official newspaper of th apma annual scientific … · 2014. 7. 28. · the national today official...

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The National Today OFFICIAL NEWSPAPER OF THE APMA ANNUAL SCIENTIFIC MEETING July 24-27, 2014 • Honolulu, Hawaii • Hilton Hawaiian Village and Convention Center Saturday, July 26, 2014 6:30–8 a.m. Breakfast Symposium 1: Overcom- ing Onychomycosis: Management Update Ballroom A Breakfast Symposium 2: Understand- ing Biologics: Update on Bone Graft Applications Ballroom C 8–9 a.m. Plenary Lecture: Tackling Tinea Pedis: Updates on Latest Treatments Ballroom B 9–9:30 a.m. Exhibit Hall Break and CECH Scanning Kamehameha Exhibit Hall 9:30–11 a.m. Track 1: Pediatrics Room 311 Track 2: Controversy Debates Room 312 9:30 a.m.–Noon Assistants’ Program: Practice Man- agement and ICD-10 Room 301B Workshop 2: Ankle Arthroscopy Workshop Room 308AB 11 a.m.–Noon Track 1: Public Health/Falls Preven- tion Room 311 Track 2: Health-Care Disparities Room 312 Noon–1 p.m. Lunch Break and CECH Scanning Kamehameha Exhibit Hall Non-CECH Lunch Symposium: Topical Antifungal Therapy: New Options, New Opportunities Ballroom A 1–2 p.m. Poster Abstracts Symposium Kamehameha Exhibit Hall For additional meeting coverage, visit apma-365.ascendeventmedia.com. Today’s Schedule MRI Provides Comprehensive Imaging for Ankle and Foot New Approaches Saving Limbs of Patients with Vascular Disease Knowing Addiction Medicine a Key in Pain Management 4 5 12 Inside this issue: see SYMPOSIUM, page 15 see SCHEDULE, page 5 Dermatology, Diabetes Treatments Addressed in Breakfast Symposium A n update of the treatment of a variety of common dermatology conditions podiatric physicians see and a look at treatment advances for type 2 diabetes as well as the role the specialty plays in controlling its effects were presented yesterday in the Breakfast Symposium “Dermatological Condition Update.” Use of Topical and Steroid Treatments From simple dry skin, to various types of dermatitis, to fungal infections, podiatric physicians see a variety of dermatologic conditions, but they need to broaden their diagnostic and treatment horizons to better serve their patients, said G. (Dock) Dockery, DPM. “It is a common misconception by most practitioners that everything that is a rash on the foot is a fungal infection, and studies show that is not the case,” said Dr. Dockery, International Foot & Ankle Foundation. “Sixty percent of rashes are eczematous dermatitis and are not fungal. “If you find out you have a bacterial infection, you treat it with an antibiotic. If you find out you have a fungal infec- tion, you treat it with an antifungal. If you have a viral infection, you treat it with an antiviral. Pretty much everything else is eczematous dermatitis that needs to be treated with steroids, and they are more complex.” Dr. Dock- ery addressed dermatitis, and he reminded cli- nicians that it is an inflammation of the dermis exhibiting spongiosis or fluid between the cells. e most common spongiotic dermatitis and eczematous dermatitis are atopic derma- titis, eczema, allergic contact dermatitis, nummular dermatitis, and dyshidrotic dermatitis. He cautioned against assuming rashes are a fungus because treating fungal and yeast infections with steroids can cause the infections to worsen and slow the treat- ment when added to antifungals. To better diagnose the condition, a punch biopsy is the best option, and ideally a practitioner should get two 2mm punches instead of one 4mm punch, Dr. Dockery said. e gold standard for treating spongiot- ic or eczematous dermatitis is topical cor- ticosteroids, and he reminded physicians to use Fitzpatrick skin typing to determine which corticosteroid to use. A recent development in the use of Interesting Cases Often Turn into Deadly Cases B radley W. Bakotic, DPM, DO, was forced to deliver his Plenary address yesterday from Atlanta, but in Honolulu the message was clear: Don’t hesitate to take biopsies of suspicious lesions. “Be open-minded to outside viewpoints. Be careful not to limit biopsies to cases of obvious malignancy. Don’t forget the mean- ing of ‘atypical,’” said Dr. Bakotic, who pre- sented “Interesting Case Studies in Podiatric Medicine.” Using an audio connection and displaying presentation slides on screens in the room, Dr. Bakotic reviewed 11 cases and answered questions from the audience. He started with more ordinary unusual cases, includ- ing a man who presented with blotches and bruises on his feet, but was diagnosed with pernio when it was discovered he worked in a cold environment. In another case, a nine- year-old girl with a toe nodule was diag- nosed with infantile digital inclusion body. Other interesting cases at first appeared innocuous, but medical investigations revealed otherwise. A 73-year-old woman with a nodule that had appeared two months earlier was found to have diffuse large B-cell lymphoma of the leg, and died. ese lymphomas oſten are not life-threat- ening, but on the legs they spread rapidly, and half of patients die, Dr. Bakotic said. “For some reason, when this occurs on the leg, the prognosis becomes much worse,” he said. “As physicians of the lower extremities, you need to be aware of this.” ree other cases also involved older women diagnosed with cancers, and a fourth involved a man diagnosed with metastatic renal cell carcinoma several years aſter being cleared of cancer, which is not unusual, Dr. Bakotic said. Yesterday’s Breakfast Symposium ad- dressed dermatology issues and Fariba Rahnema, MD, also discussed treating type 2 diabetes.

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Page 1: OFFICIAL NEWSPAPER OF TH APMA ANNUAL SCIENTIFIC … · 2014. 7. 28. · The National Today OFFICIAL NEWSPAPER OF TH APMA ANNUAL SCIENTIFIC MEETING Jul 24-27, 2014 Honolulu, Hawaii

The National TodayOFFICIAL NEWSPAPER OF THE APMA ANNUAL SCIENTIFIC MEETING

July 24-27, 2014 • Honolulu, Hawaii • Hilton Hawaiian Village and Convention Center Saturday, July 26, 2014

6:30–8 a.m.Breakfast Symposium 1: Overcom-ing Onychomycosis: Management UpdateBallroom A

Breakfast Symposium 2: Understand-ing Biologics: Update on Bone Graft ApplicationsBallroom C

8–9 a.m.Plenary Lecture: Tackling Tinea Pedis: Updates on Latest TreatmentsBallroom B

9–9:30 a.m.Exhibit Hall Break and CECH ScanningKamehameha Exhibit Hall

9:30–11 a.m.Track 1: PediatricsRoom 311

Track 2: Controversy DebatesRoom 312

9:30 a.m.–NoonAssistants’ Program: Practice Man-agement and ICD-10Room 301B

Workshop 2: Ankle Arthroscopy WorkshopRoom 308AB

11 a.m.–NoonTrack 1: Public Health/Falls Preven-tionRoom 311

Track 2: Health-Care DisparitiesRoom 312

Noon–1 p.m.Lunch Break and CECH ScanningKamehameha Exhibit Hall

Non-CECH Lunch Symposium: Topical Antifungal Therapy: New Options, New OpportunitiesBallroom A

1–2 p.m.Poster Abstracts SymposiumKamehameha Exhibit Hall

For additional meeting coverage, visit apma-365.ascendeventmedia.com.

Today’s Schedule

MRI Provides Comprehensive Imaging for Ankle and Foot

xx

New Approaches Saving Limbs of Patients with Vascular Disease

Knowing Addiction Medicine a Key in Pain Management4 5 12

Inside this issue:

see SYMPOSIUM, page 15

see SCHEDULE, page 5

Dermatology, Diabetes Treatments Addressed in Breakfast Symposium

A n update of the treatment of a variety of common dermatology conditions podiatric physicians see and a look at treatment advances for type 2 diabetes

as well as the role the specialty plays in controlling its effects were presented yesterday in the Breakfast Symposium “Dermatological Condition Update.”

Use of Topical and Steroid TreatmentsFrom simple dry skin, to various types of dermatitis, to fungal infections, podiatric physicians see a variety of dermatologic conditions, but they need to broaden their diagnostic and treatment horizons to better serve their patients, said G. (Dock) Dockery, DPM.

“It is a common misconception by most practitioners that everything that is a rash on the foot is a fungal infection, and studies show that is not the case,” said Dr. Dockery, International Foot & Ankle Foundation. “Sixty percent of rashes are eczematous dermatitis and are not fungal.

“If you find out you have a bacterial infection, you treat it with an antibiotic. If you find out you have a fungal infec-tion, you treat it with an antifungal. If you have a viral infection, you treat it with an antiviral. Pretty much everything else is eczematous dermatitis that needs to

be treated with steroids, and they are more complex.”

Dr. Dock-ery addressed dermatitis, and he reminded cli-nicians that it is an inflammation of the dermis exhibiting spongiosis or fluid between the cells. The most common spongiotic dermatitis and eczematous dermatitis are atopic derma-titis, eczema, allergic contact dermatitis, nummular dermatitis, and dyshidrotic dermatitis.

He cautioned against assuming rashes are a fungus because treating fungal and yeast infections with steroids can cause the

infections to worsen and slow the treat-ment when added to antifungals.

To better diagnose the condition, a punch biopsy is the best option, and

ideally a practitioner should get two 2mm punches instead of one 4mm punch, Dr. Dockery said.

The gold standard for treating spongiot-ic or eczematous dermatitis is topical cor-ticosteroids, and he reminded physicians to use Fitzpatrick skin typing to determine which corticosteroid to use.

A recent development in the use of

Interesting Cases Often Turn into Deadly Cases

B radley W. Bakotic, DPM, DO, was forced to deliver his Plenary address yesterday from Atlanta, but in Honolulu the message was clear: Don’t hesitate to take

biopsies of suspicious lesions.“Be open-minded to outside viewpoints.

Be careful not to limit biopsies to cases of obvious malignancy. Don’t forget the mean-ing of ‘atypical,’” said Dr. Bakotic, who pre-sented “Interesting Case Studies in Podiatric Medicine.”

Using an audio connection and displaying presentation slides on screens in the room,

Dr. Bakotic reviewed 11 cases and answered questions from the audience. He started with more ordinary unusual cases, includ-ing a man who presented with blotches and bruises on his feet, but was diagnosed with pernio when it was discovered he worked in a cold environment. In another case, a nine-year-old girl with a toe nodule was diag-nosed with infantile digital inclusion body.

Other interesting cases at first appeared innocuous, but medical investigations revealed otherwise. A 73-year-old woman with a nodule that had appeared two months earlier was found to have diffuse

large B-cell lymphoma of the leg, and died. These lymphomas often are not life-threat-ening, but on the legs they spread rapidly, and half of patients die, Dr. Bakotic said.

“For some reason, when this occurs on the leg, the prognosis becomes much worse,” he said. “As physicians of the lower extremities, you need to be aware of this.”

Three other cases also involved older women diagnosed with cancers, and a fourth involved a man diagnosed with metastatic renal cell carcinoma several years after being cleared of cancer, which is not unusual, Dr. Bakotic said.

Yesterday’s Breakfast Symposium ad-dressed dermatology issues and Fariba Rahnema, MD, also discussed treating type 2 diabetes.

Page 2: OFFICIAL NEWSPAPER OF TH APMA ANNUAL SCIENTIFIC … · 2014. 7. 28. · The National Today OFFICIAL NEWSPAPER OF TH APMA ANNUAL SCIENTIFIC MEETING Jul 24-27, 2014 Honolulu, Hawaii
Page 3: OFFICIAL NEWSPAPER OF TH APMA ANNUAL SCIENTIFIC … · 2014. 7. 28. · The National Today OFFICIAL NEWSPAPER OF TH APMA ANNUAL SCIENTIFIC MEETING Jul 24-27, 2014 Honolulu, Hawaii

3The National Today • APMA Annual Scientific MeetingSaturday, July 26, 2014

O ne of the most important chal-lenges in managing patients with diabetes is the early diagnosis and treatment of Charcot joint because many

physicians are unfamiliar with the con-dition. Despite a plethora of case re-ports and numerous published theories in pathology mechanics and chemistry, there remains a substantial population of physicians who are unaware of those at risk for this condition.

Molly Judge, DPM, director of research and publications for CHP—Healthspan physician group—Cleveland Clinic Foundation, discussed those challenges in her presentation, “The Science Behind Charcot Joint and Use of Nuclear Medicine Imaging to Differentiate Infection from Acute Charcot Breakdown.”

“People lean toward the anecdotal when it comes to managing the Charcot joint, and that is because there is not a lot of hard evidence as to how and why this may evolve,” she said. “Even in the current lit-erature there is far more reported via case reports and, essentially, in their summary is almost always an anecdotal comment or suggestion regarding management.”

Charcot joint is the progressive degen-

eration of a weightbearing joint that can be recognized and arrested at “stage zero.” However the lack of widespread awareness of this condition often results in delayed or even missed diagnoses, which increases morbidity and mortality associated with this condition. Part of the problem is that the condition is not well understood and so is likely to be underreported. That means that even the speculated incidence or prevalence for the condition is probably estimated lower than it actually occurs, Dr. Judge said.

For those who are aware of the condi-tion of neuroarthropathy, also known as Charcot joint, the condition often pres-ents as a profound single-limb swelling, warmth, and history of trivial trauma, if any. The challenge for physicians is differentiating Charcot joint from infec-tion. Podiatric physicians can play a role in improving knowledge of the condition by participating in group discussions with colleagues and other practitioners who may be unaware of this condition, she said.

Dr. Judge discussed a profile of a patient with Charcot joint, but said that treatment strategies should be focused on conserva-tive management when possible.

“Ultimately, the people who have done the most surgery for Charcot joint and have tracked their own long-term follow-up are saying, ‘If you can avoid surgery on these people, do it,’ because their morbid-ity and mortality is important.

“The most important element in treating the Charcot joint is awareness of those people at increased risk for neuroarthrop-athy and early identification of the acute process. To identify these people early and prevent them from needing surgery is perhaps the greatest power of modern-day podiatric medicine. That is the pathway to saving lives one limb at a time.”

Nuclear Medicine ImagingNuclear medicine imaging (NMI) is a unique, useful modality that can help differentiate between serious infections and more benign conditions. Dr. Judge

“The osteomyelitis lecture Thursday stands out. You had everybody saying you are supposed to use antibiotics for six to eight weeks, and he suggested that two

weeks is perfectly adequate.”Howard Weinstein, DPM, Carrollton, TX

“I liked Dr. Bakotic’s advice to biopsy early if suspicious. If you have a suspicious lesion, find out early what it is.”

Peter John Sardella, DPM, Providence, RI

“The diabetes session Thursday was interest-ing. What I picked up was to push operating to reduce the foot pressure. It is not very common in Australia to do that; we tend to stick to the

conservative therapy.” Tran T. Luc, Kew, VIC, Australia

“The use of embryonic tissue in wound care. My practice is at the VA, so we will take that back and discuss it further.”

Glenn S. Gold Jr., DPM, Bountiful, UT

Question of the DayQ:Question of the Day

The Challenge of Diagnosing, Treating Charcot Joint

Glenn Kleezens, regional sales manager for Universal Imaging, tests an ultrasound machine yesterday during the ‘Hands-On Ultrasound Workshop.’ The annual workshop is designed to teach podiatrists to use the equipment for diagnosis and treatment in their offices.

Ultrasound Workshop

discussed its use in “Basic Principles in Practice for Imaging in the Face of Acute and Chronic Infections With and Without Ulceration.”

NMI tracks a radioactive agent to identify infection or inflammation in the body, and Dr. Judge used a series of images to demonstrate the modality and how it can be used in diagnosis. A “routine bone scan” is not an agent used to diagnose infection. It is used to identify regions of inflammation that may be associated with infection. In cases where an infection is suspected, a positive bone scan indicates that infection cannot be ruled out.

“There are white blood cell imaging agents that can identify infection in people who have had previous surgery or who have had previous ulcerations and infec-tion,” she said. “These are complicated

conditions that usually throw off MRIs, and so we look for alternative imaging, such as NMI, to resolve these special cases.

“Nuclear medicine imaging using la-beled white blood cells can provide insight and allow the differentiation between in-fected ulcerations, osteomyelitis, and other more benign conditions.”

A detailed history and a through clinical exam supplemented by streamlined imag-ing are important, and Dr. Judge explained when to use which agents and how to order imaging.

“Nuclear medicine imaging is the go-to imaging modality in the complex cases where a patient has had previous surgery, a history of chronic or repeatedly infected ulcerations, or when suffering from the degenerative changes of neuroarthropa-thy,” she said.

What have you learned during the meeting that you can put to use in your practice?

Molly Judge, DPM: ‘There is not a lot of hard evidence as to how and why this may evolve.’

Page 4: OFFICIAL NEWSPAPER OF TH APMA ANNUAL SCIENTIFIC … · 2014. 7. 28. · The National Today OFFICIAL NEWSPAPER OF TH APMA ANNUAL SCIENTIFIC MEETING Jul 24-27, 2014 Honolulu, Hawaii

4 The National Today • APMA Annual Scientific Meeting Saturday, July 26, 2014

MRI Provides Comprehensive Imaging for Ankle and Foot

D ifferent imaging modalities may work best for different injuries, but MRI remains a comprehensive modality for the ankle and foot, said Ben-

jamin D. Levine, MD, who presented “MRI of the Ankle and Foot,” yesterday during the Radiology track.

“Studies demonstrate that using MRI as a diagnostic imaging tool for evaluation of the ankle and foot has been shown to change treatment and management deci-sions,” said Dr. Levine, assistant professor of radiology in the Musculoskeletal Sec-tion at the David Geffen School of Medi-cine, University of California, Los Angeles Health System.

Dr. Levine discussed different types of MRI sequences to use in specific situations when imaging the ankle and foot, but the type of MRI also can affect the quality of the scan. There are different magnetic strengths of MRI machines such as 0.5, 1.5, and 3T, which provides the highest resolution.

Because they are the latest generation and most expensive, 3T scanners are not as common, and are likely not available at smaller, private radiology centers, he said.

“For routine diagnosis around the ankle and foot, a good 1.5 scanner does the job,” he said. “For more detailed cartilage imag-ing, higher resolution, and better diag-nostic performance, 3T outperforms 1.5T. There are certain pathologies that you will only be able to see on 3T. Those usually revolve around intra-articular pathologies; however, even routine tendon tears will be better characterized with 3T.

“We used to do arthrograms of the an-kle. With the advent of 3T, we only rarely need to perform an arthrogram procedure on the ankle.”

In addition to using 3T scanners, work-

ing with a radiologist who specializes in musculoskeletal imaging is a great advan-tage when possible, Dr. Levine said.

“MRI is the most powerful and com-prehensive imaging modality, but other modalities are complementary to each other,” he said. “Ultrasound is excellent for looking at a targeted area around the ankle and foot, particularly tendon pathology. X-ray is inexpensive and fast, and should always be the baseline imaging modality to choose. CT can characterize a com-plex fracture. Dual-energy CT is newer and provides the ideal imaging modality for the diagnosis of gout with its ability to uniquely identify monosodium urate crystals.”

Update on Imaging Ankle InjuriesDr. Levine also expanded his discussion of when to use different modalities in his presentation “Ankle Injuries: Update on Imaging.” He used a variety of images to explain which imaging tests to order for the most common ankle injuries seen in a podiatric or orthopedic practice.

Among the injuries he reviewed were ligament and tendon injuries, osseous injuries, osteochondral injuries, and im-pingement syndromes.

“Impingement syndromes around the ankle are clinical diagnoses, but they have imaging features, particularly on MRI, that can suggest and help confirm the diagnosis,” Dr. Levine said. “If the patient is presenting clinically with an impinge-ment syndrome, and then you have the MRI features to go along with it, it can confirm the diagnosis.”

Foot and Ankle UltrasoundThe cost of ultrasound imaging equip-ment has decreased as digital technol-ogy has replaced analog technology, so podiatric physicians should take advan-tage of that evolution to use diagnostic ultrasound, said Nathan H. Schwartz, DPM, who presented “Foot and Ankle Ultrasound.”

“X-rays are a part of most every podia-trist’s practice, and they supply valuable information. However, X-rays give little to no soft-tissue information. Ultrasound does, and it gives unique bone and joint information. It is safe; there are no con-traindications,” he said.

Other advantages to adding digital ultrasound equipment include improved processes, such as providing images in real time so the equipment can be used during procedures.

“There are a lot of computer-based enhancements with ultrasound that make the images much clearer and eliminate the guesswork in the interpretation,” Dr. Schwartz said. “If one wants to give an injection accurately into one specific area, ultrasound not only will guide the clini-cian, but also verify that it has been given in the right location.

“There are procedures that can be per-formed percutaneously under ultrasound imaging, such as the release of the plantar

fascia and removal of calcifications within tendons.”

Training greatly decreases or eliminates the learning curve, he said.

“The key is obtaining a good picture, which is dependent on probe manipula-tion,” Dr. Schwartz said.

Advantages of CTComputed tomography (CT) is similar to X-ray and should be used to obtain images of bone trauma or bone pathology of any kind, said Albert Armstrong Jr., DPM, MS, associate professor of radiology and interim dean, Barry University School of Podiatric Medicine, Miami.

CT is an advanced X-ray imaging mo-dality that is useful in imaging intra-artic-ular fractures and bone tumors. It also is better than MRI for imaging cortical bone.

CT equipment produces images that are much sharper than X-rays because they use an X-ray beam that is thinly collimated and has less scatter radiation. An X-ray has a greater amount of scatter radiation that grays out the image, Dr. Armstrong said.

Advances in 3D Weightbearing CTA cutting-edge advancement in imaging is the development of weightbearing CT, which is used for biomechanical evalua-tion, and preoperative and postoperative surgical evaluation. Images are three-di-mensional and help to detect biomechani-cal bone abnormalities better than X-rays or MRI.

The equipment is designed so the patient can stand in it to produce images showing the effect of weight on the lower extremities. It also is useful in the diagno-sis and treatment of a collapsed arch in a patient with Charcot foot, Dr. Armstrong said.

A 3D weightbearing CT is more expen-sive than an X-ray machine and is usually

done at an imaging center because the equipment is relatively new.

Imaging Tumors of the Foot and AnkleEven though most tumors are nonspe-cific on imaging, several of them do have specific imaging features, which were reviewed by Dr. Levine in his presenta-tion “Imaging Tumors of the Foot and Ankle.”

Dr. Levine used a series of images to illustrate many of the tumors that can develop around the ankle and foot. Most of these tumors are benign, but it is im-portant to get a baseline of all suspected tumors using X-ray, he said.

If a tumor is osseous, further imaging with CT is the best step. However, if you need to determine if a tumor is a cyst or a solid, ultrasound is a good imaging option. Ultimately, MRI excels at defining the lo-cal extent of disease, Dr. Levine said.

Tendon Evaluation using Power DopplerUltrasound imaging is useful in diagnosis because it provides dynamic images in real time, which cannot be done using CT or MRI. A practitioner can evaluate the movement of a tendon in real time using ultrasound.

Power Doppler is a form of ultrasound that detects and measures blood flow by recording changes in the frequency of the ultrasound wave. Power Doppler can im-age very small blood vessels in damaged tendons. If neovessels are detected, they are a sign the tendon is injured and trying to heal itself, Dr. Armstrong said. Ultra-sound also can be used to look at tendon shape, texture, and disruptions.

“A lot of podiatrists still do not have diagnostic ultrasound equipment,” he said. “The equipment is much cheaper than weightbearing CT, but it is not widely used even though it should be. Diagnostic ultra-sound has many advantages over MRI.”

Benjamin D. Levine, MD, reviewed the ad-vantages of MRI as a diagnostic tool.

Nathan H. Schwartz, DPM: ‘The key is obtaining a good picture, which is dependent on probe manipulation.’

Page 5: OFFICIAL NEWSPAPER OF TH APMA ANNUAL SCIENTIFIC … · 2014. 7. 28. · The National Today OFFICIAL NEWSPAPER OF TH APMA ANNUAL SCIENTIFIC MEETING Jul 24-27, 2014 Honolulu, Hawaii

5The National Today • APMA Annual Scientific MeetingSaturday, July 26, 2014

Today9–9:30 a.m.Scanning in the exhibit hall2.5 contact hours

Noon–1 p.m.Scanning in the exhibit hall2.5 contact hours

1–2 p.m.Poster Abstracts Symposium Scanning in poster exhibit1 contact hour

2–4 p.mRisk Management SeminarBallroom BScanning immediately following the con-clusion of the seminar2 contact hours

Sunday10:30–11 a.m.Scanning outside lecture hallHilton Hawaiian Village, Coral 43 contact hours

12:30–1 p.m.Scanning outside lecture hallHilton Hawaiian Village, Coral 41.5 contact hours

Scanning Schedule

New Approaches Saving Limbs of Patients with Vascular Disease

N ew approaches are helping to reduce amputations in patients with vascular disease. Two presentations during Friday’s Society for Vascular Surgery

Young Surgeons Committee/APMA Young Physicians’ Vascular Disease Symposium looked at how one specialty center is expe-diting treatment to salvage limbs and the use of pedal access for minimally invasive procedures to clear occluded arteries.

Time is Tissue: The Urgency of RevascularizationTime is of the essence in any medical treatment, but particularly when trying to avoid leg amputations in patients with an ischemic diabetic foot. The processes of a center that has a limb salvage rate of more than 90 percent were discussed in “Time Is Tissue: The Urgency of Revascularization in the Ischemic Diabetic Foot.”

“A lot of leg amputations due to vascular disease could be avoided if the patients were revascularized in an adequate time frame. We try to do everything in less than three or four days, from getting them admitted to the hospital, to getting them cleared by a medical team, to getting an angiogram, to surgical intervention. We work as a team,” said David A. Pougatsch, DPM, associate medical director at the Amputation Prevention Center at Sher-man Oaks Hospital, Los Angeles.

When symptoms of vascular disease are first recognized in patients, they often wait weeks before a diagnosis is confirmed and appropriate vascular intervention is scheduled, he said.

“During this time frame, if tissue is dy-ing, it will continue to die and this necro-sis will spread,” Dr. Pougatsch said.

The Sherman Oaks Amputation Preven-tion Center has a staff of three podiatric physicians who were trained during fellowships in limb salvage, two vascu-lar surgeons, a hyperbaric management specialist, a general surgeon, and a plastic surgeon. It operates in a newly renovated facility that opened in 2013. The center, a pioneer in the technology of painless epi-dermal skin grafting, also uses biological tissues available to help heal wounds, Dr. Pougatsch said. Its hyperbaric facility is currently being upgraded with monoplace hyperbaric chambers.

“There is no longer a need for patients to bounce around from one specialist to another to treat their wounds,” he said. “The concept of our physicians working as a team to heal our patients is the reason we have a high success rate. We are able to provide for our patients a true multidisci-plinary, multimodal limb salvage center.

“The time frame in which our patients are treated for underlying vascular disease is much faster than at most facilities. By having other specialists available under one roof, we are able to work together and expedite whatever needs to be done.”

The key is to prevent any further tissue loss in the ischemic limb.

“If you can re-establish blood flow in a timely manner to an area you are trying to salvage, further necrosis can be pre-vented. Surrounding healthy tissue will be preserved and the attempt at limb salvage will not be in jeopardy,” Dr. Pougatsch said. “The problem lies in the fact that it is difficult to re-establish blood flow in an adequate time frame in the traditional way medical practices operate, going from one doctor to another.”

The center follows a “common sense”

algorithm, he said, that starts with treating an infection, determining if there is any underlying vascular disease preventing healing, and addressing any abnormal pressures or biomechanical issues.

“This is a true multidisciplinary ap-proach in an area where the patient is in need of multidisciplinary care,” Dr. Pougatsch said. “By acting quickly, we are able to preserve as much tissue as we can to heal/close the wound. The quicker one addresses and intervenes with respect to the patient’s underlying vasculopathy, the greater the presence of healthy tissue and the higher the success rate at preserving the patient’s foot and functionality. ”

Pedal Access for Endovascular InterventionsPodiatric physicians often are the first health-care professionals to diagnose criti-cal limb ischemia in patients, so they need to be aware of treatment options that can help these patients avoid amputation.

Traditionally, the most common inter-ventions to revascularize limbs have been a surgical bypass or endovascular inter-ventions with percutaneous access through the femoral artery in the groin. However, accessing occluded vessels through the foot is a newer option that is being used more often, said Rabih A. Chaer, MD, MSc, associate professor of surgery at the Division of Vascular Surgery, University of Pittsburgh Medical Center.

“This is an added avenue we can offer patients who have critical limb ischemia,” said Dr. Chaer, who presented “Transpedal Endovascular Interventions for Critical Limb Ischemia.” “What we have learned over the past few years is that when this technique is done right it provides patients

with the same outcomes as conventional endovascular interventions done through the femoral artery.”

Patients with critical limb ischemia most often have pain in their feet at rest, nonhealing foot ulcers, or toe gangrene. If they do not undergo limb revasculariza-tion, these patients face a major amputa-tion, he said.

The most durable revascularization op-tion is a surgical bypass, but these patients are often too frail to withstand surgery. Clearing the occluded vessel with a mini-mally invasive procedure is safer for sick patients, but it is not as durable a treat-ment, Dr. Chaer said.

“There is a high rate of recurrence of the blockages, but this is unaffected by the access route and is the natural history following percutaneous interventions,” he said. “Sometimes you have to accept that these interventions are not as durable as a surgical bypass because they are safer in patients who have multiple other medical problems and cannot tolerate a bypass.

“Vascular surgeons are often not the first physicians who see patients who present with critical limb ischemia. Oftentimes it is their podiatrist or their primary care physician. Sometimes the general im-pression is that these patients often are too sick to undergo surgery, so they are not referred for revascularization. But most of the time there are alternatives to surgical bypass. The key is to educate all specialties that treat patients with vascular disease about these minimally invasive approaches. Through a multidisciplinary collaboration among podiatrists and vas-cular surgeons, improved limb salvage can still be achieved in this challenging patient population.”

2–4 p.m.Risk Management Seminar: Lessons Learned From a Podiatric Malpractice SettlementBallroom B

Sunday’s Schedule7:30–9 a.m.Breakfast Symposium: Surviving the Changing Health-Care Landscape: Gen-erational and Legal ChallengesHilton Hawaiian Village, Coral 3

9–10:30 a.m.The Ultimate APMA Coding Seminar: ICD-10—It May Be Delayed, but You Still Need to Get ReadyHilton Hawaiian Village, Coral 4

10:30–11 a.m.CECH Scanning BreakHilton Hawaiian Village Coral 4

11 a.m.–12:30 p.m.The Ultimate APMA Coding Seminar: ICD-10—It May Be Delayed, but You Still Need to Get Ready (continued)Hilton Hawaiian Village, Coral 4

12:30–1 p.m.CECH ScanningHilton Hawaiian Village Coral 4

A National attendee examines surgical tools in the exhibit hall yesterday. The exhibit hall will be open from 9 a.m. to 2 p.m. today, the last day it is open during the meeting.

Tools of the Trade SCHEDULEContinued from page 1

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6 The National Today • APMA Annual Scientific Meeting Saturday, July 26, 2014

Variety Spices Up Education ProgramSessions Address Clinical, Legal, and Ethical Issues

T oday’s education program will address a variety of clinical, legal and ethical issues in several different presentation formats. Breakfast symposia will fea-

ture updates on bone grafts and treating onychomycosis, and a plenary lecture will look at tinea pedis. If you are in the mood for a debate, you can hear the pros and cons of minimalist shoes and ultrasound diagnosis for heel pain. Other sessions will look at health-care disparities and how to prevent falls. In the afternoon, see the latest research at the Poster Abstracts Sym-posium and hear the details of a podiatric malpractice lawsuit.

6:30–8 a.m. in Ballroom C, Understanding Biologics: Update on Graft Applications• “Understanding the Science of Bone

Grafts,” Aprajita Nakra, DPM, will discuss autograft, allograft, and xenograft bone grafts. She also will discuss the pros and cons of each, their clinical applica-tions in foot and ankle surgery, and their physiology.

• “Clinical Applications in Foot and Ankle Procedures,” David A. Yeager, DPM, will

review the fundamental principles of bone healing and the cutting-edge tech-nology of bone grafts.

6:30–8 a.m. in Ballroom A, Overcoming Onychomycosis: Management Updates for PodiatristsWarren S. Joseph, DPM, said the FDA has not approved any new onychomy-cosis treatments in almost 15 years, but approved two new topical agents in July. They will give podiatrists and their pa-tients new options for the treatment of this infection.

8–9 a.m., Plenary Lecture, in Ballroom B, Tackling Tinea Pedis: Update on Latest TreatmentsTracey C. Vlahovic, DPM, will discuss how the disease is spread and the newest topical treatments that have been devel-oped and analyze the products used to prevent tinea pedis. She also will address the consequences of not treating the con-dition until it is completely cured.

9:30–11 a.m. in Room 312, Controversy Debates• “Diagnostic Ultrasound for Heel Pain?”

Adam E. Fleischer, DPM, MPH, will take the pro position: “It can help you es-

tablish the diagnosis because many people who come in with chronic heel pain don’t have that classic plantar fasciitis at the origin. If you put a probe on it, which takes two seconds, you can tell where it is in the fascia, so it helps with the diagnosis of plantar fasciitis.”

Emily A. Cook, DPM, MPH, CPH, will discuss how the overuse of ultrasound can add costs and delay treatment. “Plantar fasciitis is really a clinical diagnosis, and ultrasound is not necessary to make that diagnosis. Utilizing ultrasound to diag-nose common conditions that we treat on a regular basis adds unnecessary exami-nation time, increases overall health care costs and should not be used to substitute a thorough clinical examination.”• “Minimalist/Barefoot Versus Tradi-

tional Running Shoes,” Nicholas A. Campitelli, DPM, will discuss the development of shoe gear, the biome-chanics of different types of feet, and their influence on injuries in runners. “How one runs is probably more im-portant than what is on one’s feet, but what is on one’s feet may affect how one runs,” he said.Jeffrey Ross, DPM, MD, said evidence-

based studies have shown injuries with minimalist shoes: “The moral of the story

is that for some people they’re great, for many others with medical and biome-chanical issues, they are not. The studies have indeed shown injuries in long bones of the feet and shins, the Achilles, etc., but they have shown promise in reducing knee pain and impact trauma to the knee.”

9:30 a.m.–noon in Room 308AB Ankle Arthroscopy WorkshopThis cadaveric workshop presents an introduction to ankle arthroscopy. Presenters will introduce attendees to the instrumentation required, and a new set of terms and skills, with a focus on superficial anatomy, the portals, and how to navigate the equipment, said Patrick R. Burns, DPM, who will lead the session. (Preregistration required.)

11 a.m.–noon in Room 301B, Track 1: Public Health/Falls Prevention• “Falls Risk Assessment,” Jeremy J. Cook,

DPM, MPH, will discuss the devel-opment of a reliable falls-prevention assessment tool to identify those elderly who have a higher risk of sustaining one or more falls in a one-year period and to help minimize the risk of fractures that can lead to a long-term inability to walk.

• “What Can Podiatrists Do to Prevent Falls?” Dr. Fleischer will discuss the importance of podiatrists in influencing

Page 7: OFFICIAL NEWSPAPER OF TH APMA ANNUAL SCIENTIFIC … · 2014. 7. 28. · The National Today OFFICIAL NEWSPAPER OF TH APMA ANNUAL SCIENTIFIC MEETING Jul 24-27, 2014 Honolulu, Hawaii

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the overall health of patients and the role of using a “foot visit” as an opportu-nity to exert that influence.

11 a.m.–noon in Room 312, Health-Care Disparities• “Introduction to Health-Care Dispari-

ties,” Joseph M. Caporusso, DPM, MPH, will discuss the perceptions of dispari-ties and their ramifications.

• “Cultural and Linguistic Competency,” Klaus J. Kernbach, DPM, will discuss the importance of understanding the so-cial, cultural and linguistic needs of the patient, and address the needs of some patient groups.

1–2 p.m., Poster Abstracts Symposium, Kamehameha Exhibit HallAttendees will have the opportunity to review the latest cutting-edge foot and ankle research and ask questions of the authors of around 80 posters during today’s Poster Abstracts Symposium. Pick up a Poster Abstracts booklet at the Registration Desk.

2–4 p.m., Risk Management Seminar, Ballroom BAlan S. Banks, DPM, will present “Les-sons Learned from a Podiatric Malpractice Settlement.”

The Young Physicians’ Program, “Insuring Suc-cess—Practice Survival,” provided vital

information for podiatrists trying to establish

themselves in practice.

As part of the program, Kevin West, JD,

partner, Parsons Behle & Latimer, discussed

basic health-care law for podiatrists. “This

[presentation] is a primer on many topics

about which podiatric physicians should have

a basic understanding,” West said. The talk

covered several topics, including employment

contracts, insurance contracts, the Stark law,

the Anti-Kickback Statute, malpractice insur-

ance, fraud and abuse laws, Medicare and

private insurance audits and investigations,

HIPAA, licensure and privileging issues, the

Affordable Care Act, and medical malpractice

risk management.

Learning from West is an invaluable

experience for young physicians. He has

represented health-care providers, particularly

podiatrists, for more than 25 years and wrote

APMA’s HIPAA manual and its two subse-

quent updates.

“The world of health care is one of the

most, if not the most regulated industry in the

United States,” West said. “New practitioners

must not only be well-trained from a medical

standpoint, but also well-informed of the legal

and regulatory framework with which they

must comply. In this highly regulated environ-

ment, practitioners who fail to gain a basic

understanding of health-care law concepts

run great risks of audits, licensure discipline,

loss of privileges, lawsuits, government fines

and penalties, and other potentially career-

threatening events. Health-care law is rapidly

evolving, and the past 10 years have seen

huge changes at every level on each of the

topics that we covered.”

Also during the program, Jon Goldsmith,

DPM, presented on career opportunities for

young physicians. The lecture focused on the

variety of different employment arrangements

that are available to the young physician.

“[Options] include starting a practice, being an

associate, entering a partnership, a multi-

specialty group, hospital employment, and

academic positions,” he said.

Dr. Goldsmith is only a year removed from

young physician status himself. He practices

in Omaha, NE. “My hope is that my experi-

ence with a variety of these options ben-

efits young physicians as they are planning

to graduate residency and begin their profes-

sional careers,” he said.

Also presenting during the session was Wil-

liam H. Dabdoub, DPM. Dr. Dabdoub practices

in Slidell, LA. However, that wasn’t always the

case. Until 2005, his practice in New Orleans—

but was destroyed by Hurricane Katrina. His ex-

perience formed the basis of his presentation.

“Unless you have experienced it firsthand,

it is hard to really understand what happens

during a disaster such as I experienced with

Katrina,” he said. “My staff was scattered.

I had to balance my personal life and my

worries about my family along with caring for

my staff, and I had very little to no access to

money. It took me more than three years to

return to my previous level of income.”

Dr. Dabdoub shared the lessons he

learned so young physicians can be prepared

should the worst happen. “You need to look

at your insurance,” he said. “Not just against

floods or other natural disasters, but business

interruption insurance as well. [These events]

can happen to any practice along a coast, or

in a tornado or earthquake zone.”

The program was rounded out by Harry

Goldsmith, DPM, and his presentation, “What

You Need to Know about Coding and Reim-

bursement.” Dr. Goldsmith is a renowned cod-

ing expert and APMA consultant. Although the

ICD-10 transition has been delayed for one

year, this topic remains incredibly important

for young physicians.

Young physicians can find valuable materi-

als and resources at www.apma.org/young-

physicians.

YOUNG PHYSICIANS’ PROGRAM PROVIDES PRACTICE MANAGEMENT ADVICE

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8 The National Today • APMA Annual Scientific Meeting Saturday, July 26, 2014

APMA members are eligible to receive discounts on footwear, insoles, and hosiery through APMA’s Professional Purchase Programs and Discounts!

Discounts are offered by the following companies with products awarded the APMA Seal of Acceptance:

ASICS America Corporation

Dansko, LLC

ECCO USA

Injinji Footwear, Inc.

Vionic Group LLC

SOLE

For more information, visit www.apma.org/ProfessionalPurchasePrograms

DID YOU KNOW?

Quality—REdRC lectures are generated from experts in the field and are based on competencies identified in CPME approved guidelines for residency education. Created in partnership by APMA, ACFAOM, ASPS, ASPM, and AENS, topics presented through the REdRC cover the full spectrum of podiatric medicine.

Flexibility—Lectures can be accessed anywhere, anytime through the online portal. Residency directors will not have to prepare weekly lectures, and residents will have the opportunity to learn from a range of experts.

Value—When compared with similar products currently available, REdRC represents a tremendous value for residency programs: free for residents who have activated their APMA membership. This is made possible due to the generous support of its founding sponsors, including Gebauer Company, the Podiatry Insurance Company of America, Organogenesis, Inc., Merz Pharmaceuticals, LLC, Bako Integrated Physician Solutions, Meditouch EHR/HealthFusion, and KCI USA, Inc.

Growth—By July 2015, REdRC will feature 150 lectures. Additionally, plans are in place to expand the resources available for residents to include monthly webinars, procedure- or device-specific supplemental training videos, and a résumé builder section for third-year residents.

REdRC offers:

Founding Sponsors

REdRC is an online repository of educational materials to supplement residents’ daily hands-on experience and is free for APMA members.

Visit REdRC.org to learn more and opt-in today.

It’s Never Too Soon to Plan Ahead: Register for Next Year’s National in Orlando!

W e are halfway through the APMA 2014 Annual Scientific Meeting (The National), but it isn’t too early to think about next

year’s premier foot and ankle confer-ence. Come to the APMA booth (#623) to register for The 2015 National, July 23–26 in Orlando, FL, at the Mar-riott Orlando World Center, and pay the lowest possible rate: only $295 for APMA members!

Orlando is the perfect destination for professional development and family fun. With a little bit of something for everyone, it is no surprise Orlando is one of the cities visited most often by both domestic and international travelers. With seven of the world’s top 20 theme parks, not to men-tion nearly 100 other attractions, the city certainly knows how to entertain.

After a day of lectures and walking the exhibit hall floor, you will feel refreshed and inspired by a leisurely escape to a world of imagination and fantasy. Our host property, the Marriott Orlando World Center, is the ideal launching pad for all of your Orlando adventures. The resort is advantageously lo-cated across the highway from Walt Disney World Resort and is just a short drive from Universal Studios Resort and the Wizarding World of Harry Potter.

If roller coasters aren’t your thing or you are planning to leave the kids at home, Orlando has you covered. You can see musical performances at the House of Blues in Downtown Disney and Hard Rock Live at Universal CityWalk. Is deli-cious food a priority when you travel? Orlando is a true culinary hot spot with award-winning restaurants and celebrity chefs who cater to visitors from around the globe. There’s an extensive menu of fine-dining establishments, international eateries, casual cafés, and chic wine bars for just about any taste or budget. Look-ing for an upscale steakhouse or a new neighborhood bistro? Want to check out where the locals wine and dine? Orlando has it all. For more information, visit www.VisitOrlando.com.

Orlando may lack Florida’s famous beaches, but it does have plenty of the Sunshine State’s other well-known at-traction: golf courses. With 176 courses, Orlando was recently named the North American Golf Destination of the Year by the International Association of Golf Tour Operators. Play 18 holes on courses designed by golf legends including Palmer, Watson, Nicklaus, and Norman. Be sure to book a tee time before or after the meeting at our host property’s on-site golf club, Hawk’s Landing.

For all that Orlando has to offer, you and your family can even enjoy a complete vacation without leaving the grounds of the Marriott Orlando World Center (www.marriott.com/hotels/travel/mcowc-orlando-world-center-marriott). Along with the aforementioned golf course, the property boasts numerous dining options, a luxurious spa, and a range of recreation activities for children of all ages.

The Marriott Orlando World Center is practically a water park all unto itself. For younger children, the Splash Zone with Zero Entry Pool and Water Playground featuring water trees, spray jets, and more will provide entertainment for hours. For the more daring, the Plunge Zone with Slide Tower is a must-do. Choose from three slides, including a 90-foot super-speedy drop-slide. When your children need to dry out, send them to the Gam-ing Recreational Interactive Destination, or GRID.

You will want to take a look at the daily scheduled resort activities. Parents can let loose and kids can get silly with ongo-ing, ever-changing activities and events at the Activity Center. Activities range from LEGOLAND-themed events and Gatorland animal appearances featuring alligators and snakes, to fun and festive

arts and crafts, face painting, pool games, and more!

Do you like to slow down on vacation instead of packing in a lot of activity? The spa at the Marriott Orlando World Center offers all of the services you could want: facial, massage, manicures/pedi-cures, body wrap, and more. Take some time for yourself and enjoy a peaceful, relaxing treatment.

Keep your taste buds happy by sam-pling all of the property’s dining options. Have a hankering for steak? Pick from a traditional steakhouse (Hawk’s Land-ing Steakhouse & Grille) or Japanese (Mikado). For Italian, try Siro Urban Italian Kitchen, voted the 2013 Best New Restaurant for Central Florida by Florida Trend magazine. Need to get something in a hurry? Stop by the Mangrove food court for a quick bite on the go!

After the meeting, you may register on-line at www.apma.org/TheNational. Enter the coupon code SUNSHINE to guarantee the best possible registration rate. Be on the lookout for information about this meeting in the coming months.

We’ll see you in Orlando!

*The National Today gratefully acknowledges Visit Orlando and the Marriott Orlando World Center for providing information used in this article.

Page 9: OFFICIAL NEWSPAPER OF TH APMA ANNUAL SCIENTIFIC … · 2014. 7. 28. · The National Today OFFICIAL NEWSPAPER OF TH APMA ANNUAL SCIENTIFIC MEETING Jul 24-27, 2014 Honolulu, Hawaii

9The National Today • APMA Annual Scientific MeetingSaturday, July 26, 2014

Sunday Sessions to Look at Legal and Practices Issues, ICD-10

P racticing medicine involves more than seeing patients in an exam room. Dealing with personnel matters and follow-ing federal regulations are

important parts of health care that will be examined in the Sunday Breakfast Sympo-sium and the APMA Coding Seminar.

“Surviving the Changing Health-Care Landscape: Generational and Legal Chal-lenges” will be presented from 7:30 to 9 a.m. Sunday at Hilton Hawaiian Village, Coral 3. “The Ultimate APMA Coding Seminar: ICD-10—It May Be Delayed But You Still Need to Get Ready” will be pre-sented in two parts from 9 to 10:30 a.m. and 11 a.m. to noon in Hilton Hawaiian Village, Coral 4.

A Wealth of GenerationsFrom the Silent Generation to Baby Boomers to Gen X to Millennials, four generations are working together for the first time, and they have different ap-proaches to work and life.

“It’s not that people in the different generations are not motivated, it’s that you have to understand what motivates them, and engage them based on their own motivation,” said Barry L. Scurran, DPM, chief compliance officer for the Perma-nente Medical Group. “Understanding how people of different generations view diversity, themselves, or the future makes it possible to understand what motivates different people.”

Dr. Scurran will discuss such topics as the influence of social media and how the Silent Generation and Baby Boomers want to see details on a written page while younger generations avoid paper and want to see emails or texts.

“I will discuss the concept that your history and your influences shape your emotions, actions, and perceptions of institutions, careers, and life.

Changes to HIPAA and Meaningful UseHIPAA has been part of the health-care world in the US since 2003, but it was up-dated in 2010 and 2013, and is now being enforced more strictly than ever. An ex-pert on health-care law, J. Kevin West, JD, will discuss those updates and the current HIPAA enforcement environment during Sunday’s Breakfast Symposium, “Surviv-ing the Changing Health Care Landscape: Generational and Legal Challenges.”

“In the past two years we have seen a record number of audits, fines, penalties, and investigations, none of which we saw in the early years of HIPAA. Now, it has exploded into a very aggressive enforce-ment situation,” said West, of Parsons Beh-le & Latimer, Boise, ID, who is the author of the APMA HIPAA manuals, practices health-care law and teaches a health-care law course at Boise State University.

In his presentation, “The 2013 Changes to HIPAA; HIPAA Audits; Meaningful Use Audits,” West will discuss the HIPAA security risk analysis and the interaction with Meaningful Use standards and audits.

“You need to comply with both HIPAA and Meaningful Use,” West said. “I will talk about how those rules intersect, and how important compliance with those rules has become in today’s environment.

ICD-10 SeminarThe deadline for implementing ICD-10 may have been pushed back one year, to

Oct. 1, 2015, but physicians and their staffs still need to be working hard to be ready to make the change. It will take time to train staffs, refine the resources for the transition to using new codes, and test all the processes. Failure to be ready at the deadline will violate federal regulations and endanger reimbursements.

In the ICD-10 seminar, Harry Gold-

smith, DPM, Lawrence A. Santi, DPM, and Phillip E. Ward, DPM, will present “ICD-10 Coding of Clinical Scenarios.” James Christina, DPM, will present “PQRS and Meaningful Use.” In the presentations, they will discuss the additional codes in ICD-10 and how they need to be recorded, and the role of the Physician Quality Re-porting System.

Your single online resource for:

SUBSCRIBE TODAY!Visit the APMA booth (#623) or www.APMACODINGRC.org

THE SINGLE BEST PODIATRIC CODING RESOURCE

CODINGRESOURCE CENTER

Page 10: OFFICIAL NEWSPAPER OF TH APMA ANNUAL SCIENTIFIC … · 2014. 7. 28. · The National Today OFFICIAL NEWSPAPER OF TH APMA ANNUAL SCIENTIFIC MEETING Jul 24-27, 2014 Honolulu, Hawaii

10 The National Today • APMA Annual Scientific Meeting Saturday, July 26, 2014

Shoes Can Play Key Role in Sports Injuries

T he treatment of triathlon par-ticipants’ injuries, a compari-son of over-the-counter versus custom shoe orthotics, and the effect of minimalist shoes and

stretching exercises on Achilles tendon injuries were examined yesterday in the Biomechanics and Sports Medicine track.

Diagnosing and Treating Triathlon InjuriesPodiatric physicians treat many patients suffering from injuries that occur during long runs that test athletes’ endurance. Fri-day, they heard about identifying, diagnos-ing, and treating lower extremity injuries suffered during triathlons, including one of the most grueling races in the world, the Hawaii Ironman.

A finisher of the Hawaii Ironman, Matt Werd, DPM, discussed the variety of inju-ries—from traditional running injuries to death—that participants may suffer during taxing triathlons, and that podiatrists may be called upon to treat. Dr. Werd is chief of podiatric surgery at Lakeland Regional Medical Center, Lakeland, FL, and is a past president of the American Academy of Podiatric Sports Medicine.

The Hawaii Ironman started in 1978 and includes a 2.4-mile swim in rough Pacific Ocean water, a 112-mile bike race, and a 26.6-mile marathon through blackened lava fields. It serves as the Ironman World Championship competition, and each of the 1,900 participants must qualify for entry.

The types of shoes worn in the race are tracked by the annual “Kona Shoe Count,” and range from 15 to 20 types.

“There has been a trend from traditional running shoes, to minimalist to a maxi-malist shoe, and each has led to differing injuries,” Dr. Werd said. “There is a poten-tial to trade one set of injuries for another set of injuries by switching shoes or chang-ing training techniques.”

Other issues he discussed included training, overtraining, and environmental issues, such as extreme heat and difficult running surfaces. The most common lower extremity injuries are orthopedic in nature, but fatal cardiac injuries do occur, primarily during the swim portion, he said. Deaths are rare, but occur at a rate of 15 per 1 million participants in triathlons.

The most common swimming-related problems for triathlon participants are shoulder injuries and cardiac issues. For the bicycling portion of triathlons, trauma injuries are most common, while lower ex-tremity overuse injuries are most common for the run. Twenty-two percent of injuries are trauma/orthopedic, and 72 percent of injuries are related to dehydration or exhaustion.

Innovations in OrthoticsTraditionally, the only consistency in prescribing orthotics has been the incon-sistency among practitioners. However, a meta-analysis of several studies of the effectiveness of over-the-counter (OTC) devices versus custom devices and the development of more flexible devices may help standardize approaches to orthotic prescriptions.

“The main thing we found is that it is not clear how orthotics work. It is difficult to see consistency with prescriptions be-cause you go to five people and you get five

different prescriptions and devices made. The goal is to come up with best practices based on evidence-based medicine,” said Howard E. Kashefsky, DPM.

Dr. Kashefsky, director of podiatry services at University of North Carolina Hospitals, presented “Innovations in Orthotics” Friday. His meta-analysis of data collected in several studies since 2009 found a lack of level 1 evidence when reviewing about 20 commonly prescribed uses for orthotics.

“We are trying to determine when something would be custom versus over-the-counter,” he said. “There are more devices that are more cost-efficient for patients that are over-the-counter, and the data support when it is appropriate to be using that and still have a good outcome for patients.”

The analysis also looked at developing trends in managing ankle instability and balance, and the use of 3D CAD/CAM technologies that will affect prescribing, dispensing, and modifying orthotics over the next decade or more, Dr. Kashefsky said.

“Some of the orthotics we use now are rigid, but is rigid best? Some of the newer devices and some of the data show that not everyone needs to be in a rigid device and that flexible devices have their indications as well,” he said. “This newer technology, even though it can control the foot, is not rigid.”

One new device he discussed is a pre-fabricated, ultra-thin interactive carbon insole from Germany that can be custom-ized. It is designed so adjustments can be made to gradually increase changes to a patient’s gait and posture in stages.

“This is a new concept in orthotics. If someone has a deformity, you don’t have to correct it with one device that is custom-made,” Dr. Kashefsky said. “This allows you to gradually bring the patient to what they can maximally tolerate and allows their body to adapt to it gradually.

“It also allows more normal foot function because it is not rigid. With the adjust-ments, you can target specific joints, which is a new paradigm. Before, with the custom, semi-rigid orthotic, we were locking up and controlling all the joints of the foot and altering gait and normal muscle pattern.”

Role of Minimalist Shoes, Stretching in Achilles InjuriesAn Achilles tendon injury is the third most common lower extremity injury, and 18 percent of running injuries involve the Achilles tendon. The role of minimalist shoes in these injuries, newer approaches on stretching, and treatment trends were discussed Friday during “Achilles Tendon Injuries in Sports.”

“The minimalist shoe has increased the potential strain on the Achilles. In the running shoe industry, the pendulum is swinging from the minimalist/barefoot trend in the last several years to the other end of [the spectrum] to more of a maxi-

malist shoe,” said Dr. Werd, the session presenter. “Several shoe companies are at the other extreme of minimalism, creating maximum-cushion shoes.

“My take-home on running shoes is that there is a specific shoe for each patient. Choice needs to be individualized based on running mechanics, the level of the athlete, the goals of the athlete, the distances in training, and whether this is an elite athlete or a middle-of-the-pack runner.”

The treatment of Achilles tendon injuries has changed, and now includes extracorporeal shockwave therapy, cobla-tion therapy, platelet-rich plasma, and high-speed ultrasonic ablation. Future treatments being studied include the use of growth factors for tendon repair and regeneration, marrow-derived stem cell-seeded collagen implants, and low-energy

photostimulation.Dr. Werd also discussed the controversy

over stretching, which arose after a study on the potential detriments of stretching.

“It was misinterpreted by some people,” he said. “In general, regular stretching is a good thing, but static stretching just before exercise may not be the best time. A dynamic pre-activity warm-up is recom-mended. Studies show that stretching before exercise can temporarily weaken a muscle, but in general, regular stretching is still something we do recommend, and it may be best performed after exercise.”

Finally, Dr. Werd looked at new surgical options for tendon repair, and reviewed case studies.

“For the young healthy athlete with an Achilles tendon rupture, surgical repair is still the recommended treatment,” he said. “For the less active, older, sedentary pa-tient, non-operative treatment is the more likely recommendation.”

Howard E. Kashefsky, DPM

It is difficult to see consistency with prescriptions because you go to five people and you get five different prescriptions and devices made. The goal is to come up with best practices based on evidence-based medicine.

Matt Werd, DPM, who participated in several triathlons, polls the audience to see how many attendees had been in triathlons.

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11The National Today • APMA Annual Scientific MeetingSaturday, July 26, 2014

Plantar Fasciitis Study Finds Custom Orthotics Speed Healing

P atients with planar fasciitis are more active during their recovery when using custom foot orthotics compared to prefabs and sham devices

according to a study funded by APMA. The study also found common threads to help predict which patients respond better to specific treatments.

“We found that people who had a se-verely contracted Achilles tendon seemed to do best with a regimen that centered on stretching, supportive shoe gear, and insoles,” said Adam E. Fleischer, DPM, MPH. “We know that a contracted Achilles tendon is a risk factor for developing heel pain, but we didn’t know that the greater the contraction the more likely you are to benefit from stretching and conservative treatment.”

Dr. Fleischer and James S. Wrobel, DPM, MS, presented “The APMA-Funded Plantar Fasciitis Study” Friday. Dr. Fleisher is an associate professor at the Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, and Dr. Wrobel is an associ-ate professor of internal medicine in the Metabolism, Endocrinology and Diabetes Division at the University of Michigan Medical School.

The study of 77 patients with plantar

fasciitis randomized patients into three groups, one that received custom foot orthotics, one that received prefabricated orthotics, and one that received a sham. The study followed participants for three months, and charted pain relief with the first steps in the morning and at the end of the day, and measured quality of life using surveys and activity monitoring.

“We also looked at the biomechanical findings. We recognized we had a great data set and we had one examiner with a great deal of experience doing these biome-chanical exams that podiatrists do,” Dr. Wrobel said. “We wanted to see which of the findings might be predictive of people who respond to orthotic therapy or did not respond.

“We did the same thing with our radiol-ogy measures, and Dr. Fleisher looked at ultrasound and radiographic changes to see if any of those [changes] predicted response to orthotic therapy.”

Many study participants changed their shoe sizes, did stretching and ice massage at home, received a pad they could remove, and wore house slippers, Dr. Wrobel said.

“Those therapies alone resulted in significant improvement within the first couple of weeks,” he said. “We found a great deal of improvement in spontane-ous physical activity in the people who got

custom-made foot orthotics. There was a 5.6-fold improvement over the people who got prefabricated foot orthotics, over three months. People who got custom devices were 120 percent more active after three months than the people who had prefabri-cated orthotics.”

Using ultrasound to measure the thick-ness of the plantar fascia, echostructure, and inflammation, the study found patients

who had a biconvexity plantar fascia appearance were five times less likely to respond to orthotic therapy.

“We found that people whose plantar fascia had swelling and a circular appear-ance at the origin simply did not do well with a mechanical treatment regimen,” Dr. Fleischer said, adding that the use of injec-tions or anti-inflammatory medications might be better options.

2014 Annual Meeting Sponsors As of June 27, 2014

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Attendees debated the nuances of medical ethics during yesterday’s “Track 2: Applying the APMA Code of Ethics to Practice Situations.”

APMA Deputy Executive Direc-tor and COO Jay Levrio, PhD, kicked off the session with a review of the six core concepts of medical ethics, including patient autonomy, physi-cian beneficence, non-maleficence, justice, dignity, and honesty. Dr. Levrio reminded the audience that a profes-sional code of ethics pertains not only to a physician’s public, but also his or her private life. He also explained that although APMA maintains a detailed code of ethics, the association de-pends on the state components to adjudicate ethical violations.

Scott Haag, JD, MSPH, APMA’s director of Health Policy and Practice and a licensed attorney, underscored the potentially severe consequences of an ethical violation, including loss of license and legal ramifications.

The speakers then injected some levity, as Jim Christina, DPM, APMA director of Scientific Affairs, led the audience through a review of several humorous but relevant ethical cases, allowing participants to share their input about appropriate physician

conduct in each of the scenarios. Sce-narios covered such topics as treating family members, engaging in sexual relationships with patients, addressing suspected substance abuse among colleagues, negotiating relationships with industry, and being transparent in advertising.

In one scenario, a young physi-cian is under pressure from his senior partners in practice to perform more surgeries and increase his contribution to the bottom line. An elite college ath-lete presents with an injury he wants treated quickly—with surgery. The physician knows, however, that this pa-tient could respond well to conserva-tive care. The audience discussed the many facets of the case, including the unethical behavior of the young physi-cian’s senior partners; the importance of informed consent to help the patient understand the nature of his condition, the proposed treatment and alterna-tives, and the potential for success and complications; and HIPAA issues that can arise in treating athletes who sometimes have trainers involved in their care.

For more information about APMA’s Code of Ethics, visit www.apma.org/gov-ernance and click on “Code of Ethics.”

ETHICALLY SPEAKING

James S. Wrobel, DPM, MS, (left) and Adam E. Fleischer, DPM, MPH, answer questions about an APMA-funded study of plantar fasciitis.

Page 12: OFFICIAL NEWSPAPER OF TH APMA ANNUAL SCIENTIFIC … · 2014. 7. 28. · The National Today OFFICIAL NEWSPAPER OF TH APMA ANNUAL SCIENTIFIC MEETING Jul 24-27, 2014 Honolulu, Hawaii

12 The National Today • APMA Annual Scientific Meeting Saturday, July 26, 2014

Come to the APMA booth (#623) today to learn more about how APMA is meeting your needs:

Sign up for Friday’s Young Physicians’ Program Register for the 2014 Young Physicians’ Institute, October 10–12 Learn about the Young Physicians’ Reception Explore APMA’s new online career center and eAdvocacy center Meet your young physician leaders

Attention Young

Physicians!

Be sure to add to the conversation on social media throughout the meeting with our hashtags #ASMHawaii and #youngdocsrock.

Knowing Addiction Medicine a Key in Pain Management

P ain is the most common rea-son patients visit physicians, but the majority of physicians are not familiar with how to treat pain using appropriate

medications with boundary settings, according to Howard A. Heit, MD.

“To do good pain management, you need to be at least a talented amateur in addiction medicine,” said Dr. Heit, an expert on pain both professionally and personally, who presented “Defen-sible, Rational, and Compassionate Pain Management” yesterday during Track 3, Pain Management. “Most physicians and health-care professionals do not know the difference between addiction and physical dependence.”

Dr. Heit, an assistant clinical professor at Georgetown University, is board-certified in internal medicine and gastroenterol-ogy/hepatology, and is a diplomate in addiction medicine. He moved into pain and addiction medicine while spending more than 20 years in a wheelchair for a rare, painful muscle disorder following an accident. In 2008, he was treated with deep brain stimulation and now functions with a marked decrease in pain, and no longer uses a wheelchair or other assistive devices.

Physical dependence is a neuropharma-cological phenomenon, while addiction is both a neuropharmacological phenom-enon and a behavioral phenomenon, he

said, adding that 3 percent to 16 percent of the population has the disease of ad-diction, exclusive of nicotine addiction, which affects about 20 percent of the population.

“The goals of pain management are to decrease pain, increase function, and use medicines that do not have unacceptable side effects,” said Dr. Heit, who reviewed his 2005 paper, “Universal Precautions in Pain Medicine: A Rational Approach to the Treatment of Chronic Pain.” It outlines 10 principles in treating chronic pain with scheduled medications, such as opioids.

Those principles in working with patients in pain are to make a diagnosis with an appropriate differential; make a psychological assessment, including risk of addictive disorders; get an informed consent; develop a treatment agreement; conduct a pre- and post-intervention of assessment of pain level and function; conduct an appropriate trial of opioid therapy with or without adjunctive medication; regularly assess the pain score and level of function; regularly assess the ‘four A’s” of pain medicine—analgesia, activity, adverse effects, and aberrant behavior; periodically review pain diagnosis and comorbid conditions,

including addictive disorders; and docu-ment all evaluation.

“The treatment agreement—it is an agreement, not a legal contract—puts in writing the responsibilities of the doctor to the patient and the patient to the doctor who prescribes a controlled substance, such as an opioid,” Dr. Heit said.

“You need exit strategies if the opioids are not improving the pain syndrome, the source of the pain is resolved, or the patient is displaying aberrant behavior. In an exit strategy, you can abandon the molecule, but never abandon the pa-tient,” he said.

The bottom line in treating a patient with pain is that management should always be patient-centered, Dr. Heit said.

“Pain management is what you are doing for the patient not to the patient,” he said. “You should focus on improving outcomes and managing risk. You have a responsibility to make sure these medi-cines are prescribed safely to the patient, and the patient has a responsibility once medicines are dispensed from the phar-macist to take care of these medicines so they are not lost or stolen. Pain manage-ment should be defensible, rational, and compassionate.”

Howard A. Heit, MD: ‘Most physicians and health-care professionals do not know the difference between addiction and physical dependence.’

Page 13: OFFICIAL NEWSPAPER OF TH APMA ANNUAL SCIENTIFIC … · 2014. 7. 28. · The National Today OFFICIAL NEWSPAPER OF TH APMA ANNUAL SCIENTIFIC MEETING Jul 24-27, 2014 Honolulu, Hawaii

13The National Today • APMA Annual Scientific MeetingSaturday, July 26, 2014

Your premier foot & ankle meeting… your family’s destination for fun!

APMA is pleased to announce the 2015 Annual Scientific Meeting, The National, will be hosted in Orlando, Florida.

Register today at www.apma.org/thenational.

More than 1,100 attendees were on hand Thursday evening at APMA’s Luau Reception to enjoy a stunning performance of traditional Polynesian music and dances. Guests enjoyed tiki cocktails and hors d’oeuvres as they took in the breathtaking scenery of Oahu from the Great Lawn of the Hilton Hawaiian Village. APMA gratefully acknowledges the sponsors of the Luau Reception, Anacor Pharmaceuticals, Inc.; Bako Integrated Physician Solutions; MediTouch EHR/HealthFusion; the Podiatry Insurance Company of America; and Spenco Medical Corporation.

APMA Luau ReceptionPodiatry’s Public Health Crisis

P odiatrists’ membership in the American Public Health As-sociation (APHA) is reaching an all-time low, despite podiatric medicine’s role in public health.

James DiResta, DPM, MPH, the cur-rent chair of the APHA Podiatric Section, is asking each APMA component to fund membership for its executive director and one additional member (who is not a cur-rent APHA member). “If our membership in APHA continues to dwindle, the status of our Podiatric Section will be in jeopardy,” Dr. DiResta warned. “If we lose our section, we will lose our seat at the table and will re-duce our effectiveness in many public health initiatives that should concern us all.”

Janet Simon, DPM, chair of APMA’s Pub-lic Health and Preventive Podiatric Medi-cine Committee, echoed Dr. DiResta’s call to action. “Much of what we do as podiatrists on a daily basis is public health,” she said.

Everything from screening patients for diabetic peripheral neuropathy and peripheral arterial disease to encouraging smoking cessation and assisting elderly patients to prevent falls qualifies as public health practice, Dr. Simon said, particularly as the population ages and more and more podiatrists participate in meaningful use and quality reporting initiatives.

This morning, Dr. Simon will moderate the Public Health/Falls Prevention track at 11 a.m. in Room 311.

APMA encourages state component societies to consider sponsoring member-ship for the state’s executive director and one additional member. Individual APMA members, visit www.apha.org and click on “About Us,” and “Membership Informa-tion” for links to renew your current APHA membership or join as a new member.

Passionate about Public Health?If you have an interest in public health or know a podiatrist who does, consider the APMA/The Dartmouth Institute for Health Policy and Clinical Practice (TDI) Public Health Fellowship.

The fellowship curriculum is designed to provide the fellow with fundamental skills, knowledge base, and philosophical foundation in health policy and clini-cal practice, with specific attention paid to public health, clinical/health services research, and health-care leadership.

The application period for the 2015–16 APMA/TDI Fellowship is now open. The deadline for applications is November 7. To learn more and apply, visit www.apma.org/tdi.

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14 The National Today • APMA Annual Scientific Meeting Saturday, July 26, 2014

Exhibit Hall Map

#1st Providers Choice-DPM EMR ....................... 71520/20 Imaging ................................................. 825

AABL Medical, LLC ............................................. 819ACell, Inc.......................................................... 618Air Force Recruiting Services ........................... 412American Association of Colleges of Podiatric Medicine ....................................... 416American Board of Foot and Ankle Surgery ...... 717American Board of Podiatric Medicine .............. 725American College of Foot and Ankle Surgeons.. 913American Podiatric Medical Association, Inc. .... 623American Society of Podiatric Dermatology ...... 414American Society of Podiatric Medical Assistants ......................... 427Amerx Health Care Corporation ........................ 608Amniox Medical ............................................... 716Anacor Pharmaceuticals Inc. ............................ 409ASICS America Corporation .............................. 800

List of Exhibitors

HHawaiian Moon ................................................ 522Hawaiian Museum ........................................... 923Henry Schein MicroMD .................................... 814Hilo Hattie ...................................................... 1133Horizon Pharma, Inc. ........................................ 403Hush Puppies Footwear ................................... 912

IIM Custom ....................................................... 918

JJM Orthotics .................................................... 417

KKerasal ............................................................ 714

MMedi USA, LP ................................................... 704MediTouch EHR/HealthFusion .......................... 503Medline Industries, Inc. .................................... 915Merz North America ......................................... 603Metasurg ......................................................... 818Midmark Corporation ....................................... 622Mile High Orthotics Lab., Inc. ........................... 719MiMedx Group, Inc. .......................................... 723Multi Radiance Medical .................................... 525

NNEUROGENX, Inc. ............................................. 815New Balance Athletic Shoe, Inc. ....................... 502Nomir Medical, Inc. .......................................... 419Northwest Podiatric Laboratory ........................ 528

OOrganogenesis Inc. .......................................... 709Osiris Therapeutics, Inc. ................................... 518

PPedorthic Footcare Association ........................ 429PharmaDerm, a part of Fougera Pharmaceuticals, Inc. ..................... 402Physician Claim Corp. ...................................... 628Physician Web Pages/Eppointments ................. 810Podiatry Insurance Company of America (PICA) .............................. 703Podiatry Management Magazine ...................... 826Podiatry Today ................................................. 917Premier Shockwave, Inc. .................................. 829

RRenewed Nail/Keratone ................................... 922RTI Surgical Inc. ............................................... 900

SSamuel Merritt University Health Sciences Simulation Center (HSSC) ....... 423Sarapin-High Chemical Company ..................... 827SIUI America .................................................... 513Smith & Nephew .............................................. 705SOLS Systems, Inc. .......................................... 812Spenco Medical Corporation ............................ 619

Association of Extremity Nerve Surgeons ......... 418athenahealth, Inc. ............................................ 612Axxess Compounding....................................... 727

BBako Integrated Physician Solutions................. 803Biofreeze/Performance Health .......................... 817Biomet Bone Healing ....................................... 710Bonapeda Enterprises LLC ............................... 616Brooks Running ............................................... 914Brymill Cryogenic Systems .............................. 516BSN Medical Inc............................................... 605

CCalifornia School of Podiatric Medicine at Samuel Merritt University .............. 422Cardiovascular Systems, Inc. ........................... 813CareCredit ....................................................... 514Crealta Pharmaceuticals .................................. 804

DDerma Sciences .............................................. 405

DG Instruments ................................................ 415DJO Global ....................................................... 624DOLA ............................................................... 928Dr. Comfort ...................................................... 626Dr. William M. Scholl College of Podiatric Medicine at the Rosalind Franklin University of Podiatric Medicine and Science ....................... 425

EEuropean Footcare Supply ............................... 713

FFight 4 My Feet ................................................ 711Foot Karma ...................................................... 511FootBalance System, Inc. ................................. 822Footmaxx ......................................................... 823

GGood Feet Worldwide ....................................... 916

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15The National Today • APMA Annual Scientific MeetingSaturday, July 26, 2014

SteriShoe by Shoe Care Innovations, Inc........... 609Stryker Foot and Ankle ..................................... 408Superfeet Worldwide Inc. ................................. 529Support the Foot .............................................. 614SureFit ............................................................. 610Swede-O, Inc. .................................................. 523

TTelevere Systems/TigerView ............................ 729The Tetra Corporation ...................................... 509Timberland PRO ............................................... 527

UU.S. Jaclean, Inc. ............................................. 708Universal Imaging ............................................ 504Upsher-Smith Laboratories, Inc. ....................... 809US Wound Registry .......................................... 426

VValeant Pharmaceuticals North America LLC .... 613Vasamed, Inc. .................................................. 611VIONIC with Orthaheel Technology.................... 908

WWestern University of Health Sciences-College of Podiatric Medicine ............ 424Wright Medical Technology .............................. 515

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steroids is a new classification scheme with four classes, down from the seven or five classes that used to be followed.

“My approach is to have just one drug for each of the four classes so you only have to remember four drugs. This is a new concept not talked about much,” Dr. Dockery said.

He also recommended showing patients the “fingertip unit” as the correct amount of corticosteroid to apply. The patient should squeeze a line of medicine the length of the index finger—the bigger the person, the longer the index finger.

Podiatry a Key in Controlling Effects of DiabetesThe latest National Diabetes Statistic Report said that 9.3 percent of the US population—29.1 million people—had diabetes in 2012, and more than one-quar-ter of them will have foot ulcers, which illustrates the important role podiatric physicians must play in controlling the effects of this epidemic.

Fariba Rahnema, MD, discussed the latest treatment advances for patients with diabetes and the role of podiatry in treat-

ing patients during her presentation, “The Physiology of Dermatological Conditions in Diabetes.”

Research shows that optimal glycemic control greatly decreases the risk for the development of chronic sequelae of diabe-tes, including macrovascular disease and its complications, she said. Every 1 percent reduction in A1C levels is associated with a 36-percent reduction in microvascular complications and a 16-percent reduction in macrovascular complications.

The lack of any comprehensive podiatry service in most countries is a major barrier to improved care of people with diabe-tes, said Dr. Rahnema, director of Valley Endocrinology, Las Vegas.

The American Diabetes Association has stated that podiatrists play a key role in providing appropriate foot care for people with diabetes and that a person with diabe-tes should have an annual comprehensive diabetic foot examination by a podiatrist. Depending on the findings on the compre-hensive diabetic foot examination based on the risk status of the person, a regular schedule of foot care should be established.

More than 8,000 amputations are per-formed on patients with diabetes each year in the US, and almost 50 percent of ampu-tations are preventable, Dr. Rahnema said.

About 85 percent of all diabetes-related lower extremity amputations are preceded by foot ulcers

Foot ulcers are a major complication in patients with diabetes and remain one of the most common causes for hospitaliza-tion and the high costs associated with this disease, she said.

The latest guidelines for treatment of pa-tients with diabetes stress the importance of a multidisciplinary team, including infectious disease specialists, podiatrists, surgeons, and orthopedists, in providing optimal care for this widespread problem, she said.

Dr. Rahnema discussed new directions in the management of patients with type 2 diabetes, including:• a focus on earlier diagnosis, such as

monitoring A1C levels;• earlier, more intensive interventions,

including multiple drugs;• focusing on treat-to-goal, not treat-to-

failure;• a greater emphasis on weight control

and using treatments that avoid weight gain;

• greater individualization of therapy; and• focusing on reducing complications/

costs through more rigor in perfor-mance assessment.

SYMPOSIUMContinued from page 1

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