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Podiatric Health
Section Newsletter
Spring 2010

Chair's Report: Janet Simon, DPM

For many of us, airplane travel is not an enjoyable experience. Seats are uncomfortable, air quality is questionable, seat mates may be too talkative, crying babies often are within close earshot and you have no control of your destiny while in flight. I’m writing this message having just completed a flight where luckily only a few of the above existed and I had the opportunity to catch up on some of my professional reading that always invigorates me.

 

After reading several articles in the most recent Diabetes Care, WOUNDS, and Journal of Foot and Ankle Surgery that have direct relationships to podiatry and public health, my brain was in overdrive. Thoughts were generated as to how our Section could input into the research processes that are needed to answer the questions we formulate in our quest to provide the best care to our patients. Several of the articles identified the long-term problem of subject numbers in studies and the effects that small numbers have on the relevancy of the results. One article from the United Kingdom looked at the mortally associated with acute charcot foot and neuropathic foot ulcerations (NFU) in a 27 year time span. This study started with 136 subjects (70 acute charcot and 66 NFU as the control group). This subject number is not as exceptionally small as we know exists in many podiatric studies, but I can only imagine the increased importance of the results if the subject numbers were 10 times more.

 

I believe this imagined subject population is possible through collaboratve efforts of our podiatric colleges and residency programs with our Section being in a coordinating role. The Section to be successful in this endeavor needs to reeducate our educators as to the important connections between the podiatric medicine world focused on the individual patient and the public health realm whose focus is on the larger community. This reeducation effort would have positive trickle down effects on our students and young physicians and surgeons who are looking to invest wisely in their futures.

 

I am not naïve in believing that our efforts aimed at the students and residents will show immediate results (i.e. our Section membership numbers swell to 500), but I do know that steady efforts will show achievement (the tortoise does win!).

 

In closing I send out two specific action items for you, our Section member, to participate in:

 

  1. Submit your research study recommendations to the section that could be used within our medical colleges and residency programs.
  2. Sponsor a student member – A small investment ($65 annually) will contribute to the future of our Section.

Salud,

 

Janet Simon, DPM

POD Section Chair

Editor's Perspective: Emily A. Cook, DPM, MPH

As some readers may be aware, my practice is based in Boston.  In March and April of this year I was flooded with the typical group of patients aspiring to compete in the Boston Marathon. This year was different because I was also inundated with questions surrounding “barefoot” running options.  Some patients had tried or were about to try “barefoot” running plus or minus one of the barefoot running shoe brands on the market.  Others presented with injuries from barefoot running which included foreign bodies, stress fractures, tendinitis, plantar fasciitis, and other acute problems.  Most concerning was that a handful of people were preparing for their first full marathon in Boston and were not sure if there would be any negative consequences to changing their running preferences a few weeks before the race.

An element common to all their visits was that they had recently heard that barefoot running was more beneficial because running in shoes causes musculoskeletal weakness with prolonged use. Probing deeper I found that in most cases patients came by this information from three sources: 1. advertisements/salespeople; 2. other runners; 3. media coverage.  The leading answer was recent media coverage as the reason why their interest had increased. Recent media coverage has been centered on Lieberman et al’s article appearing in Nature this year. His team found differences in impact forces in barefoot runners versus those in shoes. Several news agencies picked up on the topic and ran stories with headlines like “Study: Running shoes could cause joint strain” or “The best running shoes may be nature’s own: study”. In nearly all of the articles and broadcasts I’ve come across, at least a few members of the general population were interviewed and offered their own anecdotal opinion on the benefits of barefoot running.  Several of these reports presented a one-sided argument based on the study’s findings, but in a few cases the opposing view is expressed. One such report by CNN included another investigator that had previously found the benefits of shoe gear during normal walking. Dr. Lieberman even stated during the interview that people had misunderstood him and that he was not advocating for or against barefoot running. At no point during this or any other report that I’ve come across on the matter is the quality of the research or the level of evidence that it provides discussed.  The public at large is unaware of these concepts and accepts media reports as fact.  That being said, Nature is a highly respected journal with a rigorous review process -- their publication of the study speaks well for the quality of the manuscript.  The fact remains that this article is only a small component in the body of evidence surrounding this topic and is not generalizable to all people.  However, the media presents the findings as the final verdict.

The intent of this article is not to diminish barefoot running or the work of those in the media. Rather, I’m trying to demonstrate the influence that such reporting can have on our patients. As health care providers we can provide a balanced discussion with our own patients, but those without need or desire for podiatric care get only a 30 second sound bite to base health decisions on.  As a member of the public health community, I know I can do more to educate individuals beyond those within my own patient panel. My group has intermittently given seminars for runners open to the general public, and I have incorporated a brief discussion on the risks and benefits of running barefoot.   I don’t overwhelm them with study design terminology, but I do comment on the context of these papers as they relate to the entire discussion of this topic.              

In closing I’d like to emphasize that education remains a potent weapon in the public health arsenal.  As new developments occur in our relevant fields, I encourage you to take your expertise to the public. This can be in the form of seminars at a local gym or even an editorial for your local newspaper.  Regardless of the method, get your message into your community.  As I’ve discussed in this case, the media may only present the most exciting or appealing information and a complete picture is frequently lost.   Be your community’s advocate for better podiatric health.

Emily A. Cook, DPM, MPH

Harvard Medical School

Beth Israel Deaconess Medical Center

Editor, APHA Podiatric Health Newsletter

Podiatric Public Health Alert: APMA HOD

Public Health concerns were well represented at the 2010 APMA House of Delegates (HOD). Three resolutions having direct public health relevance were introduced, with two passing and the third withdrawn but not without thoughtful discussion.

 

The Public Health and Preventative Podiatric Medicine Committee (PHPPMC) in conjunction with the Massachusetts Podiatric Medicine Society (MPMS) introduced the resolution encouraging all APMA state components to have an “official” public health committee. MPMS has developed a working model that can be used by other components in fostering beneficial networks with public health entities. This resolution passed, and several states have given their verbal commitment to moving forward with developing working structures within their components for public health focused relationships.

 

The PHPPMC prior to the HOD had been working on a disaster relief plan for many months and moved into high gear since the January earthquake in Haiti. Several POD Section members have been exemplary in their humanitarian medical work and have been advisors to the PHPPMC in developing this plan for APMA. The resolution that was introduced and passed will document that APMA considers disaster relief an important role that our profession should be formally involved in. 

 

The third resolution that PHPPMC introduced related to the importance of vital sign documentation in daily practice. The consensus of PHPPMC is that the taking of blood pressure, height and weight, and BMI are standards within medicine that podiatric medicine should follow. These points of health information are important in the health advisor roles that all physicians should be involved in. PHPPMC will continue to promote the importance of podiatric physicians and surgeons documenting vital signs for their patients.

 

In closing, public health was very visible during the HOD and will continue to be a recognized entity for podiatry.

 

Janet Simon, DPM

Chair, Podiatric Health Section

Chair, Public Health and Preventative Podiatric Medicine Committee (PHPPMC)

Podiatric Public Health Alert: Patrick A. DeHeer, DPM

       

Wound Care Haiti, Incorporated, is a nonprofit organization established and incorporated on March 26, 2009. Led and directed by Patrick A. DeHeer, DPM, Wound Care Haiti, Incorporated, strives to provide comprehensive wound care services in Haiti primarily through establishing wound care centers in the country, as well as by conducting educational seminars and hands-on workshops about wound care and treatment, both to the entire Haitian population and Haitian medical community.

 

Haiti’s health care and wound care system were already in dire shape and dying even before the powerful earthquake hit the country in the early part of 2010. Prior to the current surge of wounded and injured individuals, which was one of the aftermaths of the earthquake, Haiti has had limited medical equipment and supplies, as well as very few competent and skilled medical workers.

 

The onslaught brought about by the recent earthquake only heightened Haiti’s need for quality medical services and sufficient medical supplies and medication. Weeks after the earthquake, the numbers of injured and wounded individuals and also the country’s death toll are rapidly increasing. This is primarily due to the lack of sufficient wound care and treatment and few wound surgeons to efficiently tend the exceeding numbers of casualties.

 

Due to this, Wound Care Haiti, Incorporated, proposes this project to establish wound care centers in Haiti and conduct necessary educational seminars and hands-on workshops. The organization intends to supply these clinics with sufficient medical personnel and supplies, educate Haitians with necessary information on wound care and prevention, and share necessary skills and knowledge on wound care and surgery with the Haitian medical community.

 

The proposed project calls for: a funding capital, which would be allocated completely for the establishment of wound care centers in Haiti; purchase of necessary medical equipment for wound surgeries, treatment, and healing; and acquisition of necessary medical supplies and medication.

 

Wound Care Haiti, Incorporated, anticipates that the proposed project would help increase competent and skilled Haitian medical personnel, provide better treatment and healing of wounds, decrease the spread of infections, reduce amputation and death rates, and consequently save lives.

 

    

 

Contact:

Patrick A. DeHeer, DPM

Founder and Director

Wound Care Haiti, Incorporated

* 12205 Castle Row Overlook, Carmel, Indiana 46033
( (317) 557-6710 / (812) 378-5770

: padeheer@sbcglobal.net
: www.woundcarehaiti.org 

 

Podiatric Public Health Alert: Shout Outs to CPMA

Stephen Wan, DPM, president of the California Podiatric Medical Association (CPMA), attended the Governor’s 2010 Summit on Health, Nutrition and Obesity. The moderated discussion with Gov. Schwarzenegger and President Clinton focused on three topic areas that will help create a healthier California promoting healthy beverages, increasing physical activity and incorporating the idea of “health in all policies.” CPMA’s presence at this summit highlights the major role podiatry has in this important public health effort. CPMA is a good act to follow – Keep up the great work.

Janet Simon, DPM

POD Section Chair

Podiatric Public Health Alert: New Massachusetts Podiatric Medical Society Community Service Foundation

The Massachusetts Podiatric Medical Society (MPMS) Community Service Foundation (CSF), a tax-exempt 501(c)3 charitable foundation, is now fully operational and working on a number of exciting public health related projects. It serves as the charitable arm of MPMS focusing on foot and ankle related public health and education. The foundation aims to expand community podiatric health services and support educational projects largely through volunteer involvement, donations and grant funding. It also serves as the grantor institution for MPMS members' (and others) research and educational grants, offering a low overhead fiscal intermediary, and the good name of the MPMS. Our primary goal is to improve the podiatric health and welfare for people of the Commonwealth of Massachusetts. For information or to discuss project ideas contact Gary Adams, executive director of MPMS, at (978) 646-9671 or e-mail gadams@massdpms.org.  

Our Mission and Work

Our MPMS CSF mission is to advance the foot health of the people of Massachusetts by expanding community health services, improving access to podiatric health care services and conducting educational projects that strive to improve podiatric and public health.

The MPMS Community Service Foundation serves to collaborate with other community health organizations on projects such as our Amputation Prevention Initiative with the Massachusetts Public Health Association and our Diabetes Education Program with member organizations in eye care, dental care and pharmacy. Future projects including work on fall prevention in the elderly, childhood obesity prevention, smoking cessation, childhood sports injury prevention, osteoporosis screening, diabetic foot health education, screening and awareness of peripheral arterial disease and much more.

In the physician professional and educational programs arena, planned projects include use of health information technology in improving patient care, application of evidence based medicine to podiatric practice and workshops to assist member podiatric physicians and surgeons in applying for research and education grants.

Student's Corner: Ajitha Nair, DPM, MPH

The Uganda Sustainable Clubfoot Care Program has been providing free congenital clubfoot treatment and education since 2000. Recent evaluation of interventions includes a study on barriers to adherence to treatment. According to the USCCP, it is estimated that there is a 17 percent drop out rate during the casting phase of treatment. Treatment results in a 95 percent success rate; however, there is a 90 percent recurrence if the bracing phase is not followed to completion. These barriers that prevent access to treatment and ultimately lead to morbidity and societal burden is of great concern to the people of Uganda and their public health.

 

In April 2010, I spent one month conducting research with the USCCP.  Over this period I collected and analyzed data on barriers to adherence of clubfoot treatment. Variable factors of interest included socio-demographic characteristics, socio-economic conditions, and factors related to distance to the closest active clubfoot clinic. This data will be paired and analyzed with Dr. Isidor Ngayomela and Bradley Locke’s 2007 research data using the same survey instrument. 

 

Preliminary results of the combined 2007 and 2010 data suggest that logistical constraints including impermanent housing, domestic issues such as gender disparity, as well as lack of medical material availability have been barriers to treatment adherence within specific districts in Uganda. Formal results of the collected data will be presented at an international orthopaedic meeting being held in Africa during winter 2010.

 

Along with participating in research, I received training in clubfoot casting at biweekly clinics at Mulago Hospital and Masaka Regional Hospital and lectured to medical and nursing students at Makerere University on the pathoanatomy and treatment of clubfoot.

 

 

Ajitha Nair, DPM, MPH, a recent recipient of the ACFAOM Timothy Holbrook Memorial Award of Excellence, will begin her residency training this year at the Community Medical Center in Scranton, Pa.  For comments or questions, please contact her at ajithaknair@gmail.com.

Scientific Report: Pathomechanical Configuration of the Metatarsal Heads

As you may recall, my research that was published in the last two podiatric newsletters concerned the interrelated geometry of the metatarsal heads. Different conic curve types such as ellipse, hyperbola and parabola were obtained from various configurations of the five metatarsal heads and their related conic types. This enabled the conic types to diagnose which configurations were pathomechanical and which were healthy.

Further Update:
I am now looking into treatment. This is being done on the computer screen where a graph of a pathomechanical conic type is converted into a healthy conic type. This is done by changing coordinates of the pathomechanical conic type into coordinates of a healthy conic type. The coordinates of a healthy conic type will be situated along a single branch of a hyperbola because this allows forces and pressures to move from the 5th to the 1st metatarsal head along a smooth, consistent path. Any other alignment of the metatarsal heads including the rare parabola is not a healthy alignment. Thus far, a large sample of pathomechanical conic types are being converted into healthy conic types. Surgeons usually use osteotomies that include their own techniques to realign the configuration of the metatarsal heads. Successful outcomes using my technique as explained above will be the road to validation.

Nonsurgical treatment is also being considered. It involves the placement of pads around the metatarsophalangeal joints according to directions given by the diagnosis and treatment of my research. If the pads are properly placed and the outcomes are successful, an orthotic can be made so that it replaces the pads. This will be a new orthotic modification.

I will also consider genetic factors which are important in the evolutionary process. HOX genes can cause changes in length of metatarsals. Pathomechanical configurations may indicate genetic changes in the genes. Malalignment of metatarsal heads could act as a biomarker which should make one look for other abnormalities in skeletal growth.

A pathomechanical configuration of metatarsal heads with no symptoms should be considert as Latent. A surgical operation that is considered to be a success may still have a Latent configuration and better alignment is still to be decided. This can be preventive medicine.

Philip H. Demp, AB, DPM, MA, MS, PhD, CMath, FIMA
Temple University
Adjunct Clinical Professor, School of Podiatric Medicine
Adjunct Professor, Department of Mathematics
Adjunct Professor, Department of Mechanical Engineering

Scientific Report: Healthcare Cost and Utilization Project (HCUP) Statistical Brief

Hospital Charges For the Uninsured Up Substantially

The amount that hospitals charge the uninsured for inpatient care grew by 88 percent between 1998 and 2007, according to a recent report from the Agency for Healthcare Research and Quality. After adjusting for inflation, the average charge for an uninsured hospital stay increased from $11,400 in 1998 to $21,400 in 2007.

The analysis found that:

·         From 1998 to 2007, the number of uninsured hospital stays increased by 31 percent, which far exceeds the 13 percent overall increase in hospital stays during the period.

·         The percentage of uninsured hospital stays increased the most in the South, rising from 5.8 percent to 7.5 percent. In contrast, in the Midwest, the percentage of uninsured hospital stays declined from 4.7 percent to 4.0 percent.

·         The top reason uninsured patients were hospitalized was for childbirth. In 2007, roughly a quarter of a million uninsured women gave birth in hospitals. This was followed by depression and bipolar disorder (94,300); chest pain with no observed cause (77,000); skin infections (which more than doubled from 31,000 to 73,300); and alcohol-related disorders (66,600).

These findings are based on data described in Trends in Uninsured Hospital Stays, 1998-2007.  The report uses statistics from the 2007 Nationwide Inpatient Sample, a database of hospital inpatient stays that is nationally representative of inpatient stays in all short-term, non-federal hospitals. The data are drawn from hospitals that comprise 90 percent of all discharges in the United States and include all patients, regardless of insurance type, as well as the uninsured.

Healthcare Cost and Utilization Project (HCUP) reports from the HCUP Statistical Brief series

APHA Announcements: Initiatives on Transportation

APHA Initiatives on Transportation and Public Health  

 

As we all appreciate, our health is profoundly affected by our transportation decisions and options. Limited opportunities for physical activity, higher exposure to poor air quality, higher incidences of adult and childhood obesity and greater prevalence of asthma and cardiovascular disease are a few of the inequities brought by poor transportation policies. As part of our effort to enhance crosscutting activity and knowledge among various APHA members and sections, APHA is developing advocacy materials and helpful information related to the links between transportation and public health. If anyone is interested in learning more about this initiative, sharing success stories or lessons learned, or establishing a new Forum on Transportation and Public Health, please reach out to us! Interested members are asked to contact Eloisa Raynault at eloisa.raynault@apha.org.