Podiatric Health
Section Newsletter
Winter 2006

Welcome to New Section Members

Richard Gosnay, DPM, of Danbury, Connecticut

Bradley C. Haves, DPM, of Miami, Florida

Linda L. Alexander, DPM, of Jacksonville, Florida

Message from the Chair

THANK YOU.

I would like to thank everyone who worked on making the Philadelphia meeting a turning point in our Section's history. We have the most dedicated membership and this allows grand things to happen. As our attention turns to Boston, we need to take action now to insure the viability of the Section and take advantage of the energy generated in Philadelphia. Our success depends on you, our loyal member.

WHAT YOU CAN DO:

There are many things we all can do to contribute to the important work of the Section. The first is, please make sure you have renewed your membership. All other activity stems from this step. The second is to bring your friends into the Section. Just like the patients we all value the most are those that have been referred by a happy patient, so too will be the value of those you can recommend to join APHA. You can be more persuasive than you often realize, and there are many colleagues around you who look to you for leadership and experience. Your advice to join APHA will result in a rush of talent that we all can benefit from. We are also looking to increase the number and quality of abstracts given in Boston. CME Chair Dr. Pat DeHeer is taking on the charge to make our Annual Meeting a showcase, and he needs all students, residents and residency directors as well as clinicians with an interest in research to submit abstracts. The exposure of presenting your material in a major meeting is such a valuable one and one of the benefits of having a Section in APHA. Let us utilize this stage to discuss obesity, arthritis, diabetes and the hundreds of other topics that are of broad interest to the Public Health Community.

I also would like to continue to work towards the long term goal of having our Section a meeting place for all podiatrists interested in global health. If you lecture overseas, participate in indigent medical programs, here or abroad, or are looking to begin a mission to serve the poor, please work to make APHA your home. Being able to share resources, ideas, grant availability and many more benefits could be the result of acting now. In closing, Boston is a wonderful city with an active podiatric community. I am looking forward to the leadership change to come at the end of that meeting and welcoming my friend, Dr. Chris Robertozzi, to the helm. We ain't seen nothing yet! Please help us, join us and work with us. We need you!

Annual Meeting a Success

The year 2005 presented many challenges to APHA. The original plan was to have the Annual Meeting take place in New Orleans. After Hurricane Katrina made this impossible, the meeting date and place were changed to Philadelphia in December. This herculean effort to change such a large meeting to a new city was appreciated and acknowledged during the opening ceremonies.
Despite the last-minute change, the Podiatric Health Section had a very well attended and successful meeting. Important issues such as the membership crisis, the lack of enough quality submitted abstracts, the exciting upcoming publication of the Public Health text edited by Dr. Art Helfand, and leadership strategies were brought up and worked on.

The members present left re-energized and anxious to make the great potential of the APHA Podiatric Health Section a reality.

Section Membership Drive Continues

Under the guidance of Rodney Peele, JD, chairman of the Membership Committee, the membership numbers of the Podiatric Health Section enjoyed the greatest percentage increase of any Section over the past year. While this is good news, during the Annual Meeting in Philadelphia, it was evident that the Podiatric Health Section is the smallest section in APHA and is far below the minimum number for section viability. There was the suggestion from APHA leadership that our Section might devolve into a Special Interest Group (SPIG). Podiatric Health Section leadership strongly fought against this possibility.

In response to the threat of devolution from APHA and a letter from Dr. Helfand, the Section obtained a commitment from APMA President Harold Glickman that attention to this problem would be a priority. A membership drive was instigated moments after the meeting concluded. Rodney Peele arranged for a membership letter to appear in the APMA Alert mailing sent to all APMA members. This letter, signed by Section Chair Patricia A. Moore, DPM, and Phil Ward, DPM, APMA BOT, and APHA Action Board member, urged podiatrists to join APHA now.

Current APHA members are encouraged to ask their colleagues to assist the Section by joining or rejoining and contributing to another year of rapid growth.

Resolution Submitted to APMA HOD

RESOLUTION – 2006 MEETING
THE HOUSE OF DELEGATES
AMERICAN PODIATRIC MEDICAL ASSOCIATION

Whereas the American Podiatric Medical Association Board of Trustees, during its Mid-Winter Board Meeting on Jan. 21, 1972, endorsed the Council on Public Health’s Resolution that a Podiatric Health Section be established within APHA, and
Whereas on Feb.19, 1972, the Executive Board of the American Public Health Association approved a recommendation that the establishment of a Podiatric Health Section be recommended to the APHA Governing Council for action at the 1972 Annual Meeting of the Association, and

Whereas during the 100th APHA Annual Meeting in Atlantic City, Nov. 12-15, 1972, the Association’s Governing Council created the Podiatric Health Section, as Agenda Item 7.02, and

Whereas the Governing Council of the American Public Health Association approved the following Resolutions:

FOOT HEALTH AND PUBLIC POLICY
Resolution 1973 #03
Comprehensive health care has become the prerogative of every American. If health services delivery systems are to effectively relate to the health care needs of the nation, a comprehensive scope of services will be required. Comprehensive health care ceases to be comprehensive when one significant aspect of the human person is deleted from the provision of services.

Whereas foot health and podiatric services are recognized as an essential service in any comprehensive health care program; and
Whereas the relationship of foot health to general health has been well documented; and

Whereas any legislative attempt to provide comprehensive health services should therefore include podiatric care.

Be it Resolved that the American Public Health Association recommends and urges that any national health legislation providing for comprehensive health services should require that podiatric care be included as an essential service, including legislative proposals for National Health Insurance, Health Maintenance Organizations, or other systems for the delivery and upgrading of health services.

PODIATRIC EDUCATION, RESEARCH, AND HEALTH PROGRAMS IN OCCUPATIONAL SETTINGS
Resolution 1975 #09
Whereas, many if not most occupations require that workers have the ability to work to bear weight upon their pedal extremities and,
Whereas, disorders of the foot and its contiguous structures diminish or even negate the ability of such workers to carry out their occupational activities; and
Whereas, most attention to date concerning occupationally related or affected foot problems have emphasized care and treatment;
Therefore Be It Resolved that the American Public Health Association with the assistance of its Podiatric Health Section and in cooperation with the Occupational Health and Safety Section encourage the initiation of programs of education, research, and safety by Schools of Podiatric Medicine, other health professional schools, industry, and related groups designed to prevent, identify, and reduce the extent of podiatric disorders that relate to employment conditions or affect employment efficiency.

STUDY OF A FATIGUE AND ACCIDENT REDUCING FLOOR SURFACE METHODOLOGY
Resolution 1978 #20
The American Public Health Association,
Recognizing that workers have long sought a method of relieving the fatigue which is concomitant with flat hard surfaces, and that some of these systems have long been known to health professionals who have been interested in preventive or occupational health; and
Observing that significant injury reduction at work sites has been recorded where workers are required to stand for more than four hours when a floor surface designed to meet certain parameters has been provided the workers; and
Noting that research has demonstrated that the foot was designed for the varied terrain of the natural surface of the earth; and
Recognizing that the venous pump system suffers a major disadvantage when the foot is confined to a flat surface and that this condition limits the proper functioning of this system in pumping blood back to the heart from the lower extremities; and
Noting that a methodology has been developed which can meet definite normal physiological parameters;
Supports the further study of methodologies for floor surface systems which are planned changes in environmental surfaces, and which prove to be beneficial in gently stimulating the peripheral venous pump, reducing fatigue, pathology, and accidents.

HOSPITAL PRIVILEGES AND POSTGRADUATE TRAINING IN PODIATRY
Resolution 1981 #22
The American Public Health Association,
Knowing that a shortage of podiatric residency programs currently exists; and
Knowing that almost all physicians serve a one-year or two-year residency after graduating from medical school; and
Knowing that today's podiatry student acquires skills in addition to palliative care of superficial skin lesions, such as knowledge of drug prescription and medication, surgery on bones and soft tissues, use of X-rays, and other sophisticated techniques; and
Realizing that podiatrists as members of the modern health care team have assumed an important role in the provision of foot care; and
Believing that the podiatrist's responsibilities include being called upon as the primary care practitioner; and
Knowing that a maldistribution of podiatrists exists nationally, with greater numbers practicing in urban areas; therefore
1. Encourages a greater awareness of the need for additional postgraduate training facilities for podiatric graduates;
2. Encourages health care institutions to expand their current structure by initiating podiatric residency programs for postgraduate training;
3. Requests that health care institutions review their bylaws and amend where necessary any portion which denies or inhibits trained podiatrists from gaining access to their diagnostic and operatory facilities; and
4. Requests health care institutions to extend hospital privileges to qualified podiatrists for management of foot pathology.

REDUCING THE INCIDENCE OF BLINDNESS, LOWER EXTREMITY AMPUTATION, AND ORAL HEALTH COMPLICATIONS IN MINORITY POPULATIONS DUE TO DIABETES MELLITUS
Resolution 2000 #02
The American Public Health Association,
Observing that epidemiological studies have shown that the prevalence of diagnosed diabetes has increased dramatically in the last 30 years; and
Noting that diabetes has reached epidemic proportions, with more than 20 million Americans of every age, gender, and race now afflicted; and
Recognizing that diabetes is a serious public health concern, with a prevalence in minority populations of African-Americans, Hispanic-Americans and Native-Americans that is two to three times that of non-Hispanic whites; and
Noting that type 2 diabetes is also emerging as a problem among minority children and adolescents; and
Realizing that the increasing prevalence of diabetes among all groups has lead to an increase in the microvascular and macrovascular complications, including blindness, lower extremity amputation, and destructive periodontitis and tooth loss; and
Understanding that the lower extremity, periodontal and visual complications of diabetes are generally a function of the duration of diabetes and the level of glycemic control; and
Recognizing that approximately 67,000 amputations occur among the diabetic population annually, an incidence of at least 15 times greater than non-diabetic populations; and
Noting that foot ulcers precede amputation in 85 percent of cases; and
Recognizing that the 5-year mortality rate of diabetic patients increases by 39 to 68 percent following lower extremity amputation; and
Understanding that periodontal complications may lead directly to tooth loss and chronic infection. This adversely affects glycemic control; and
Recognizing that diabetic retinopathy is the new leading cause of blindness among working-age Americans, accounting for approximately 8 percent of all cases of legal blindness and 12 percent of all new cases of blindness in the United States each year; and
Knowing the health benefit and cost-effectiveness of well established strategies of prevention and treatment in diabetic foot and vision care; and
Knowing that much of the vision loss, periodontal disease, and lower extremity amputation in diabetes mellitus is preventable through early detection and timely treatment; and
Recognizing that annual foot examinations by podiatrists and other foot care providers, vision examinations through a dilated pupil by ophthalmologists and optometrists, and dental examinations by oral health providers are the accepted standards of care for all persons with diabetes; therefore,
The American Public Health Association urges health care professionals to
1. Promote awareness of the need for annual foot screening and examinations for individuals with diabetes and make appropriate referrals to podiatrists and other foot care providers;
2. Promote awareness of the need for annual dilated fundus exams for all individuals with diabetes and to make appropriate referrals to ophthalmologists and optometrists;
3. Promote awareness of the need for at least annual oral health examinations for all individuals with diabetes and to make appropriate referrals to oral health providers; and
4. Encourages federal, state, and privately funded health care organizations to target high-risk minority populations, including African-American, Hispanic-Americans, and Native-Americans, for annual foot and vision care.
5. Promote interdisciplinary diabetes management and appropriately timed referrals.

Therefore Be It Resolved that the 2006 House of Delegates of the American Podiatric Medical Association reaffirm the Policy of the American Podiatric Medical Association of 1972 to endorse a Podiatric Health Section within the American Public Health Association and encourages support for this important public health effort.

Kick-off Lunch for Podiatry Students

The venue change for the APHA Annual Meeting to Philadelphia presented a good opportunity for the Podiatric Section to meet with podiatry students at the Temple University School of Podiatric Medicine (TUSPM). Our section has as one of its focus areas to introduce the concept that podiatry is involved in public health on a daily basis to students. Being in the same city as TUSPM and in fact only a few blocks from the convention center allowed the Podiatric Section to begin our student presentations on Dec.13, 2006. With the assistance of several Temple staff, our lunch presentation occurred in the second floor conference room at TUSPM.

Lunch was graciously provided by APMA’s Public Health Committee. The first- and second-year students had completed a morning of exams, and the third-year students were able to wander in from their clinic responsibilities. Before lunch arrived, the Podiatric Section members were able to speak with the hungry students and hear what their interests for attending were. Several attendees related an interest in the dual degree MPH-DPM program available to podiatry students at TUSPM and information was dispensed to them. Several of the first-year students were eager to know how public health connections could assist them in the future.

The program began with an overview of public health given by Philip H. Demp, AB, DPM, MA, MS, PhD, adjunct clinical professor, Temple University School of Podiatric Medicine and Department of Mathematics. Drew A. Harris, DPM, MPH, assistant director of the New Jersey Center for Public Health Preparedness at UMDNJ and assistant professor, UMDNJ School of Public Health, related how he was drawn into the public health realm from podiatry and what he currently is involved with in his position. His mentor, Marvin Shapiro, DPM, spoke next relating his experiences with working with local and state public health associations. Chris Robertozzi, DPM, APMA Board member and chair elect to our Podiatric Section, spoke on the day-to-day usage of public health concepts in our podiatry practices.

The Section felt that this first attempt was a success and will continue its efforts to introduce the importance of public health to our upcoming future leaders – today’s students.

Is Public Health Contagious?

An Editorial: All podiatrists practice public health. Too often we think of public health as preventing an epidemic like the avian flu. But in reality, public health is what most podiatrists practice on a daily basis. When we treat an obese child with calcaneal apophysitis and we discuss with the child and their parents the dietary and physical activity impact on the obesity and subsequently on their heel condition, that is public health. When we treat a diabetic with an ulceration and discuss the prevention of an amputation, that is public health. Educating a diabetic patient about their disease process can lower the possibility of amputation. That is public health. Talking with older patients about staying active and how that can lower their possibility of cardiovascular problems and help them continue an active healthy life style is public health.

We treat patients with infections daily. When we communicate the importance of cleanliness in the home and workplace in an effort to lower the possibility of transmission of the infection, that is public health. When you realize that the average podiatrist is subconsciously dealing with public health aspects on a daily basis, it makes sense to bring that thought process to a conscious level.

In addition to raising our conscious level of awareness, we need to become more involved in the established public health processes. There are many ways to become involved. We can become involved in the local city or county health department by volunteering a few hours a month to help staff a public health clinic. Set aside a few hours a month to see free clinic patients. Serve on a governmental health board. Lecture to health related groups. Get active in the health community. Podiatrists are uniquely positioned to serve and only through increased involvement in the recognized local, state and national public health organizations can we influence public policy. Influencing public policy as it relates to the welfare of citizens is public health. Public health is contagious – catch it!

Program Chair Report

My apologies to Dr. DeHeer, for his submitted article was lost in cyberspace as this newsletter was being prepared. The following is a brief synopsis of what he had wished to say to Section members.  Janet Simon, DPM

2005 was my inaugural year for being the program chair and my first APHA Annual Meeting attended. I feel the APHA experience has much to offer our podiatry profession. The most demanding aspects of my position were learning the process for submitting proposed presentations online and obtaining submissions from our Section and podiatry community. APHA provides a venue for networking and having podiatry visible. I am looking forward to the 2006 Boston meeting and encourage members to submit proposals for presentations. I feel much more confident in assisting any presenters in getting through the online process for submitting proposals in 2006.

Podiatric Section Presentation December 2005: Disparities in Diabetes

Podiatric Primary Health Case Addresses Disparities in Diabetes, Steve Maynard, DPM, Open Door Health Center, Barry University School of Graduate Medical Sciences, 11300 NE 2nd Avenue, Miami, FL 33161 and Chih Yen, DPM, Barry University School of Graduate Medical Sciences, 11300 NE 2nd Ave., Miami Shores, FL 33161, (305) 859-7777, chih_j_yen@yahoo.com.

Diabetes Mellitus severely impacts the minority populations of the United States, including the Hispanic population, which is twice as likely to suffer from diabetes as the general U.S. population. The Barry University School of Graduate Medical Science's Podiatric Medicine and Surgery program has embarked on the development of a new institute for community health and minority medicine that has the goals of: 1) training minority health professional students in primary care, 2) conducting research on disparities in health for ethnic and racial groups, and 3) providing free primary health care services to disadvantaged and medically underserved individuals living in Miami-Dade County, Fla. At the Open Door Health Center, Barry University provides diabetes screening, education, and prevention programs to reach the 23,000 migrant and seasonal farm workers of Hispanic descent that lack access to primary care services. This presentation summarizes the five-year history of the podiatric program's endeavors to improve health care access, encourage community collaboration, and offer public health education pertaining to reducing the disparities in diabetes care for the migrant population. These public health initiatives are part of the foci of the new Institute for Community health and Minority Medicine.

Learning Objectives: Describe attempts to improve heath care access, community collaboration, and public health education to underserved populations at risk for diabetic complications Keywords: Diabetes, Health

Presenting author's disclosure statement: I wish to disclose that I have NO financial interests or other relationship with the manufactures of commercial products, suppliers of commercial services or commercial supporters.

Podiatric Section Presentation December 2005: Pediatric Foot Screening

Community Project of Pediatric Foot Screening as an effective tool in preventing foot and ankle deformities in children
James Losito, DPM1, Chih Yen, DPM2, and Avila T. Jackson, PMSIII1. (1) Podiatric Medicine/Surgery, Barry University Graduate Medical Sciences, 11300 NE 2nd ave, Miami, FL 33161, (2) Podiatric Medicine/Surgery, Barry University School of Graduate Medical Sciences, 11300 NE 2nd Ave., Miami Shores, FL 33161, 305-859-7777, chih_j_yen@yahoo.com

Podopediatrics is a subspecialty in the field of Podiatric Medicine and Surgery which is not well known by the public. Many congenital and growth conditions that affect children often lead to severe foot and ankle problems in adulthood. Barry University School of Graduate Medical Science's Podiatric Medicine and Surgery Program has partaken in the development of a community project with the goals of: 1) Training podiatric medical students and resident physicians in Podopediatrics, 2) Providing free pediatric foot and ankle screening services to disadvantaged youths, 3) Educating the community about various lower extremity congenital and growth abnormalities in the pediatric population.

Barry University provides podopediatric screening services to Gratigny Elementary Full Service School, a member of The Miami-Dade County Public School System. This collaboration has been established since 1997 to serve the largely Haitian-American school populations. This community project reaches out to hundreds of children and offers of public health education in Podopediatrics. This presentation will summarize the work from the past four years. The efforts and design of this community project should be a model for those interested in promoting Podopediatrics as a part of podiatric public health.



Learning Objectives:

Describes the efforts and services provided by podopediatrics to disadvantaged youths, in a largely Haitian-American school population. With these modalities, various podopediatrics deformities can be identified at an early age and appropriate podiatric medical treatment can be initiated.
Keywords: Child/Adolescent Mental Health, Pediatrics

Presenting author's disclosure statement:


I wish to disclose that I have NO financial interests or other relationship with the manufactures of commercial products, suppliers of commercial services or commercial supporters.

Podiatric Section Presentation December 2005: Correcting Clubfoot Deformities in Haiti

Purpose

To treat and cure clubfoot deformity in Haitian infants less than 2 years old with the Ponseti method of non-surgical clubfoot treatment.

Demographics

Based on census population results, birth rates for 2003 and the rate of occurrence of clubfoot deformity in Caucasians (1/1000), Malawi (2/1000) and South African Blacks (3/1000), there will be approximately 300 to 700 Haitian babies born with clubfoot deformity annually.

Need to Treat

 Clubfoot is the most common congenital cause of locomotor disability in the developing world. Due to a limited number of surgeons and facilities in developing countries, the majority of these cases are either neglected or inadequately treated. The effect of the neglected or recurrent clubfoot on quality of life is severe in developing countries. The result is limited ability to ambulate with dependency for daily activities which produces significant economic impact on a country that is the third poorest country in the world and poorest in the western hemisphere. It is also well documented that children with clubfoot are associated with considerable social stigma and less likely to receive an education. Girls in particular are even more so affected due to a higher incidence of physical and sexual abuse with the disability.

What is the Ponseti Method of Clubfoot Treatment?

 This technique consists of serial manipulations and casting of the clubfoot. Typical course of therapy consists of five castings followed by bracing to maintain the correction up to the age of three. Approximately 80-85 percent of the patients require an Achilles tendon release, which is done in the clinic setting under a small amount of local anesthetic to correct the final aspect of the clubfoot. The fifth cast maintains this final position for three weeks. The bracing aspect is then initiated. The Ponseti method of correction has been used for over 50 years to correct clubfoot deformity and has replaced the older, less reliable Kite’s method of casting. When the Ponseti method is done correctly, the extensive posterior medial release surgery on infants is rarely required. Results of the Ponseti Method Long term study by Cooper and Dietz reported 78 percent good and excellent results at a minimum follow-up of 25 years. The Uganda Clubfoot project had a 96.7 percent success rate in 176 children with 182 clubfeet over a 3-year period of time. Several other areas have instituted a similar protocol to the Uganda Project and shown likewise results.

Why Not Surgery?

Early and even initial surgical procedures instead of casting have been advocated in the past due to the under-corrected, recurrent or over-corrected deformities using the traditional Kite’s method of casting. These surgical procedures have led to several documented failures and significant complications.

Course of Action

An initial conference with American and Haitian doctors will take place after January 2006 to introduce this technique and start the project. Most of the infants in PAP with clubfoot and being treated the Hospital St. Vincent, which would be the initial treatment center. Further treatment centers would open upon training of physicians from other cities in Haiti modeled after the Uganda Project. Supplies, post-casting bracing, travel expenses, and training/educational material would be funded by tax-deductible donations through the Timmy Foundation. Ongoing documentation and supervision of the medical portion of this project would be the crucial to the long-term success of the project. Surgical correction of resistant cases and the arrangements of such cases will be determined. The post-casting braces ideally will be made locally in Haiti by training a local artisan to make similar braces to those used in the Uganda Project.

Read All About it: NYT Headlines Diabetes

The New York Times recent four-part series brought the epidemic of diabetes to the front pages. The first article by N.R. Kleinfield cited the following:

"An estimated 800,000 adult New Yorkers -- more than one in every eight -- now have diabetes, and city health officials describe the problem as a bona fide epidemic. Diabetes is the only major disease in the city that is growing, both in the number of new cases and the number of people it kills. And it is growing quickly, even as other scourges like heart disease and cancers are stable or in decline.

Diabetes is a disease defined by economic disparity. In heavily Hispanic East Harlem in Manhattan, the illness plagues 14 percent of the population; just to the south, across 96th Street on the more affluent Upper East Side, the rate is under 2 percent."

The second article written by Ian Urbina focused on how profit motive in health care rules decision making. The following is a quote from the article:

Insurers, for example, will often refuse to pay $150 for a diabetic to see a podiatrist, who can help prevent foot ailments associated with the disease. Nearly all of them, though, cover amputations, which typically cost more than $30,000.”

The above statements are not foreign to our podiatry profession and brings heart ache to all of us when prevention was a treatment alternative prior to amputation.

As podiatrists we are key players in responding to this current public health epidemic. Our Section, with the support of APMA, should be assisting in developing a coordinated plan with our public health peers.