. Jacobs, DPM
The article by Lium, et al. was a systematic review and dose-response meta-analysis. The article concluded that serum B12 concentration was "positively associated" with the risk of all-cause mortality, especially in older adults. There is a distinct difference between association and causal pathways, and therefore we must be careful in drawing conclusions from this one paper. B12 is necessary for many reasons as we are all aware, including RBC production and normal neurologic function. The Office of Dietary Supplements states that B12 has not been demonstrated to cause any harm, even at higher dosages. B12 is a water-soluble vitamin, and excess Vitamin B12 is eliminated in the urine.
There is no universal agreement which defines the "normal" serum levels of B12. Excess B12 may rarely cause symptoms, in less than 4% of patients affected, such as nausea, dizziness, or headache. Conversely, B12 deficiency is not uncommon in diabetic patients, particularly those taking metformin, as well as elderly patients. There is no established toxic level for B12, nor for other water-soluble vitamins such as thiamine or benfotiamine. Overdosage of thiamine is rare, but may cause paralysis, convulsion, respiratory, and/or cardiac failure for example.
I have long believed that many of our patients, particularly the elderly and diabetic patients, benefit from B12 supplementation, as well as benfotiamine, L-methyl folate supplementation. The widespread use of vitamin and supplement therapy is now included in discussions of the treatment of diabetic neuropathy as evidenced by recent clinical guidelines by the AAN, and recent publications in Diabetes Care. More importantly, those podiatrists who have employed these supplements and others (e.g.: alpha lipoic acid) have witnessed the positive effects on our patients, resulting in the widespread use of these supplements.
Allen M. Jacobs, DPM, St. Louis, MO
02/13/2025
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1A
From: David Secord, DPM
There are different classes of medications used to treat peripheral neuropathy, including SSRIs, tri-cyclics, SSRNIs, anti-convulsants, and anti-depressants. My experience is with gabapentin, pregabalin, duloxetine, doxepin, and amitriptyline. The goal in dosing these (besides drug/drug interaction concerns) is a balance between effectiveness and anticholinergic side-effects while also looking at potential onset of extrapyramidal syndrome. The medication which has a flag for extrapyramidal symptoms is amitriptyline and I always avoid its usage in anyone with peripheral neuropathy who is over the age of 60 and may have a drug/drug interaction exacerbating this.
I’ve found that amitriptyline is very effective and inexpensive, but can have the most pronounced anticholinergic side-effects. My "go-to" med for peripheral neuropathy is duloxetine, as it appears to have the least anticholinergic side-effects and the least incidence of extrapyramidal...
Editor's note: Dr. Secord's extended-length letter can be read here.
02/13/2025
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1B
From: Allen M. Jacobs, DPM
Dr. Kesselman has asked PM News readers to comment regarding their experience with commonly utilized medications for the treatment of symptomatic diabetic sensory neuropathy and risk of falls. I would like to share my approach to this problem.
Frequently, the symptoms of symptomatic diabetic neuropathy are exacerbated or occur primarily during the evening hours. Therefore, in many patients, I will prescribe a shorter-acting adjunctive analgesic (e.g.-pregabalin, gabapentin, or a tricyclic antidepressant) at bedtime, reducing or eliminating the risk of falls. Oftentimes, a relatively low dosage, almost sub-therapeutic dosage, may be sufficient to provide the patient with a restful, restorative night's sleep and improve...
Editor's note: Dr. Jacobs' extended-length letter can be read here.
02/11/2025
RESPONSES/COMMENTS (RELEVANT RESEARCH)
RE: Fall Risk Assessment When Choosing Between Gabapentin and Duloxetine
From: Paul Kesselman, DPM
A recent article, “Rethink Fall Risk Assessment When Choosing Between Gabapentin and Duloxetine for Older Adults” in Medscape Orthopedics provided a comparative fall risk for new users of Cymbalta vs. gabapentin. Many podiatrists prescribe these pain medications for diabetic neuropathy. It is therefore inherent that prescribers understand that for many geriatric patients, these two medications place already high-risk patients at a greater risk for falls. The study concluded that the fall risk was less in those take who took gabapentin, but this may be due to starting them at a lower dose.
For those readers still in clinical practice, I wonder if you might share your experiences with these two medications and how they may compare to this recent published study.
Paul Kesselman, DPM, Oceanside, NY
01/09/2025
RESPONSES/COMMENTS (RELEVANT RESEARCH)
From: Daniel Chaskin, DPM
There is a text I bought on this topic titled VisualDx: Essential Dermatology in Pigmented Skin. Please understand that dermatoscopic findings might be interpreted differently in pigmented skin of the feet. This is especially true of the palms and soles.
Daniel Chaskin, DPM, Ridgewood, NY
10/31/2024
RESPONSES/COMMENTS (RELEVANT RESEARCH)
From: Howard Friedman, DPM
Dr. Kesselman calls attention to a test which measures how long one can stand on one leg as a test podiatrists can administer to evaluate patients for risk of falling. However, the "Timed Up and Go" test is a quicker test to administer and has been tested and validated to asess balance and fall risk and it has been described as the most frequently used test in the world for this condition. I administer this test to any patient I feel has an untreated balance and gait issue.
Patients begin seated. At the start of the test they are instructed to stand, walk 3 meters, turn around, walk back to the chair and sit down. A time greater than about 12 seconds is considered predictive of a risk of falling. I then refer those patients to a physical therapist for gait training.
Howard E. Friedman, DPM, Suffern, NY
10/30/2024
RESPONSES/COMMENTS (RELEVANT RESEARCH)
From: Paul Kesselman, DPM
A recent article which appeared in Medscape, which has now been picked up by many local papers, suggests that as we age, our balance ability in particular our ability to unilaterally balance, deteriorates, placing us at increased risk for falling.
By measuring how long one can stand on one leg (with eyes open or closed), the researchers found some interesting findings. This is another call for podiatrists to be on the forefront of biomechanics and suggests that waiting until patients fall to assess for fall risk is too little, too late. Examining patients for unilateral balance should be done prior to patients reaching their 60th birthday, suggests the author.
Paul Kesselman, DPM, Oceanside, NY
08/20/2024
RESPONSES/COMMENTS (RELEVANT RESEARCH)
RE: Hepatotoxicity of Common Medications
From: Richard Rettig, DPM
I just read a real-world data study of hepatotoxicity of prescription medications published in JAMA Intern Med. 2024;184 (8):943-952 . Researchers used Dep’t of VA data of almost 8 million individuals prescribed one of 194 oral Rx medications which have been reported as hepatotoxic, and compared that to admission data for severe acute liver injury (ALI). The results were extremely intriguing, particularly with regard to terbinafine. They grouped the medications into 5 groups based on the number of hospital admissions per 10,000 person-years.
Podiatrists do not use any of the 7 most toxic Group 1 drugs. There are 10 drugs in Group 2, which includes the fluoroquinolones ciprofloxacin and levofloxacin, and the imidazoles ketoconazole and fluconazole, as well as amox/clavulanate and sulfamethoxazole. Group 3 of lesser toxicity includes cephalexin and azithromycin. Group 4 includes many medications we use including clindamycin, doxycycline, naproxen, piroxicam, and allopurinol. The most intriguing finding is that terbinafine and statins were in a much lower incidence group 5, and terbinafine is at the very bottom of group 5 with an incidence of less than 1 occurrence in 20,000 person-years.
My take-away is that there are many drugs commonly used by us that we should approach with a higher awareness for ALI, and that terbinafine may be overrated as hepatotoxic. Finally, and this shouldn't be news to anyone, but ketoconazole should never be used orally for onychomycosis.
Richard Rettig, DPM, Philadelphia, PA
08/08/2024
RESPONSES/COMMENTS (RELEVANT RESEARCH)
From: Paul Kesselman, DPM
A recently released article discussed this very interesting topic. For those who are dealing with a large diabetic patient population, it is certainly worthy of more review and discussions with the medical specialists managing the patient's glycemic control. The authors discussed their experiences in a 2-year retrospective analysis at 2 Level 1 Trauma Centers. Their conclusions were that in certain patient populations, the fructosamine levels were a better predictor of perioperative complications of infection, dehiscence, joint replacement failure, and others than HbA1C.
I am left wondering if other podiatrists, including Dr. Allen Jacobs, have had similar experiences with fructosamine levels in their patient population, including office-based and or other outpatient elective surgical patients. For more information, Please click here
Paul Kesselman, DPM, Oceanside, NY
07/31/2024
RESPONSES/COMMENTS (RELEVANT RESEARCH)
From: Paul Kesselman, DPM
Dr. Jacobs’ post is unfortunately true, despite similar posts, from many esteemed colleagues, many who have called for a re-emphasis of biomechanics. In the three or more years I personally have been posting on this issue, nothing in a positive direction has changed. Dr. Jacobs alludes to my review of charts not having sufficient biomechanical or basic gait data. That alone is bad enough! What he failed to mention is it’s far worse than that. In my role as advisor for a myriad of orthotic labs, the sheer volume of improperly completed order forms is staggering. And it’s not just limited to podiatrists.
Chiropractors, orthotists and pedorthists also somehow feel the orthotic lab can fix a bad scan or cast, or somehow figure out the right prescription for what ails the patient. That’s like leaving it to the pharmacist to know which hypertensive medication a patient should take. No ill will towards the pharmacist, but that’s not their responsibility. Just as it’s not the labs issue to repair a cast or predict how much posting or shell rigidity your patient can tolerate. Fabrication labs can do just so much. It’s up to the clinician to do a proper work-up!
Our residents need more time in clinical rotations in biomechanics and less time doing reconstructive trauma surgery. That should be left to post-residency fellowships. We need to spend more time educating the next generation of DPMs on in-office, everyday routine matters and less time-on the less frequent. If that means CPME or other acronyms make changes, so be it. I’m not involved in academia but sometimes it takes an outsider to see what’s wrong. I believe that Dr. Jacobs, I, and many others of our generation see the problems too well!
Paul Kesselman, DPM, Oceanside, NY
07/30/2024
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1A
From: Rod Tomczak, DPM, MD, EdD
Dr. Kesselman asks why a podiatrist has never led a team of researchers or published research concerning the correlation between gait and general health. Dr. Jacobs very succinctly states the reason is because we don’t perform a true gait analysis anymore. Besides, it’s difficult to perform a true evidence-based examination in the office. Experience-based maybe, but real objective data is hard to glean from the equipment most podiatrists have on hand. Most reputable journals would scoff at an article submitted with the title, “Too Many Toes Sign and…” or “Wet Foot Impressions on the Floor in Diagnosing Pes Planus and Pes Cavus.”
But Dr. Kesselman’s question addressed why a podiatrist hasn’t authored the study. I posit there are a few reasons. One, a biomechanics paper is simply not as sexy as a supramalleolar osteotomies manuscript. Secondly, podiatry is primarily an action profession, not an...
Editor's note: Dr. Tomczak's extended-length letter can be read here.
07/30/2024
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1B
From: Ben Pearl, DPM
I agree with Dr. Jacobs' assessment that commercial driven ideas are often passed off as vetted gait research. In addition to all the direct access “biomechanic solutions” that are directly marketed to patients at online and brick and mortar retail outlets, other specialties have begun to fill the void that has been created by many but not all residency programs and other podiatry seminars. Recently, a friend sent me a popular podcast that featured a chiropractor talking about gait and a strong pitch for the benefits of minimalist shoes. There are physical therapy clinics that have specialty run clinics that also fill the void. Another colleague sent me a course called Gait Gurus that reviews cases and is organized by chiropractors.
When I was consultant at NIH, we used to routinely have a biomechanics PhD, orthopedic surgeon, physical therapist, physiatrist, and me watch a patient walk and collectively make recommendations for treatment. I make it a point to try to video my patients’ gait as much as possible and review it with them.
Hopefully, our profession is past the recognition point that we are being superseded by other commercial entities and specialties and is now making active course corrections to remain relevant in the area of gait.
Ben Pearl, DPM, Arlington, VA
07/29/2024
RESPONSES/COMMENTS (RELEVANT RESEARCH)
From: Allen Jacobs, DPM
Some years ago, tapentadol was released as an alternative for the treatment of post-operative pain. Bunionectomies were selected for the study. No podiatrists were authors. Dr. Kesselman, if you speak to students on outside rotations and particularly residents, you will find that patients seldom if ever are subjected to weight-bearing examinations. Of course ABPM and CPME will quickly raise the requirement for a limited number of so called “biomechanical examinations” as a requirement. However, this is an examination that should be ongoing daily for 3 years. This includes patients being evaluated and treated for conditions undergoing surgical decision-making.
The fact is that gait analysis is not a routinely observed part of the podiatry evaluation observed by many podiatry residents. Therefore, it is not surprising that an evaluation of the relationship between gait and general health did not include podiatry...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
07/26/2024
RESPONSES/COMMENTS (RELEVANT RESEARCH)
From: Paul Kesselman, DPM
In a recent publication entitled, "What Your Gait Says About Your Health", the author(s) went into great detail about some issues every person experiences during their lifetime. As podiatrists, we should be on the forefront of monitoring these issues, documenting them, and referring patients to a variety of other practitioners as deemed medically necessary. A question to ask is why wasn't a podiatrist lead team or institution performing this study?
Paul Kesselman, DPM, Oceanside, NY
09/06/2023
RESPONSES/COMMENTS (RELEVANT RESEARCH)
From: Ivar E. Roth, DPM, MPH
Tip, here is the answer. I have studied intensely nail pathology for over 20 years. I have a 98% success rate to CURE any fungus toenail. I mean the worst of the worst. Regularly with the same success rate, I can get nails to re-attach and grow normally. The answer is to treat the nail bed.
Ivar E. Roth, DPM, MPH, Newport Beach, CA
09/04/2023
RESPONSES/COMMENTS (RELEVANT RESEARCH)
RE: Nail Biology and Nail Science
From: Tip Sullivan, DPM
I have always wondered why no one has ever figured a way to entice a nail to re-attach to the nail bed after trauma. I have finally found a great source of information and would like to share it.
Tip Sullivan, DPM, Jackson, MS
04/29/2023
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 2
From: Richard Jaffe, DPM
I have been watching the movement to MIS foot procedures for well over 40 years. I always hoped that I could rationalize the negatives and include the technique in my list of available procedures. Now that we have a serious study to help evaluate the efficacy of the technique, I am as steadfastly opposed to it as ever. Twice the complication rate? Twice the rate of a second surgical procedure? And for what? Has it eluded our practitioners that recovery from foot surgery takes much longer for bone than for soft tissue? Pain and swelling come from bone healing, and not much from skin. And the sum of 3 small incisions is almost as long as a scarf incision. So, what are the advantages of MIS?
In the early years, it took only a few minutes to perform the procedure. Indeed, I noticed the first comments made by orthopedists who tried it always...
Editor's note: Dr. Jaffe's extended-length letter can be read here
04/29/2023
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1
From: Ben Pearl, DPM
While the results of the survey are a little surprising, there is an inherent selection bias in that only runners that were not suffering with debilitating knee arthritis would be participating in the Chicago Marathon.
Ben Pearl, DPM, Arlington, VA
04/26/2023
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1A
From: Neal Blitz, DPM
As you know, MIS bunion surgery is a hot topic, game-changing, and no longer the mark of an "inferior surgeon." You might particularly appreciate the parallels I draw between new MIS bunion repair to the history of laparoscopic surgery, which was once considered an "unethical procedure" and now is the global gold standard.
Neal Blitz, DPM, Beverly Hills, CA
04/26/2023
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1C
From: Robert Kornfeld, DPM
I graduated NYCPM in 1980. Back then, there was a huge divide between “closed” and “open” surgeons. I did lots of MIS bunionectomies with a Shannon #44 burr in those years. There was no question that the x-rays weren’t always pretty but the patients were happy. But applying MIS to certain levels of deformity was not satisfying. While I spent most of my surgical career doing mainly traditional open surgery, I always found MIS preferable for certain cases.
To be honest, this many decades later, it is surprising to me that there are still “evaluations” of MIS being reported. It has been around for a really long time. It is being performed all over the world. I say let each surgeon choose the technique that is most satisfying in his or her hands. If it did not produce positive outcomes, it would no longer be a surgical option for thousands of surgeons around the world.
Robert Kornfeld, DPM, NY, NY
04/26/2023
RESPONSES/COMMENTS (RELEVANT RESEARCH) - PART 1B
From: Keith L. Gurnick, DPM
A total of 911 subjects were included, and 1088 MIS procedures were performed. The average follow-up was 23.8 months. All used the Shannon burr and performed distal metatarsal osteotomies which needed screw fixation. This review found a 16.6% complication rate with MIS hallux valgus correction, which is higher than that reported in the literature for open procedures of 7% to 8%. Many reasons for this increase in complication rate with MIS hallux valgus surgery can be considered. The hardware removal rate accounted for almost 40% of all complications as is likely due to screw prominence after swelling resolves given the entry point on the medial border of the first ray.
1) The review of 17 studies on MIS bunion using a Shannon 44 burr and screw fixation showed twice the complication rate of...
Editor's note: Dr. Gurnick's extended-length letter can be read here.
02/15/2023
RESPONSES/COMMENTS (RELEVANT RESEARCH)
RE: AFOs and PAD
From: Paul Kesselman, DPM
The effectiveness of community-based walking programs for patients with peripheral artery disease (PAD) can be limited by calf claudication during exercise. Recent evidence finds adding carbon fiber ankle foot orthoses (AFO) to a walking program can result in improvements in patient mobility and delay claudication onset when walking.
Paul Kesselman, DPM, Oceanside, NY
01/19/2023
RESPONSES/COMMENTS (RELEVANT RESEARCH)
RE: Aspirin or Low - Molecular-Weight Heparin for Thromboprophylaxis After a Fracture
From: Elliot Udell, DPM
In the January 19, 2023, the Journal of the New England Journal of Medicine, a paper titled: "Aspirin or low - Molecular-Weight Heparin for Thromboprophylaxis After a Fracture" was published by the Major Extremity Trauma Research Consortium. The paper studied post-operative management of lower and upper extremity fractures and this included fractures of the foot as well as the hands.
It showed that placing a patient on low dose aspirin if the fracture was reduced surgically, was as good as giving heparin in preventing thrombosis. The paper studied patients starting at age 18. The paper did not indicate a need for prophylaxis if the pedal fractures were reduced, non-surgically.
Elliot Udell, DPM, Hicksville, NY
01/05/2023
RESPONSES/COMMENTS (RELEVANT RESEARCH)
From: Robert D. Phillips, DPM
I note the discussion in the last couple of days about recurrence rates after hallux valgus surgery. This discussion makes me reflect on some recent actions in our profession's residency education standards.
The question has to be asked, what is an acceptable recurrence rate? If it is 1/1000 or 5/100? If I am one of the patients in which it occurs, I don't care what the recurrence rate is. The fact that it happened to me is of primary importance and I want to know why. I also expect that the person who performed the surgery also wants to know why. Did that person do any type of exam before surgery besides take a couple of x-rays on...
Editor's note: Dr. Phillips' extended-length letter can be read here.
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