Podiatric Health Schedule, APHA Denver 2010
Monday, Nov. 8, 2010: 6:30 a.m.
Hyatt – Location: Mineral Hall E
Business Meeting for the Podiatric Health Section
All presenters and interested APHA attendees are invited to this meeting.
Coffee and light breakfast snacks provided.
Tuesday, Nov. 9, 2010: 8:30 a.m.
Low back pain/radiculopathy and its impact on health care costs. Need for early assessment and treatment to avoid future disability
Sandra R. Gotman DPM, Miami, Fla.
Burning on the bottom of the foot/feet is an early sign of lower extremity radiculopathy. The podiatrist is usually the first health care provider the patient will consult. Lumbro-sacral-radiculopathy causes muscle weakness of the lower extremities as a result of nerve compression at the lumbro-sacral level, and affects one's ability to walk. Exercise is an imperative part of a healthy regimen. Therefore, the public needs to be made aware of this problem early on. The information would be made available to the general public with inclusion of how to recognize signs and symptoms, and seek treatment from health care providers. This education combined with conservative therapy on various levels would ultimately help these people avert worsening of this condition, and prevent subsequent disability. Over 20 years in practice, I have diagnosed too many patients with radiculopathy. I have become acutely aware that as the U.S. population ages, most elderly patients need to ambulate with the assistance of canes, walkers, wheelchairs and scooters. We tend to be a society of cars, and are in predominantly seated positions. The sitting position is very stressful on the lumbro-sacral spine. As a whole we do very little walking unless we are going to a gym, or incorporating it in our daily activities as exercise. This is a public health issue and needs to be remedied because not only does it affect the quality of life, but also incurs tremendous costs on the health care system.
Learning Areas:
Clinical medicine applied in public health
Learning Objectives:
Identify lumbro-sacral radiculopathy early on via clinical assessment and nerve conduction studies of the lower extremity. Formulate treatment involving patient education, and implementation of lumbro-sacral ergonomics in order to prevent future disablities.
Keywords: Disease Prevention, Ergonomics
Tuesday, Nov. 9, 2010: 8:50 a.m.
Exposure to High Levels of Fluoride in the Ground Water of the Ethiopian Rift Valley Results In Lower Extremity Skeletal Fluorosis & Neuropathy
Kelly Powers, DPM, 2010 and MS, Environmental Management, 2010
New York College of Podiatric Medicine (NYCPM) and University of San Francisco (USF), New York, NY
High concentrations of fluoride in the ground water of the Ethiopian Rift Valley results in lower extremity skeletal fluorosis & neuropathy. It has been noted that the World Health Organization (WHO) recommends a guideline maximum fluoride exposure value of 1.5mg/L in consumed drinking water. However, in the Ethiopian Rift Valley ground water fluoride levels far exceed these sanctions. The water ingested by the people of certain Ethiopian communities contains levels considered toxic to human health. The Rift Valley is of particular concern because of the substantial geothermal activity in the ground water. Thus affecting nearby lakes, hot springs, and rivers.
Chronic exposure of high levels of fluoride has been shown to manifest as skeletal fluorosis (SF). SF is a crippling pathological condition in which accumulation of fluoride in bones results in a bone structure metamorphosis characterized by increased bone density. If high fluoride intake persists over a long duration of time joint stiffness, pain, calcification of ligaments, and lower extremity neuropathy may ensue. Lastly, this paper describes defluoridation techniques, implementation tactics, and future recommendations of medical and education outreach are presented.
Learning Areas:
Chronic disease management and prevention
Environmental health sciences
Planning of health education strategies, interventions, and programs
Learning Objectives:
-Define "skeletal fluorosis" -Discuss the fluorosis endemic worldwide and, specifically, in Ethiopia -Identify sources of high levels of fluoride exposure -Describe the 3 progressive stages of skeletal fluorosis -Evaluate radiographic evidence of skeletal fluorosis in the feet/ankle/leg -Identify structural & biomechanical abnormalities of the lower extremity associated with high fluoride exposure -Discuss defluoridation techniques and on-going projects in Ethiopia -Evaluate future recommendations/efforts on improving the Ethiopian water supply -Design a medical and educational outreach plan
Keywords: Environmental Exposures, Water Quality
Tuesday, Nov. 9, 2010: 9:10 a.m.
Soft Tissue Fillers for Feet
Jeffrey S. Brooks, DPM, FACFS, FACFO, Surgical Director for the Mineral Area Residency Program, Midwest Podiatry and Associates, Creve Coeur, MO
Background: Radiesse is a Calcium Hydroxyl Apaptite filler for soft tissue. Completed in 2009. Radiesse can be used off label for replacing soft tissue padding overlying boney prominences. “Technique for Implant Injections eliminates Pain Associated with Dorsal and Interdigital hyperkeratotic lesions of the Foot” that cause pain. Method: This technique incorporates the fanning technique from the dorsum to plantar of the skin interdigitally. Sculptra is the brand name of Poly-L-Lactic Acid (PLLA). Dr Levine has used Sculptra successfully, teaching the administrative technique to podiatrists through the IAFS- the Priemier Professional Network for Podiatrists. This skin filler is diluted in sterile water and injected beneath the skin on the plantar aspect of the foot. A very effective soft tissue relief treatment for porokeratomas, painful calluses and metatarsalgia. Sculptra following injection under the skin stimulates the formation of new collagen, which increases skin volume which acts as a padding where placed in the ball of the foot. Method: Sculptra following dilution is used in a cross hatch fashion under the plantar aspect of the foot as described in detail in the technical use paper. Conclusion: Dr Susan Levine and Dr Jeffrey Brooks feel that the treatment of interdigital soft tissue lesions using Radiesse and the use of Sulptra for plantar lesions and metatarsalgia of the foot, are excellent conservative treatment remedies and surgical care should be reserved as a last option of treatment.
Learning Areas:
Chronic disease management and prevention
Clinical medicine applied in public health
Learning Objectives:
Discuss and differentiate the various use of dermal fillers for feet. Use of dermal fillers and applied techniques to erradicate painful corns and prevent ulceration on the top and in between toes. Use of dermal fillers and applied techniques to reduce pain in the ball of the foot.
Tuesday, Nov. 9, 2010: 9:30 a.m.
American Podiatric Medical Association Spearheading the Efforts to Combat Mycobacterium fortuitum in Nail Salon Footbaths
Lisa Nhan , California School of Podiatric Medicine, Samuel Merritt University, San Francisco
Mycobacterium fortuitum is ubiquitous in our environment with recent outbreaks of this organism reported in the whirlpool footbaths found in nail salons. Due to the non-standardized protocols to sanitize these whirlpool footbaths in nail salons, M. fortuitum have thrived in such optimal conditions offered in these footbaths, causing an immunocompromised host susceptible to a multitude of localized cutaneous infections. Delays in treating the infections may result in this rapidly growing mycobacteria to enter the bone, rendering the foot susceptible to an amputation. In order to overcome this epidemic, the American Podiatric Medical Association (APMA) needs to spearhead the efforts to combat M. fortuitum in nail salons. This paper presents a step approach to how the APMA can develop an organization that sets the standards for nail salon sanitation, bring awareness to the public, increase hygienic standards for all nail salons and help rid the problem of cutaneous infections caused by M. fortuitum in unsanitary nail salon footbaths.
Learning Areas:
Planning of health education strategies, interventions, and programs
Protection of the public in relation to communicable diseases including prevention or control
Public health or related laws, regulations, standards, or guidelines
Public health or related organizational policy, standards, or other guidelines
Learning Objectives:
Propose a plan for how the American Podiatric Medical Association can combat Mycobacterium fortuitum in nail salon footbaths.
Tuesday, Nov. 9, 2010: 12:30 p.m.
216474 "Step Up For Foot Care" - Addressing podiatric care needs for the homeless in San Francisco
Bright Chen, DPM , California School of Podiatric Medicine, Samuel Merritt University, Oakland, Calif.
Analiza Mitchell, DPM , California School of Podiatric Medicine, Samuel Merritt University, Oakland, Calif.
David Tran, DPM, MS, California School of Podiatric Medicine, Samuel Merritt University, Oakland, Calif.
INTRODUCTION – Studies have shown that homeless people are at high risk for lower extremity limb and life-threatening pathologies. These conditions can increase the spread of infection and burden health care costs. In order to identify these concerns and their extent, a needs assessment along with a service project was conducted for the homeless in San Francisco.
METHODS – Service project and study was performed at two San Francisco homeless shelters. Educational sessions were conducted on proper foot care practices. Donated shoes, socks, and insoles were distributed to the homeless. Adult homeless subjects who met study criteria were invited to complete a survey regarding demographics, health status, hygiene practices, and self-reported foot conditions.
RESULTS – Among 299 surveryed, 74 percent of subjects stated total time on feet daily was at least five hours per day, and 31 percent related they had seen a health professional for a foot problem. As much as about 1 in 8 subjects stated they had chronic foot pain. Most common self-reported pathologies include fungal nails, calluses, and tinea pedis. 27 percent reported previous foot injury.
CONCLUSION – Most of homeless subjects were quite aware of proper foot care. However, there was notable lack of resources and high incidence of self-reported pathologies that have potentially dangerous sequelae. This project revealed considerable foot care needs for a vulnerable population and thus emphasizes lower extremity health as a pressing public health concern.
Learning Areas:
Administer health education strategies, interventions and programs
Advocacy for health and health education
Assessment of individual and community needs for health education
Chronic disease management and prevention
Implementation of health education strategies, interventions and programs
Public health or related research
Learning Objectives:
1. Describe the public health implications of lower extremity pathologies in vulnerable populations. 2. List the pressing podiatric health needs of the homeless in San Francisco. 3. Formulate an action plan to address the podiatric health needs of indigent populations.
Keywords: Homeless Health Care, Survey
Tuesday, Nov. 9, 2010: 1:10 p.m.
229378 Predicting Lower Extremity Injuries in a Two Week Overweight Obese Children's 2- Week Summer Camp Exercise Program- A 2-Year prospective Study Untilizing Computerized gait Analysis
Jeffrey Ross, DPM, MD , Medicine-Endrocrinology, Baylor College of Medicine, Houston, Texas
Overweight and obese children suffer from a multitude of co-morbidities. Of particular interest are those that effect the lower extremity. Conditions such as knock knees, (genu valgum), bow legs (tibial varum), flat feet (pes plannus), and high arches (pes cavus) can cause skeletal deformities to develop which can result in poor biomechanical balance of the feet and legs. These abnormalities can cause collapsing of the feet, severe internal rotation of the knees, resulting in arthritic changes and permanent deformities. Utilizing a computerized gait analysis, we are able to determine which children are at risk for developing these conditions as well as injuries of the feet and lower extremities. With this computerized gait analysis data prior to the commencement of the two-week camp program, we were able to predict which children were at risk for potential injury. A pre-camp questionnaire was also used to help predict potential injury.With this information biomechanical intervention with the use of insoles, orthtotics or proper shoe gear can be made.
Learning Areas:
Basic medical science applied in public health
Chronic disease management and prevention
Epidemiology
Implementation of health education strategies, interventions and programs
Public health or related education
Public health or related research
Learning Objectives:
To demonstrate the use of computerized gait analysis to predicit lower extremity injuries during exercise during a two-week summer camp program for obese children. To identify which children are at risk for developing overuse injuries as a result of biomechanical issues prior to the commencement of the exercise program. To analyze the data to show which children reported pain or injuries during the two-week exercise program, and compare them to the non-injured individuals.
Keywords: Injuries, Obesity
Tuesday, Nov. 9, 2010: 2:30 p.m.
220972 Podiatric Care and the Likelihood of Amputation or Hospitalization for People with Diabetes and Foot Ulcers
James R. Christina, DPM , Department of Scientific Affairs, American Podiatric Medical Association (APMA), Bethesda, Md.
OBJECTIVE: Some patients with diabetes and foot ulcers eventually require amputation or hospitalization. This study examines whether patients with diabetes and foot ulcers who receive care from podiatrists have different likelihoods of amputation and hospitalization than those who do not receive care from podiatrists. METHODS: Privately insured adults with diabetes and foot ulcer were found in the MarketScan Research Databases. One year of continuous enrollment prior to the date of the first claim with evidence of foot ulcer (index) was required. Patients with evidence of foot ulcer or amputation prior to index were excluded, resulting in 35,721 patients aged 65 (Medicare) and 28,796 patients aged <65 (non-Medicare). Patients were followed for up to 48 months following index. Patients with pre-index podiatrist visits were matched to patients with no podiatrist visits using propensity score (PS) matching within caliper, to control for differences in sociodemographic variables, plan type, and health status. Cox proportional hazard models estimated the hazard of amputation or hospitalization controlling for the same covariates in the PS match.
RESULTS: Care by podiatrists was associated with a lower hazard of amputation (hazard ratio [HR]=0.801, P<0.01) and hospitalization (HR=0.917, P<0.01) in the Medicare population. The results were consistent in the non-Medicare population (HR=0.765, P<0.01 for amputation; HR=0.852, P<0.01 for hospitalization). Sensitivity analysis revealed similar results for PS-matched cohorts without caliper and unmatched cohorts.
CONCLUSION: In a population of commercially insured adults with diabetes and foot ulcer, care by podiatrists appears to prevent or delay amputation and hospitalization.
Learning Areas:
Biostatistics, economics
Chronic disease management and prevention
Clinical medicine applied in public health
Learning Objectives:
1. Describe the benefits of podiatric care in reducing amputations and hospitalizations in people with diabetes. 2. Demonstrate the value of podiatric care to improving the quality of life of people with diabetes.
Keywords: Diabetes, Quality of Life
Tuesday, Nov. 9, 2010: 3:00 p.m.
221492 One Year Retrospective Study of Limb Salvage Versus Amputation in Patients Presenting to the Emergency Department with Diabetic Foot Infections
John Steinberg, DPM , Plastic surgery- Center for wound healing, Georgetown University Hospital, Washington, D.C.
Farah Siddiqui, DPM , Department of Plastic Surgery, Division of Wound Healing, Georgetown University Hospital, Washington, D.C.
Purpose: The team approach to limb salvage is becoming increasingly widespread as means of treatment for diabetic foot infections. However, just as limb salvage has become more common practice, the long-term result of many patients is still amputation. Reviewed, are cases of diabetic foot infections that presented through the Emergency Department requiring operative debridement. Methods: A retrospective chart review of patients from the past year who presented to Georgetown University Hospital (GUH) with diabetic foot infections. The authors evaluated to see if the limb was salvageable or if it went on to amputation by 1-year follow-up. Results: Complete results are still under going statistical analysis, however early results have shown a positive value to the team approach to limb salvage. Statistics so far from GUH have shown a lower amputation rate than the national average. Conclusion: This review reveals that the limb salvage rate at GUH is currently higher than the national average. It's been shown that patients undergoing an amputation have an increase of oxygen consumption (9 percent higher unilateral BKA, 49 percent higher unilateral AKA, 280 percent higher bilateral AKA) and mortality rate (4 years 9 months BKA & 4 years 3 months AKA). This further supports limb salvage over amputation in diabetic foot infections.
Learning Areas:
Chronic disease management and prevention
Clinical medicine applied in public health
Other professions or practice related to public health
Learning Objectives:
1.Compare limb salvage to amputation on long term outcomes and quality of life. 2.Explain why the team approach is an important entity in limb salvage.
Tuesday, Nov. 9, 2010: 3:20 p.m.
228785 Incidence of depression in diabetic patients with lower extremity wounds utilizing the PHQ-9
Jean-Jacques Kassis, DPM , Podiatry, Miami Veterns Affairs Medical Center, Miami, Fla.
Jasmaine Shelford, MPH , School of Podiatric Medicine and Surgery, Barry University, Miami Shores, Fla.
OBJECTIVE: To investigate the incidence of depression in diabetic patients with lower extremity complications and to introduce the PHQ-9 (Patient Health Questionnaire) to health care providers involved in care of patients with diabetes and lower extremity wounds. METHODS: As part of an observational trial for diabetic patients, subjects with and without diabetic lower extremity ulceration will complete the PHQ-9. This questionnaire is a 9 item summed scale, with scores ranging from 0 to 27. All patients will require completion of the questionnaire prior to clinical evaluation. All wound care will follow standard protocol of debridement, offloading and moist wound care. AIM 1: To propose that diabetic patients with lower extremity wounds will have an increased PHQ-9 score, as compared to patients without wounds AIM 2: To introduce the PHQ-9 to podiatric physicians and other wound care specialists in efforts to identify depression and eliminate the associated negative effects on wound healing. CONCLUSION: There is currently a substantial amount of literature available on the association of depression and poor wound healing. Conversely, there is minimal literature on the utilization of PHQ-9 as an additional tool to identify depression in these at risk patients. The goal of this research is to correlate the incidence of depression in diabetic patients with lower extremity complications, identify depression as a potential barrier to adherence with prescribed wound care protocols, and to introduce the PHQ-9 as an additional simple tool for wound care providers. ( still in progress but will be completed by June 30.)
Learning Areas:
Chronic disease management and prevention
Clinical medicine applied in public health
Other professions or practice related to public health
Learning Objectives:
1. Identify the incidence of depression in diabetic patients with lower extremity complications. 2. Compare depression in diabetic patients with lower extremity complications and diabetic patients without lower extremity complications. 3. Evaluate the effectiveness of PHQ-9 as a screening tool to assess depression in patients with lower extremity complications. 4. Define depression as a barrier to wound healing in diabetic patients with lower extremity complications.
Keywords: Diabetes, Depression
See individual abstracts for presenting author's disclosure statement
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Training and Assessment of Resident Physicians: Jeffrey M. Robbins, DPM
The Use of Direct Observation of Competency in the Training and Assessment of Resident Doctors.
Jeffrey M. Robbins, DPM
Director, Podiatry Service
Department of Veteran Affairs Central Office
Mailing address
Louis Stokes Cleveland VAMC
10701 East Boulevard
Cleveland, Ohio 44106
(216) 231-3286 – Voice
(216) 231-3446 Fax
The teaching and evaluative model for most of modern medical education and training has revolved around The Flexner Report published in 1910. Its basic philosophy is “An education in medicine, involves both learning and learning how; the student cannot effectively know, unless he knows how." Flexner also held that the physician should be a “social instrument... whose function is fast becoming social and preventive, rather than individual and curative."1
Since that time medical education has struggled to develop effective methods of teaching and competency evaluation. The time honored “see one, do one, teach one” paradigm is recognized as being woefully inadequate and significant resources and study have gone into improving how medical education and training is done. At the colleges and schools of podiatric medicine most professors are full time dedicated staffs who participate in medical education faculty development programs. By contrast residency program directors and faculty are generally a loose collaboration of well meaning and successful practitioners who generally lack much formal training in medical education. This is not unique to any particular field of medicine, and since this level of training involves a much higher cognitive level of knowledge, skills and attitudes, it demands that our accrediting bodies address the issue of residency director and faculty development. Eric Holmboe states that “The public has spoken and expects us to move forward and improve. Clinical skills are important to patients and they are clearly important to physicians who desire to be successful professionals.” …. “The major challenge…for medical educators is how to ensure that the educators themselves possess strong clinical skills…and the necessary skill to effectively observe, evaluate and provide feedback to trainees regarding clinical skills”2
Each level of learning builds on the next and requires different teaching and evaluative strategies. Millers Pyramid 3 is a representation of the stages of learning and the evaluative strategies for assessment at each level. The chart below identifies four levels of skills, knowledge and attitude that increase in importance and complexity ultimately leading to competency. The foundation is "knows" or has the basic fundamental knowledge. This is the lowest and easiest level to assess using multiple choice examinations. The next level is "knows how" and represents a higher cognitive level as it requires some basic analytical thinking. This level can be assess using tools such as clinical reasoning or extended matching questions. The next level is the "shows how" level where knowledge, skills and problem solving skills are incorporated. This level may use standardized patients for assessment. Finally, putting it all together the top level, which is supported by the foundation of the first three levels, is "does" and requires a more independent demonstration of knowledge, skills, attitudes, problem solving and competency. This level is best assessed using calibrated direct observation where the faculty has agreed in advance on what is acceptable performance and what is not and applies them uniformly for all trainees.
Miller’s Pyramid
Holmboe, Hawkins, Huot demonstrated the effectiveness of direct observation in their 2004 study The Effects of Training in Direct Observation of Medical Residents’ Clinical Competence: A randomized trial. 4 In this study they used a cluster randomized designed to assess faculty satisfaction and changes in faculty rating behaviors after a one day direct–observation workshop in faculty from 16 internal medicine programs. They found that there were meaningful changes in both rating behaviors and the faculty comfort with the direct-observational methods of assessment.
Holmboe and Hawkins have recommended substantial changes in the way we train our doctors including; giving higher priority to evaluation of clinical skills at medical schools and residency programs; developing educational champions and a core group of physician-educator faculty to serve as experts for clinical skills teaching; measuring outcome of training programs; and expecting certification, evaluation and accreditation organizations to provide meaningful resources for research and development involving the evaluation of clinical skills.
The Council on Podiatric Medical Education in its CPME 320 document mandates that residency directors participate in faculty development specifically geared toward medical education, training and evaluation.5 Most recently the Council of Teaching Hospitals of the American Association of Colleges of Podiatric Medicine has recognized its responsibility in this area and has developed faculty development programs in the direct observation of competency.
Conclusion:
We have a long way to go regarding how we teach and assess of competency of students and residents. Studies have continued to show significant deficiencies in clinical skills in students and practicing physicians alike. The direct observation of skills is not a new concept; however, the current iteration takes it to a new level proving the framework for consistency and validity. Specifically the calibration of faculty on what is and is not acceptable performance should provide the framework necessary for more accurate and timely summative and formative evaluation.
1. Flexner, Abraham (1910), Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching, Bulletin No. 4., New York City: The Carnegie Foundation for the Advancement of Teaching, pp. 346, OCLC 9795002, http://www.carnegiefoundation.org/publications/medical-education-united-states-and-canada-bulletin-number-four-flexner-report-0, retrieved April 20, 2010
2. Holmboe, ES. Faculty and the Observation of Trainees’ Clinical Skills: Problems and Opportunities, Academic Medicine Vol 79, No.1. January 2004
3. Miller, G: The Assessment of clinical skills/competency/performance, Acad Med 1990;65 (Suppl):S63-S67
4. Eric S. Holmboe, Richard E. Hawkins, Stephen J. Huot, The Effects of Training in Direct Observation of Medical Residents’ Clinical Competence: A randomized trial, Annals of Internal Medicine, Volume 140, Number 11, June 2004
5. CPME 320: STANDARDS AND REQUIREMENTS FOR APPROVAL OF RESIDENCIES IN PODIATRIC MEDICINE AND SURGERY COUNCIL ON PODIATRIC MEDICAL EDUCATION, July 2007
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