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Podiatric Health
Section Newsletter
Fall 2008

Chair Message

Message from the Chair

Where did the time go?

Christian Robertozzi, DPM

 

My two-year term as chair of the APHA Podiatric Health Section is coming to a rapid end.  It has been a rewarding time and one that I will always remember.  Our incoming chair, Janet E. Simon, DPM, will be hitting the ground running.  She has been an invaluable asset to me over the past two years.  There is no doubt Janet will bring the Podiatric Health Section to new heights.  Thank you for giving me the opportunity to serve as chair of the Podiatric Health Section of APHA.

 

This year the APHA 136th Annual Meeting and Exposition will be in San Diego at the San Diego Convention Center from Oct. 25-29, 2008.  The theme is public health without borders.  There will be more than 700 booths attracting more than 13,000 national and international public health professionals.  You should be there!

 

The Podiatric Health Section organized three scientific sessions for the Annual Meeting and Exposition.  Two of the three sessions are Humanitarian/Mission Activities in Foot and Ankle Care.  The other lecture will discuss Diabetic Foot Care and Podiatric Manpower. As you can see, these are going to be exciting lectures you don’t want to miss.  If you haven’t signed up, don’t waste another minute. 

 

The Podiatric Section is not alone in efforts to boost its numbers.  It is understandable that we are frustrated with the direction health care is taking in general despite our continued efforts to make it better.  However, continue to focus on the big picture and remain optimistic.  Your membership in this worthwhile organization must not be dropped.  Please renew your membership if it has slipped by.   Encourage your friends if they have not renewed to send in their dues money.  Share the benefits of the APHA with a friend and recruit a new member.  There is strength in numbers as APHA speaks for the public good.  Health care is going through a crisis, and we must be at the table in order to make a positive change for our patients.  With a new president being elected in November, and health care being one of the major domestic issues, we must not allow this opportunity to pass us by.  No other group can speak for podiatry better than we can.

Fit Feet and Healthy Athletes: Keeping Special Olympics Athletes on Their Feet and in the Game

Patrick J. Nunan, DPM
Senior Global Clinical Advisor, Fit Feet
Healthy Athletes/Special Olympics

There still exists in the modern world insufficient proper health care for patients who have intellectual disabilities. This is not just a third world problem but occurs in developed countries as well.  Many health care professionals are never trained in dealing with people with intellectual disabilities.  Most medical and dental schools do not have organized rotations or course work in disability medicine, especially in the intellectual area.   Typically, training occurs in pediatric programs.  As the patients age, the family or doctor may not feel comfortable going to a "children's doctor" for evaluation and care.  Another barrier is that many of the patients are enrolled in Medicaid type programs that many doctors do not accept due to low reimbursement.  Lastly, there is a lack of communication between health care providers, agencies and patients or parents on programs that are available to patients.

The Healthy Athletes program of Special Olympics was founded in response to lack of proper evaluation, treatment and care for those with intellectual disabilities.  There are seven disciplines that comprise the program; Special Smiles (dentistry), Opening Eyes (optometry), Healthy Hearing (audiology), Fun Fitness (physical therapy), Health Promotions (nutrition, bone density, healthy lifestyles), Fit Feet (podiatry) and MedFest (medical evaluations).  Most of the screenings occur at world, regional, national or state games.  The goal is to eventually have evaluations on the local level where the athletes first enter Special Olympics competitions.  More important than the screening is getting follow-up care for the athletes and access to quality health care. 

Fit Feet was founded in 2002 as a project of the American Academy of Podiatric Sports Medicine.  Today, the program has spread worldwide and has another partner in the Federation of International Podiatrists.  Fit Feet programs exist in about 38 states and all the provinces of Canada as well as 18 countries in Europe, five countries in Latin America, two programs in Africa and China, Japan, India, Australia, New Zealand, Hong Kong, Korea, Taipei and Indonesia.  While podiatry does not exist as a profession in some of those countries, we use other health care professionals with experience in foot and lower extremity diseases.  These include orthopaedic surgeons, physical medicine and rehabilitation physicians, family physicians, physical therapists, orthotists/pedorthotists, internal medicine specialists and nurses. 

During a Fit Feet screening, the athletes' skin, nails, bone structures and gait are evaluated.  Shoes and socks are also inspected for wear patterns, fit and correct type for that particular athlete and sport.  Foot health education and recommendations are given before the patient leaves the venue.  At the recent 2007 World Summer Games in Shanghai, China, over 4,000 athletes were seen in the Fit Feet venue.  More than 51 percent of those athletes had some type of nail or skin disorder.  During games in Europe, a team of podiatrists/biomechanists using in-shoe pressure systems and video gait analysis determined that 70 percent of the athletes could benefit from a functional orthotic.  We have seen at some games that 75 percent of the athletes either have the wrong size shoe, worn out shoes or the wrong shoe for the sport they are participating in.  Many of them have never had their feet inspected by any health care provider.  As you can see, this is a large public health care problem.  Also at the recent World Games in China we saw a young man who had a neglected clubfoot deformity. His gait revealed that he was walking on the dorsal lateral aspect of his foot, mostly on the cuboid and lateral cuneiform bones.  He would develop a callus that would ulcerate and get infected from time to time.  It was amazing to find out that he was the captain of the cricket team from Barbados.  Through an international effort, we were able to get him connected with a podiatrist and an orthotist in his home country who are in the process of making him orthotics and modifying his shoes to reduce the pressure and eliminate the infections. 

As our program continues to grow, we hope to expand the services we provide.  We have conducted pilot programs in the United States, Japan and England using various pre-formed orthotics that can be molded to the athletes feet at games.  Many of our athletes cannot afford the running or athletic shoes they truly need, so we hope in the future to provide some type of discount or voucher program by partnering with a major shoe company.  Many of our athletes not only have intellectual disabilities but various degrees of physical disabilities as well.  Through proper screening, education and follow up care, we can keep our athletes "on their feet and in the game."  For more information about Healthy Athletes and Fit Feet, please visit our website at www.specialolympics.org

Membership Challenge

It may be surprising to many of our members to know that our Podiatric Health Section is the smallest APHA section when it comes to numbers of members. One of our ongoing challenges is maintaining our membership numbers and recruiting new members. I put forth this challenge to our current members to identify one new member for our section.  A wonderful place to fulfill this challenge is to sponsor a student or resident that you know. Introducing the world of public health to a young practitioner will ensure that our section will continue into the next generation.  It will also offer our young practitioners opportunities to participate in APHA student activities as well as Section projects.

Janet Simon, DPM

Chair-elect, POD Section

Summary Report of the Task Force of the Foot Care Interest Group of the American Diabetes Association

 

Paraphrased by Janet Simon, DPM

 

A task force was therefore assembled by the ADA to address and concisely summarize the recent literature in this area and then recommend what should be included in the comprehensive foot exam for adult patients with diabetes.  The committee was co-chaired by the immediate past and current chairs of the ADA Foot Care Interest Group (AJMB and DGA), with other panel members representing primary care, orthopedic and vascular surgery, physical therapy, podiatric medicine and surgery, and the American Association of Clinical Endocrinologists.

 

Committee members:

Andrew JM Boulton, MD, FRCP

David G. Armstrong, DPM, PhD

Stephen  F Albert, DPM, CPed

Robert G. Frykberg, DPM, MPH

Richard Hellman, MD, FACP

M Sue Kirkman, MD

Lawrence A. Lavery, DPM, MPH

Joseph W LeMaster, MD, MPH

Joseph L. Mills, Sr., MD

Michael J Mueller, PT, PhD

Peter Sheehan, MD

Dane K Wukich, MD

 

This report summarizes a simple protocol for evaluating the diabetic foot. If abnormalities are present, more frequent evaluation of the diabetic foot is recommended, depending on risk category as shown in  Table 1. It is through systematic examination and risk assessment, patient education, and timely referral that we may further reduce the unnecessarily high prevalence of lower extremity morbidity in this population. 

 

Table 1:

Risk classification based on the comprehensive foot examination

 

Risk Category

Definition

Treatment Recommendations

Suggested Follow-up

0

No LOPS, no PAD, no deformity

·         Patient education     including advice on appropriate footwear

Annually (by generalist and/or specialist)

1

LOPS ± deformity

·         Consider prescriptive or accommodative footwear. 

·         Consider prophylactic surgery if deformity is not able to be safely accommodated in shoes.  Continue patient education.

Every 3-6 months (by generalist or specialist)

2

PAD ± LOPS

·         Consider prescriptive or accommodative footwear

·         Consider vascular consultation for combined follow-up.

Every 2-3 months (by specialist)

3

History of Ulcer or Amputation

·         Same as category 1

·         Consider vascular consultation for combined follow-up if PAD present

Every 1-2 months (by specialist)

LOPS = loss of protective sensation

PAD = peripheral arterial disease

 

COMPONENTS OF THE FOOT EXAM

 

a)  History

A patient cannot be fully assessed for risk factors for foot ulceration on history alone, and a careful foot exam is the key component of this process, but the history remains a pivotal component of risk assessment. Key components of the history are previous foot ulceration or amputation.  Other important assessments in the history (Table 2) include a history of neuropathic or peripheral vascular symptoms as well as impaired vision or a history of renal replacement therapy. Lastly, tobacco usage should be recorded, as cigarette smoking is a risk factor not only for vascular disease but also for neuropathy.

 

Table 2:Risk factors for foot ulcers

 

*  Previous amputation

*  Past foot ulcer history

*  Peripheral neuropathy

*  Foot deformity

*  Peripheral vascular disease

*  Visual impairment

*  Diabetic nephropathy – especially patients on dialysis 

*  Poor glycemic control

*  Cigarette Smoking

 

b)  General Inspection

A careful inspection of the feet in a well-lit room should always be carried out after the patient has removed shoes and socks.  As inappropriate footwear and foot deformities are common contributory factors in the development of foot ulceration (1, 5), the shoes should be inspected and the question asked, “Are these shoes appropriate for these feet?"  Examples of inappropriate shoes would be those that are excessively worn or are too small for the person’s feet (too narrow, too short, toe box too low) resulting in rubbing, erythema, blister or callus.

 

The features that should be assessed in the foot inspection are outlined in Table 3, and subdivided as below.

 

Table 3

Key Components of diabetic foot exam

 

INSPECTION

Dermatologic:

  • skin status:  color, thickness, dryness, cracking
  • sweating
  • infection – check between toes for fungal infection
  • ulceration
  • calluses/blistering:  hemorrhage into callus?

Musculoskeletal:

  • deformity e.g., claw toes, prominent metatarsal heads,

           Charcot joint (Fig. 3)

  • muscle wasting (guttering between metatarsals)

 

NEUROLOGICAL ASSESSMENT

  • 10 g monofilament + one of the following four:
  • Vibration using 128 Hz tuning fork
  • Pin prick sensation
  • Ankle reflexes
  • Vibration Perception Threshold

 

VASCULAR ASSESSMENT

  • Foot pulses
  • Ankle Brachial Index, if indicated

b.1)  Dermatological Assessment

The dermatological assessment should initially include a global inspection, including interdigitally, for the presence of ulceration or areas of abnormal erythema. The presence of callus (particularly with hemorrhage), nail dystrophy or paronychia should be recorded (9), with any of these findings prompting referral to a specialist or specialty clinic. Focal or global skin temperature differences between one foot and the other may be predictive of either vascular disease or ulceration and could also prompt referral for specialty foot care (10-13).

 

b.2)  Musculoskeletal Assessment

The musculoskeletal assessment should include evaluation for any gross deformity (14). Rigid deformities are defined as any contractures that cannot easily be manually reduced, and are most frequently found in the digits. Common fore foot deformities that are known to increase plantar pressures and are associated with skin breakdown include metatarsal phalangeal joint hyperextension with inter phalangeal flexion (claw toe) or distal phalangeal extension (hammer toe) (15-17). Examples of these deformities are shown in Figure 3.

 

An important and often overlooked or misdiagnosed condition is Charcot arthropathy. This occurs in the neuropathic foot and most often affects the midfoot. This may present as a unilateral red, hot swollen, flat foot with profound deformity (18-20). A suspected Charcot arthropathy should be immediately referred to a specialist center for further assessment and care.

 

c)  Neurological Assessment

Peripheral neuropathy is the most common component cause in the pathway to diabetic foot ulceration (1, 4, 5, 7).  The clinical exam that is recommended, however, is designed to identify loss of protective sensation (LOPS) rather than early neuropathy.  The diagnosis and management of the latter is covered in the 2004 ADA technical review (7). The clinical examination to identify LOPS is simple and requires no expensive equipment.

 

Five simple clinical tests (Table 3), each with evidence from well-conducted prospective clinical cohort studies, are considered to be useful in the diagnosis of LOPS in the diabetic foot (1-7).  The task force agreed that any of the five tests listed below could be used by clinicians to identify LOPS, although ideally, two of these should be regularly performed in the screening exam, and would normally comprise the 10g monofilament and one other test. One or more abnormal tests would suggest LOPS, while at least two normal tests (and no abnormal test) would rule out LOPS. The last test listed, vibration assessment using a biothesiometer or similar instrument, is included as it is widely used in the United States: however, identification of the patient with LOPS can easily be carried out without this or other expensive equipment.

 

i)  10 gram monofilaments

Monofilaments (MF), sometimes known as Semmes-Weinstein MFs, were originally used to diagnose sensory loss in leprosy (21).  Many prospective studies have confirmed that loss of pressure sensation using the 10g MF is highly predictive of subsequent ulceration (3, 21,22).  Screening for sensory loss with the 10g MF is in widespread use across the world, and its efficacy in this regard has been confirmed in a number of trials including the recent Seattle Diabetic Foot Study (4, 21,23,24).

Nylon MFs are constructed to buckle when a 10g force is applied:  loss of the ability to detect this pressure at one or more anatomic sites on the plantar surface of the foot has been associated with loss of large-fiber nerve function.  It is recommended that four sites (1st, 3rd and 5th metatarsal heads and plantar surface of distal hallux) be tested on each foot.

 

The technique for testing pressure perception with the 10g MF is illustrated in Fig 1: patients should close their eyes while being tested. Caution is necessary when selecting which brand of MF to use as many commercially available MFs have been shown to be inaccurate.  Single-use disposable MFs or those shown to be accurate by the Booth and Young (23) study are recommended.  The sensation of pressure using the buckling 10g MF should first be demonstrated to the patient on a proximal site (e.g., upper arm).  The sites of the foot may then be examined asking the patient to say “yes” or “no” when asked if they believe that the MF is being applied to the particular site: the patient should recognize the perception of pressure as well as identifying the correct site. Areas of callus should always be avoided when testing for pressure perception.

 

ii)  128 Hz turning fork

The turning fork is widely used in clinical practice and provides an easy and inexpensive test of vibratory sensation.  This should be tested over the tip of the great toe bilaterally, and an abnormal response can be defined as when the patient loses vibratory sensation and the examiner still perceives it while holding the fork on the tip of the toe (3, 4).

 

 

iii) Pin-prick sensation

Similarly, the inability of a subject to perceive pin-prick sensation has been associated with an increased risk of ulceration (4).  A disposable pin should be applied just proximal to the toe nail on the dorsal surface of the hallux, with just enough pressure to deform the skin.  Inability to perceive pin-prick over either hallux would be regarded as an abnormal test.

 

iv)  Ankle reflexes

Absence of ankle reflexes has also been associated with increased risk of foot ulceration (4).  These can be tested with the patient either kneeling or resting on a couch/table.  The Achilles tendon should be stretched until the ankle is in a neutral position before striking it with the tendon hammer.  If a response is initially absent, the patient can be asked to hook fingers together and pull, with the ankle reflexes then re-tested with reinforcement.  Total absence of the ankle reflex either at rest or on reinforcement is regarded as an abnormal result.

 

v)   Vibration Perception Threshold Testing

The biothesiometer (or neurothesiometer) is a simple, hand-held device that gives semi-quantitative assessment of vibration perception threshold.  As for vibration using the 128 Hz tuning fork, the vibration perception using the biothesiometer is also tested over the pulp of the hallux.  With the patient lying supine, the stylus of the instrument is placed over the dorsal hallux, and the amplitude increased until the patient can detect the vibration:  this figure is known as the vibration perception threshold (VPT).  This should be demonstrated on a proximal site initially, and then the mean of three readings is taken over each hallux.  A VPT > 25 volts is regarded as abnormal and has been shown to be strongly predictive of subsequent foot ulceration (15,22).

 

d)  Vascular Assessment

Peripheral arterial disease is a component cause in approximately one-third of foot ulcers and is often a significant risk factor associated with recurrent wounds (5,25). Therefore, its assessment is important in defining the overall lower extremity risk status.  Vascular examination should include palpation of the posterior tibial and dorsalis pedis pulses (10,26).  These should be characterized as either “present” or “absent”(26).

 

Diabetic patients with signs or symptoms of vascular disease (Table 2) or absent pulses on screening foot examination should undergo ankle brachial pressure index (ABI) testing and be considered for a possible referral to a vascular specialist. The ABI is a simple and easily reproducible method of diagnosing vascular insufficiency in the lower limbs. The blood pressure at the ankle (dorsalis pedis or posterior tibial arteries) is measured using a standard Doppler ultrasonic probe. This technique is outlined in Figure 2). The ABI is obtained by dividing the ankle systolic pressure by the higher of the two brachial systolic pressures (8). An ABI of > 0.9 is normal, values < 0.8 are associated with claudication, and those < 0.4 are commonly associated with ischemic rest pain and tissue necrosis.

 

An ADA Consensus panel on peripheral arterial disease recommended measurement of the ABI in diabetic patients over 50 years old, and consideration of ABI measurement in younger patients with multiple PAD risk factors, repeating normal tests every 5 years (8). The ABI may therefore be part of the annual comprehensive foot exam in these patient subgroups. ABI measurements may be misleading in diabetes because the presence of medial calcinosis renders the arteries incompressible and results in falsely elevated or supra-systolic ankle pressures. In the presence of incompressible calf or ankle arteries (ABI > 1.3), measurements of digital arterial systolic pressure (toe pressure) or transcutaneous oxygen tension may be performed.

 

g)  Risk Classification and Referral/Follow-Up

Once the patient has been thoroughly assessed as described above, he or she should be assigned to a foot risk category (Table 4). These categories are designed to direct referral and subsequent therapy by the specialty clinician or team (17,20), and frequency of follow-up by the generalist or specialist. Increased category is associated with an increased risk for ulceration, hospitalization and amputation (17). Patients in risk category 0 generally do not need referral, and should receive general foot care education and undergo comprehensive foot examination annually. Patients in foot risk category 1 may be managed by a generalist or specialist every 3-6 months. Consideration should be given to an initial specialist referral to assess the need for specialized treatment and follow-up. Those in categories 2 and 3 should be referred to a foot care specialist or specialty clinic and seen every 1-3 months.

San Diego POD Section Meetings and Sessions

Monday, Oct. 27, 2008

6:30 a.m.-8:00 a.m.

306.0 Podiatric Section Business Meeting

Tuesday, Oct. 28, 2008

8:30 a.m.-10:00 a.m.

4051.0 Humanitarian/Mission Activities in Foot and Ankle Care

187692 "Operation Footprint", Baja Project for Crippled Children, Inc

Donald W. Adams, DPM , Framingham Podiatry Associates, Framingham, MA

The Baja Project began in Southern California 30 years ago. At the onset podiatric surgeons and podiatric medical residents established a clinic in Mexicali, Mexico. The clinic was attended on a weekly basis with podiatric surgeons where hundreds of clubfoot cases were treated. Treatments included both surgical and non-surgical. Due to the high success of the program many cases on neglected clubfoot were treated and eradicated. The program in Mexicali ended due to a surgical manpower shortage. The project then moved to Central America.

Operation Footprint initially began in El Salvador 11 years ago. Due to a series of devastating earthquakes and a hospital workers' strike, the program was temporararliy suspended after three years. The program then expanded to Tegucigalpa ,Honduras seven years ago. A team of highly qualified podiatric surgeons from across the United States travel to Central America to perform reconstructive clubfoot surgery on neglected clubfoot patients. Some of the members of the team were former residents of the Baja Program and Mexicali clinic.

"Operation Footprint 2007-Honduras" involved 11 podiatric surgeons from the United States as well as nine senior podiatric residents. Post-operative treatments and care are provided by two local orthopedic surgeons. These physicians perform all cast changes, pin removals and follow-up visits. These physicians are integral to the program by providing thorough knowledgeable post-operative treatments. The trip involved two days of patient screenings and five surgical OR days. Thirty-one patients had 40 surgical procedures.

Learning Objectives:


1. Discuss a humanitarian project on treating children in Baja. 2. Enlighten attendees about participating in humanitarian foot and ankle surgical programs.

182566 California School of Podiatric Medicine rotation with the Uganda Sustainable Clubfoot Care Project

Ajitha Karunakaran Nair, MPH , California School of Podiatric Medicine, Berkeley, Calif.

The Uganda Poverty Eradication Plan has stated that disability is a frequent cited cause of poverty in Uganda. In response, the Uganda Ministry of Health has approved the free administration of the Ponsetti Method, a serial casting technique standard for clubfoot treatment, for treatment of congenital clubfoot through 2010. Medical students and orthopedic surgeons are few of the practitioners being educated in this effort to provide treatment of congenital clubfoot. In response, the Uganda Sustainable Clubfoot Care Project (USCCP), a partnership between the University of British Columbia and Makerere University, was created. USCCP is publishing an ethno-cultural survey on perceptions associated with clubfoot, developing awareness programs, and holding workshops.

The Canadian Project Director of the USCCP has invited students from the California School of Podiatric Medicine (CSPM) to train with the program at Makerere University. This collaborative opportunity would be a beneficial experience to podiatric medical students who will have the opportunity to rotate through this clinic until 2010, at which time the Canadian International Development Agency funding for the USCCP ends. Rotating students will train with orthopedic assistants and surgeons in the application and surgical procedures of the Ponsetti method.

The students will observe how environmental, political, and socioeconomic issues affect the health of a population, learn epidemiologic principles important in evaluating the health of a community, compare and contrast health care delivery systems in the United States with those of developing countries, and will help develop in students a better understanding of challenges of intercultural medical research and partnerships.

Learning Objectives:


1.Recognize the clubfoot deformity problem in developing countries. 2. Learn the spectrum and classification of the clubfoot deformity. 3. Describe the pathoanatomy of the clubfoot deformity. 4. Apply the Pirani clubfoot score. 5. Apply the Ponseti method of clubfoot treatment. 6. Utilize the Steenbeek Foot Abduction brace. 7. Apply follow-up methods. 8. Assess recurrent clubfoot deformity .9. Discuss common errors in the treatment of the clubfoot. 10. Apply an algorithm for treatment of clubfeet in Africa.

171958 Raising the Bar: Improving Access to Education, Healthcare Services and Nutrition in Haiti on the Local Level through International Volunteerism.

Thomas F. Ertle, DPM, CWS , Belhaven Foot and Ankle Clinic, Belhaven, N.C. Luke A. Ertle, BA , Master's of Public Health Program, Brody School of Medicine, East Carolina University, Belhaven, N.C.

Many governments throughout the world face having to serve their people's health care needs despite a lack of infrastructure, resources and trained personnel. In order to fill this gap, often private individuals, foundations, and civic and church groups have responded to these peoples' health care and nutritional needs. The combined efforts of two organizations, the Belhaven-Pantego Rotary Club and the Hearts for Haiti Foundation, in collaboration with village and church leaders, provide Haitian children with a balanced meal 3-5 times a week, vitamins, access to medical care, and education. This project, which began approximately 15 years ago with one child's club-foot surgery has expanded into a feeding, education and child sponsorship program supporting more than 500 children in three villages.

Learning Objectives:


1. Valuable, life-changing projects can sprout and grow from small beginnings. 2. Collaborating with civic and church leaders is an effective means of delivering basic health care and educational needs. 3. The American public, in general, is very generous and willing to give of their time, talents and resources provided the mechanism is trustworthy and reliable.

12:30 p.m.-2:00 p.m.

4209.0

Diabetic Foot care and Podiatric Manpower

175643

Nutritional Assessment of the Chronic, Non-Healing Diabetic Wound Patient Emily Marie Splichal, DPM , New York College of Podiatric Medicine, New York, N.Y.

Although people with diabetes comprises only 4.5 percent of the U.S. population, last year alone the United States health care system spent an astounding $100 billion on diabetic complications. The chronic complications associated with diabetes account for a majority of this expenditure, with diabetic foot ulcers being the most common reason for hospitalization. Diabetic foot ulcers are estimated to occur in roughly 15 percent of diabetic patients, with 85 percent of these ulcers leading to amputation.

Despite the existence of algorithmic management of diabetic ulcers, many diabetics still present with chronic, non-healing ulcers. A chronic wound results when the normal repair process is interrupted or there are insufficient nutrients and oxygen locally at the ulcer site. These non-healing wounds are a challenge to the patient, physician and health  ,care system thus necessitating the need to look at all possible causes for impaired wound healing in the diabetic patient.

Healing is influenced by poor nutritional status, which includes inadequate vitamin requirements, excessive methionine and AGE's and insufficient caloric intake. Nutritional assessment of the diabetic patient with a non-healing ulcer is an essential piece to the puzzle of solving why chronic wounds are non-healing. Learn how a diabetic diet can uniquely impair their wound healing and how we as podiatrists can assess for possible vitamin supplementation or work with a nutritionist to reduce chronic ulcers and possible amputations in our patients.

Learning Objectives:


1. Describe the difference between acute and diabetic wounds. 2. List the phases of wound healing and describe what nutritional requirements are needed for each phase. 3. Discuss why podiatrists need to consider nutrition in diabetic wound patients. 4. Describe hyperhomocysteinemia and its impact on wound healing. 5. Recognize if diabetic patients need nutritional supplementation to improve wound healing.

182714 Call to Action: Urbanization and the Increasing Need of Podiatric Care Ajitha Karunakaran Nair, MPH , California School of Podiatric Medicine, Berkeley, Calif.

This article examines published literature and relates it to the increased need for international podiatric health care due to urbanization. A worldwide trend for the rural poor to migrate to the city for work has left this population in transitory environments lacking basic health resources. Current podiatric related morbidity and mortality statistics will only increase as a result of the absence of podiatric care especially due to the direct correlation of foot health to disability.

Learning Objectives:


1. Recognize and prioritize the relationship of urbanization and podiatric care. 2. Raise awareness of developing worlds cities who are undergoing rapid urbanization and their future health needs.

187661 Review of Podiatric Medicine Workforce Study

James Christina, DPM , Department of Scientific Affairs, American Podiatric Medical Association (APMA), Bethesda, Md.

The American Podiatric Medical Association (APMA) contracted with the Center for Health Workforce Studies, School of Public Health, University at Albany to complete a podiatric medicine workforce study in 2007. This study was completed in January 2008. The oral abstract will review the results of the study and discuss the implications if the assumptions in the study prove to be correct.

APMA believed that the combination of an increasing aged population, a decreasing number of podiatric physicians through retirement and increases in the population in obesity and diabetes will lead to a significant shortage of podiatric physicians to meet the foot and ankle health care needs of the population in the next 10-15 years. Working with these assumptions, the Center for Health Workforce Studies developed projections on the number of podiatric physicians that we be available in the future to provide these services and developed five potential scenarios.

The oral presentation will analyze the results and discuss the potential scenarios in detail.

187839 Can obesity related foot pain be relieved by the use of premolded or custom molded shoe inserts - a two part study.

(Meredith Ward, Foot and Ankle Center of N.C., Pinehurst, N.C.

As obesity rates rise, the prevalence of foot pain caused by excess weight and body stress also rises. One non-invasive treatment for certain types of foot pain caused by obesity is the prescription of pre-molded or custom molded inserts by a podiatric professional. The preliminary findings of a two-year study will be reported with a final presentation planned for the 2009 APHA Annual Meeting.

Learning Objectives:


1. Recognize the potential foot problems related to obesity. 2. Analyze the ability of pre-fabricated and custom molded foot orthoses to relieve obesity related foot pain.

 

2:30 p.m.-4:00 p.m.

4299.0

Humanitarian/Mission Activities in Foot and Ankle Care,

171599 Associations of overweight and obesity with existing morbidities in the podiatric patient population of Miami Florida

Kaloian G. Ouzounov, DPM , School of Podiatric Medicine, Barry University, Miami Shores, Fla.

Associations of overweight and obesity with existing morbidities in the podiatric patient population of Miami, Florida.

This cross-sectional study will explore the prevalence of overweight and obesity among the podiatric patient population of Miami, Florida. Formal study approval will be obtained from the Barry University Institutional Review Board. History and physical (H&P) exam data will be obtained for 400 patients from the four clinics of Barry University Foot and Ankle Institute. Obesity/overweight status will be determined for each patient according to their Body Mass Index (BMI). Patient morbidities will be stratified in relation to BMI, and the strength of the associations evaluated statistically. Observed associations in the podiatric patient population will be compared to existing associations reported for the general population.

Learning Objectives:


1. Recognize overweight and obesity in the podiatric patient. 2. Learn how to caclulate BMI in the podiatric patient. 3. Analyze BMI and rule out exceptions for application of BMI. 4. Stratify patients in categories of overweight and obesity. 5. Prioritize risks for the patients in the identified patient overweight/obesity category. 6. Inform and educate patient on option of fighting overweight and obesity. 7. Implement a plan for monitoring progress of podiatric patients with overweight/obesity. 8. Assess periodically progress for control of overweight/obesity in the podiatric patient. 9. Apply multispecialty approach to the podiatric patient for maximizing patient benefits. 10. Develop a local network of health care providers for delivering education/prevention/treeatment and control of overweight and obesity in the podiatric patient.

182778 Hills to Climb and Vistas to Enjoy: The Challenge of Medical Missions.

Darren M. Woodruff, BSc, BA , Podiatric Medicine, Midwestern University, Glendale, Ariz.

Most people in the world are altruistic and feel the need to help take care of their fellow man; physicians ought to be a major part of this group. One opportunity for physicians to share their talents and help others in need is the medical mission. The medical mission is set up to try and maximize the assistance that physicians can render in areas that are deficient of such assistance. Even though these missions are very beneficial, they do not occur without their obstacles. There are many challenges that people participating in medical missions must face every time they are undertaken. These challenges range from lack of proper equipment for various reasons, to impedance of certain procedures such as the clinician not being able to follow up, and to customs and immigration problems. These challenges may be overcome on different levels in varying missions. Challenges, however, do not halt the continuation of medical missions. The altruistic work of humanity will continue even in the face of hardships. Therefore, these medical missions will continue even though challenges will always be present.

POD Section Supports Vision Care Resolution

  Promoting Interprofessional Education

Statement of the Problem: The standard of care deemed appropriate for the management of many common medical and health conditions requires integration of multiple disciplines as well as accessing care at different sites.  The lack of a coordinated approach to multidisciplinary assessment can result in delays in diagnosis, delayed development of appropriate treatment plans and barriers to the receipt of care.[i] There is a need for health care delivery, family, and community health services that are well coordinated, free of errors, sensitive to patient needs and responsive to the patient’s subjective experience.  To fulfill these requirements frequent and full collaboration between health care professionals is imperative.[ii],[iii],[iv] Globalization, migration and widespread health disparities call for interdisciplinary and interprofessional approaches to improve the health status of individuals, families and communities in the United States and abroad.[v],[vi],[vii] Evidence from some educational programs strongly suggests that future health care providers and public health workers would be better prepared to effectively meet the challenges of  today’s health care systems through interdisciplinary curricula and interprofessional education.

 

In 2000, the National Academies of Practice brought together an expert panel representing 10 health care disciplines to define the issues of interdisciplinary health care and formulate clear objectives to move towards an interprofessional education plan.  It was hoped that such a plan would lead to interprofessional practice and better heath care for all Americans. The objectives developed included funding requests for both interprofessional education and interprofessional research along with a call for consensus on the curriculum components required for interprofessional education. [viii]  In 2001 and in 2002, additional reports were issued because the many existing barriers resulted in only small movements toward interprofessional practice.  These reports amplified the call to action for new modes of health care delivery utilizing interprofessional care.  Multiple researchers have conducted studies with differing models of interprofessional education.  While the results have been published, there has been little if any global movement to integrate health professions and public health educational programs.[ix],[x] 

 

The concept of multiple disciplines addressing of the needs of patients, families and communities together requires that each of the disciplines understands the skills and knowledge of other health care professionals in an effort to bridge communication between disciplines.  The terms multidisciplinary, transdisciplinary and interdisciplinary refer to the characteristics of a health care delivery team.  In a multidisciplinary team, each discipline independently contributes its experience to an individual patient’s care.  Team members who work parallel to one another and direct communication among team members is rare, except through the provider who is in charge (usually the patient’s primary care physician). In transdisciplinary practice, roles of individual team members are blurred, and their functions frequently overlap.  Here, each team member must become sufficiently familiar with their colleagues’ disciplines in order to assume a significant portion of the others’ roles.  In an interdisciplinary team, members work closely together and communicate frequently to optimize care for the patient.  In clinical practice, this type of model is also referred to as “interprofessional” care.  The interprofessional team is organized around a common set of problems, as opposed to being organized around a single physician, and meets frequently to consult.  Each team member’s assessment is taken into account to allow for global patient management.[xi]

 

The focus of this resolution is interprofessional education of health care and public health professionals.  This is simply shared learning by students from multiple health disciplines. 

Interprofessional Education (IPE) has been defined as an educational intervention during which members of more than one health and/or social care profession learn interactively together, for the purpose of improving collaborative practice and/or the health and well-being of patients.4

 

The American Academy of Pediatrics has been vocal about the need for the health and related systems to focus on coordinating the health and related care of children with special health care needs.  In 1999 a recommendation was made that stated primary care providers and tertiary care centers would work cooperatively in an effort to link patients and their families to a full spectrum of services.  The purpose of this resolution was to ensure the care was appropriate, not fragmented or duplicated, streamlined efforts to ensure appropriate services are delivered and that services were patient centered.[xii] These services include health, education and social services.  A study published in 2008, concluded that a poor medical home leads to barriers in accessing needed therapeutic and supportive services.[xiii] It is incumbent on the team to “cooperate, collaborate, communicate and integrate” as one of the core competency recommended for health profession education.[xiv] A team approach to health care has gained support from many organizations [xv],[xvi]  and has shown promise in many health care[xvii],[xviii],[xix],[xx] and health professions education [xxi],[xxii],[xxiii],[xxiv],[xxv],[xxvi],[xxvii],[xxviii],[xxix],[xxx],[xxxi],[xxxii],[xxxiii],[xxxiv] programs.  The Institute of Medicine strongly suggests that one must include the interdisciplinary approach into the education of our health care providers in an effort to improve patient-centered health outcomes.[xxxv] 

 

 

The use of interprofessional  teams in health professions programs have enhanced student learning and created opportunities for service to the community[xxxvi] and have supported the attainment of important elements of community capacity such as participation, training in groups, information sharing, networking, critical reflection,[xxxvii] and cultural competency.[xxxviii]  Interprofessional student health teams have been used to address the maldistribution of health care professionals and to improve access to care for under-served rural populations[xxxix],[xl]

 

APHA has previously adopted policy resolutions supporting interprofessional cooperation in the management of hypertension[xli] and diabetes[xlii] and within community health centers.[xliii]

 

Despite a growing body of evidence, the ultimate impact of interprofessional education and multidisciplinary approaches to patient care remains uncertain[xliv], and a lack of knowledge about key non-physician professional roles persists.[xlv] More rigorous studies are required to provide reliable evidence.[xlvi],[xlvii]

 

Despite the potential benefits, many barriers to interprofessional education persist, including already overcrowded curricula in health professions schools and schools of public health, lack of support from faculty and administration, financial constraints, and perceived isolation of some health professions.[xlviii]  The development and successful implementation of an interprofessional education approach is dependent on a variety of factors including the attitudes of students, faculty, administrators and practitioners.[xlix],[l],[li] Strong individual disciplinary cultures often persist, which may lead to territorialization, not integration. Stereotyping of other disciplines continues and providers need to be taught how to properly function within a team approach to care.

 

Three inter-related barriers to interprofessional collaboration were recently identified: the way in which each profession educates its students, the lack of a common foundation when health professions try to work in team settings, and health care delivery models that make it difficult to provide high quality patient care.[lii]  It is quite natural for providers to be resistant to change and fearful about the potential loss of autonomy in an interprofessional model. In addition, some organizations that employ health care teams may be more resistant to innovation and change.

 

In order to create a culture for interprofessional collaboration in clinical practice, these barriers must be overcome. A shared learning environment and collaborative practice setting may help to alleviate these tendencies. Interprofessional continuing education may also help to facilitate a positive and collegial team environment.  Evaluation of a program’s effectiveness is a key element to overcome the relative lack of evidence for an interprofessional approach to education and ultimately to interprofessional patient care environments. Such evaluations would provide the opportunity to assess health outcomes and patient satisfaction. In this way, programs can learn from previous success and failures.

 

Carroll-Johnson summarizes what interprofessional collaboration could achieve for all, “Imagine a world where each group’s expertise is held in regard, offered, and shared as the need arises.  Imagine a time when the patient can determine which kinds of practitioners he or she needs or wants, and then imagine a system that makes those professionals available.”[liii]

 The American Public Health Association

1.       Calls upon health professions education programs and schools of public health to incorporate coursework and clinical training emphasizing cross-disciplinary and interprofessional interactions including the development of an interdisciplinary curriculum;

2.      Calls upon health professions education programs and schools of public health to evaluate the outcomes of curricular changes to assess differences in students’ and graduates’ communication skills, knowledge, attitudes, and understanding of the roles of different members of the interprofessional health care team;

3.      Urges health professions education programs and schools of public health to rigorously evaluate the impact of interprofessional education on professional practice and health care outcomes;

4.      Encourages providers of continuing professional education to offer training and courses in interprofessional care featuring a multidisciplinary faculty of recognized experts from different disciplines and different health care fields;

5.      Urges health care researchers to form interprofessional collaborations for the study of health care education and health policy;

6.      Urges the Agency for Healthcare Research and Quality and other funding agencies to fund research on the effectiveness of interprofessional health care education.

 

Submitted by:

Elizabeth Hoppe, OD, MPH, DrPH, FAAO

Member, Vision Care Section

Founding Dean

Professor of Optometry

College of Optometry

Western University of Health Sciences

309 E. Second Street

Pomona, CA 91766-1854

(909) 706-3497

ehoppe@westernu.edu

 

Sandra S. Block, OD, MEd, FAAO

Member, Vision Care Section
Professor
Illinois College of Optometry
3241 S. Michigan Avenue
Chicago, IL 60616-3878
(312) 949-7276
sblock@ico.edu

 

Joseph J. Pizzimenti, OD, FAAO

Member, Vision Care Section

Associate Professor

Director of Interdisciplinary Clinical Education

College of Optometry

Nova Southeastern University

3200 South University Drive

Ft. Lauderdale, FL 33328-2018

(954) 262-1474

pizzimen@nsu.nova.edu

 

Pablo J. Calzada, DO, MPH, FAAFP

Individual Member

College of Osteopathic Medicine

Department of Family Medicine and Public Health

 Nova Southeastern University

3200 South University Drive

Ft. Lauderdale, FL 33328-2018

(954) 262-1918

calzada@nsu.nova.edu

 

Lawrence B. Harkless, DPM

Member, Podiatric Health Section

Founding Dean

Professor of Podiatric Medicine and Surgery

College of Podiatric Medicine

Western University of Health Sciences

309 E. Second Street

Pomona, CA 91766-1854

(909) 706-3505

lharkless@westernu.edu

 

Elaine Cooperstein, DC

2007-2008 Section Chair, Chiropractic Health Care Section

(510) 921-9323

elainedc@sbcglobal.net

 



[i] Preece MP, Mott J. Multidisciplinary assessment at a child development centre: do we conform to recommended standards? Child Care Health Dev. 2006 Sep; 32(5):559-63.

[ii] Annandale E, Clark J, Allen E.  Interprofessional working: an ethnographic case study of emergency health care. Journal of Interprofessional Care 1999; 13:139-50.

[iii] Soothill K, Mackay L, Webb C. Interprofessional relations in health care. London:Edward Arnold, 1995.

[iv] Zwarenstein M, Reeves S, Barr H, Hammick M, Koppel I, Atkins J. Interprofessional education: effects on professional practice and health care outcomes (Review). The Cochrane Library 2007, Issue 3.

[v] Haq C, Baumann L, Olsen CW, et al. Creating a center for global health at the University of Wisconsin-Madison. Acad Med. 2008 Feb;83(2):148-53.

[vi] Carey TS, Howard DL, Goldmon M, et al. Developing effective interuniversity partnerships and community-based research to address health disparities. Acad Med. 2005 Nov;80(11):1039-45.

[vii] Goldmon MV, Roberson JT Jr. Churches, academic institutions, and public health: partnerships to eliminate health disparities. NC Med J. 2004 Nov-Dec; 65(6):368-72.

[viii] Brashers VL, Curry CE, Harper DC, et al. Interprofessional health care education: recommendations of the National Academies of Practice expert panel on health care in the 21st century. Issues in Interdisciplinary Care: National Academies of Practice Forum 2001; 3(1):21-31.

[ix] Greiner A. Educating health professionals in teams: Current reality, barriers, and related actions. 2002; Washington, DC: Institute of Medicine.

[x] Committee on Quality of Health Care in America, Crossing the quality chasm: a new health system for the 21st century. 2001, National Academy Press, Washington, DC: Institute of Medicine.

[xi] Hall P. Weaver L. Interdisciplinary education and teamwork: a long and winding road. Review. Med Educ 2001;35(9):867-75.

[xii]  Ziring PR, Brazdziunas D, Cooley WC, Kastner TA, Kummer ME, Gonzalez de PL, Quint RD, Ruppert ES, Sandler AD, Anderson WC, Arango P, Burgan P, Garner C, McPherson M, Michaud L, Yeargin-Allsopp M, Johnson CP, Wheeler LS, Nackashi J, Perrin JM. American Academy of Pediatrics. Committee on Children With Disabilities. Care coordination: integrating health and related systems of care for children with special health care needs. Pediatrics 1999 Oct;104(4 Pt 1):978-81.

[xiii] Benedict RE. Quality medical homes: meeting children's needs for therapeutic and supportive services. Pediatrics 2008 Jan;121(1):e127-e134.

[xiv] Greiner AC, Knebel E. Editors, Committee on the Health Professions Education Summit. Health Professions Education: A Bridge to Quality.  Accessed at http://www.nap.edu/catalog/10681.html February 5, 2008.

[xv] World Health Organization. Learning to work together for health. Report of a WHO Study Group on Multiprofessional Education of Health Personnel: the Team Approach. World Health Organization Technical Report Series 1988; vol. 769:1-72.

[xvi] Committee on Quality of Health Care in America, Crossing the quality chasm: a new health system for the 21st century. 2001, National Academy Press, Washington, DC: Institute of Medicine.

 

[xvii] Sidorov J, Shull R, Tomcavage J, et al. Does diabetes disease management save money and improve outcomes? Aa report of simultaneous short-term savings and quality improvement associated with a health maintenance organization-sponsored disease management program among patients fulfilling health employer data and information set criteria.  Diabetes Care. 2002 Apr;25(4):684-9.

[xviii] Cutler TW, Palmieri J, Khalsa M, Stebbins M. Evaluation of the relationship between a chronic disease care management program and California pay-for-performance diabetes care cholesterol measures in one medical group. J Manag Care Pharm. 2007 Sep; 13(7):578-88.

[xix] Van Gils CC, Wheeler LA, Mellstrom M, et al. Amputation prevention by vascular surgery and podiatry collaboration in high-risk diabetic and nondiabetic patients. The Operation Desert Foot experience. Diabetes Care. 1999 May; 22(5):678-83.

[xx] Mollica RL, Gillespie J. Care coordination for people with chronic conditions. National Academy for State Health Policy, Portland, ME. January 2003.

[xxi] Horsburgh M, Merry A, Seddon M, et al. Educating for health care quality improvement in an interprofessional learning environment: a New Zealand Initiative. Journal of Interprofessional Care. 2006 Oct;20(5):555-7.

[xxii] Larson EL. New rules for the game: Interdisciplinary education for health professionals. Nurs Outlook. 1995 Jul-Aug; 43(4):180-5.

[xxiii] Johnson AW, Potthoff SJ, Carranza L, et al. CLARION: a novel interprofessional approach to health care education. Acad Med. 2006 Mar; 81(3):252-6.

[xxiv] Horsburgh M, Lamdin R, Williamson E. Multiprofessional learning: the attitudes of medical, nursing and pharmacy students to shared learning. Med Educ. 2001 Sep; 35(9):876-83.

[xxv] Pollard KC, Miers ME, Gilchrist M, Sayers A. A comparison of interprofessional perceptions and working relationships among health and social care students: the results of a 3-year intervention. Health Soc Care Community. 2006 Nov; 14(6):541-52.

[xxvi] Hind M, Norman I, Cooper S, Gill E, Hilton R, Judd P, Jones SC. Interprofessional perceptions of health care students. Journal of Interprofessional Care 2003 Feb; 17(1):21-34.

[xxvii] Gavin J, Lempp H, Elliman A, Grogan C. Teaching partnership: linking a medical school and a community trust. Br J Community Nurs. 2002 Jan;7(1):32-6.

[xxviii] Lowry LW, Burns CM, Smith AA, Jacobson H. Compete or complement? An interdisciplinary approach to training health professionals. Nurs Health Care Perspect. 2000 Mar-Apr; 21(2):76-80.

[xxix] Kahn N, Davis A, Wilson M, et al. The interdisciplinary generalist curriculum (IGC) project: an overview of its experience and outcomes. Acad Med. 2001; 76:S9-S12.

[xxx] Kutner JS, Westfall JM, Morrison EH, et al. Facilitating collaboration among academic generalist disciplines: a call to action.  Ann Fam Med 2006 4:172-176.

[xxxi] Haq C, Baumann L, Olsen CW, et al. Creating a center for global health at the University of Wisconsin-Madison. Acad Med. 2008 Feb;83(2):148-53.

[xxxii] Vermund SH, Sahasrabuddhe VV, Khedkar S, et al. Building global health through a center-without-walls: the Vanderbilt Institute for Global Health. Acad Med. 2008 Feb;83(2):154-64.

[xxxiii] Koplan JP, Baggett RL. The Emory Global Health Institute: developing partnerships to improve health through research, training, and service. Acad Med. 2008 Feb;83(2):128-33.

[xxxiv] Andrus NC, Bennett NM. Developing an interdisciplinary, community-based education program for health professions students: the Rochester experience. Acad Med. 2006 Apr; 81(4):326-31.

[xxxv] Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century.  March 2001.

[xxxvi] McWilliams A, Rosemond C, Roberts E, Calleson D, Busby-Whitehead J. An innovative home-based interdisciplinary service-learning experience. Gerontol Geriatr Educ. 2008; 28(3):89-104.

[xxxvii] Gilkey MB, Earp JA. Effective interdisciplinary training: lessons from the University of North Carolina’s student health action coalition. Acad Med. 2006 Aug; 81(8): 749-58.

[xxxviii] Matsunaga DS, Rediger G, Mamaclay B. et al. Building cultural competence in an interdisciplinary community service-learning project. Pac Health Dialog. 2003 Sep; 10(2):34-40.

[xxxix] Hamilton CB, Smith CA, Butters JM. Interdisciplinary student health teams: combining medical education and service in a rural community-based experience. J Rural Health. 1997 Fall; 13(4): 320-8.

[xl] McNair R, Brown R, Stone N, Sims J. Rural interprofessional education: promoting teamwork in primary health care education and practice. Australian Journal of Rural Health. 2001 December suppl; 9(s1):S19-S26.

[xli] American Public Health Association. (1981, January 1). Inter-Professional Cooperation in High Blood Pressure Control. Policy Number 8118 .

[xlii] American Public Health Association. (2000, January 1). Reducing the Incidence of Blindness, Lower Extremity Amputation, and Oral Health Complications in minority populations due to diabetes mellitus. Policy Number 20002.

[xliii] American Public Health Association. (1963, January 1). The development of community health service centers – present and future. Policy Number 6319.

[xliv] Hammick M, Freeth D, Koppel I, Reeves S, Barr H. A best evidence systematic review of interprofessional eeducation: BEME Guide no. 9. Med Teach. 2007 Oct; 29(8):735-51.

[xlv] Keough ME, Field TS, Gurwitz JH. A model of community-based interdisciplinary team training in the care of the frail elderly. Acad Med. 2002 Sep; 77(9):936.

[xlvi] Zwarenstein M, Reeves S, Barr H, Hammick M, Koppel I, Atkins J. Interprofessional education: effects on professional practice and health care outcomes (Review). The Cochrane Library 2007, Issue 3.

[xlvii] Cooper H, Carlisle C, Gibbs T, Watkins C. Developing an evidence base for interdisciplinary learning: a systematic review. Journal of Advanced Nursing. 2001 July; 35(2):228-237.

 

[xlviii] Rafter ME, Pesun IJ, Herren M et al. A preliminary survey of interprofessional education. J Dent Educ. 2006 Apr;70(4):417-27.

[xlix] Curran VR, Deacon DR, Fleet L. Academic administrators’ attitudes towards interprofessional education in Canadian schools of health professional education. J Interprof Care. 2005 May; 19 Suppl 1:76-86.

[l] Curran VR, Sharpe D, Forristall J. Attitudes of health sciences faculty members towards interprofessional teamwork and education. Med Educ. 2007 sep;41(9):892-6.

[li] Pollard KC, Miers ME, Gilchrist M, Sayers A. A comparison of interprofessional perceptions and working relationships among health and social care students: the results of a 3-year intervention. Health Soc Care Community. 2006 Nov; 14(6):541-52.

[lii] Kirch DG. Interprofessional collaboration: we are willing – can we find the way? AAMC Reporter, 2008 May; 17(8):2.

[liii] Carroll-Johnson RM.  Redefining interdisciplinary practice.  Oncology Nursing Forum, 2001. 28(4): 619.

 

Welcome to Our New Newsletter Editor

David Bernstein, DPM, will become our section’s newsletter editor after this edition. Dave currently practices in Bremerton, Wash., in The Doctor’s Clinic, a multispecialty medicine group practice. Dave is active in a number of organizations and is currently the chairman of the Washington State Podiatric Medical Board, residency evaluator for CPME, and member of the APMA Coding Committee. He has served as president of the American College of Foot and Ankle Orthopedics and Medicine. Welcome aboard, Dave.

It's a with a little bit of joy that I hand over the reins to our new editor. I have enjoyed the time I've been our newsletter editor but look forward to moving into our section's chair position. I hope to encourage our members to contribute more to our newsletter, for it is a forum that is underutilized. One of our section's requirements for maintaining our section status is to publish a newsletter at least twice per year. I know there is important news and points of views that our section membership can be sharing along with policy concerns. Along with assisting with recruiting at least one new Section member, please consider sending one item for our newsletter.

Janet Simon, DPM

Soon-to-be Past Editor

 

 

 

 

estimated Average Glucose, eAG

The results of the A1C-Derived Average Glucose study (ADAG), published in Diabetes Care, have affirmed the existence of a linear relationship between A1C and average blood glucose levels.

In light of the study results, ADA is recommending the use of a new term in diabetes management, estimated average glucose, or eAG. Health care providers can now report A1C results to patients using the same units (mg/dl or mmol/l) that patients see routinely in blood glucose measurements.

Help your patients make the connection between daily and long-term glycemic control. Introducing estimated Average Glucose (eAG), a new way to talk to patients about diabetes management.

For years, the A1C test has given patients and health care providers an invaluable tool for measuring diabetes control and guiding treatment decisions. However, A1C as an indicator of diabetes control is not always easy to explain to patients.

The measurement — expressed as a percentage — is not something that intuitively relates to the glucose measurements that patients encounter through home glucose monitoring or their lab values. This may make A1C targets difficult for patients to translate into action.

The relationship between A1C and eAG is described by the formula 28.7 X A1C – 46.7 = eAG.

Go to www.diabetes.org/professional/eAG  for an online calculator that is easy to use.

The Science of Eliminating Health Disparities

Join the NIH Institutes, Centers, Offices, and their many partners engaged in research on minority health and health disparities to:

 

 

  • Highlight the research progress of the NIH on health issues among racial/ethnic minority and medically underserved populations; 
  • Increase awareness and understanding of disparities in health;  
  • Showcase best-practice models in research, capacity-building, outreach, and integrated strategies to eliminate health disparities; 
  •  Identify strengths and gaps in health disparities research; and 
  • Network and dialogue with the nation’s leading experts on minority health and health disparities.

Dec. 16-18, 2008

Gaylord National Resort and Convention Center

National Harbor, MD 

 

REGISTER NOW ONLINE for this FREE Summit: www.ncmhd.nih.gov

Sponsored by: National Center on Minority Health and Health Disparities (NCMHD)