The topic of pain management remains a minor component of the formal education and training of residents and physicians in the United States. Misguided attitudes concerning acute and chronic pain management, in addition to reservations about the legal aspects of pain management, often translate into a “fear of the unknown” when it comes to narcotic prescription. The intentionally limited scope of this review is to promote an understanding of the laws regulating pain management practices in the United States and to provide recommendations for appropriate pain management assessment and documentation based on the Model Policy for the Use of Controlled Substances for the Treatment of Pain established by the Federation of State Medical Boards of the United States. (J Am Podiatr Med Assoc 100(6): 511–517, 2010)
A 2004 survey of US adults found that 19% had experienced foot problems at work at some time. As a result, 38% reported lost productivity and 28% missed time at work. Younger, less educated male workers were more likely to suffer from foot problems. The percentage of the total population surveyed who missed time at work owing to foot problems was 5.4% in 2004. In a previous survey conducted in 2000, the corresponding percentage was 6.6%. (J Am Podiatr Med Assoc 94(6): 604–607, 2004)
Diabetes-related foot ulcers are a leading cause of global morbidity, mortality, and health-care costs. People with a history of foot ulcers have a diminished quality of life attributed to limited walking and mobility. One of the largest concerns is ulceration recurrence. Approximately 40% of patients with ulcerations will have a recurrent ulcer in the year after healing, and most occur in the first 3 months after wound healing. Hence, this period after ulceration is called “remission” due to this risk of reulceration. Promoting and fostering mobility is an integral part of everyday life and is important for maintaining good physical health and health-related quality of life for all people living with diabetes. In this short perspective, we provide recommendations on how to safely increase walking activity and facilitate appropriate off-loading and monitoring in people with a recently healed foot ulcer, foot reconstruction, or partial foot amputation. Interventions include monitored activity training, dosed out in steadily increasing increments and coupled with daily skin temperature monitoring, which can identify dangerous “hotspots” prone to recurrence. By understanding areas at risk, patients are empowered to maximize ulcer-free days and to enable an improved quality of life. This perspective outlines a unified strategy to treat patients in the remission period after ulceration and aims to provide clinicians with appropriate patient recommendations based on best available evidence and expert opinion to educate their patients to ensure a safe transition to footwear and return to activity.
An updated selection of high-quality Internet resources related to wound and ulcer care is presented. Of potential use to the podiatric medical practitioner, educator, resident, and student, some Web sites that cover hyperbaric medicine, antibiotic use, and wound and ulcer prevention are also included. These Web sites have been evaluated on the basis of their potential to enhance the practice of podiatric medicine, in addition to contributing to the educational process. Readers who require a quick reference source to wound and ulcer care may find this report useful. (J Am Podiatr Med Assoc 96(3): 264–268, 2006)
Onychomycosis is a fungal infection, and, as such, one of the goals of treatment should be eradication of the infective agent. Despite this, in contrast to dermatologists, many podiatric physicians do not include antifungals in their onychomycosis treatment plans. Before initiating treatment, confirmation of mycologic status via laboratory testing (eg, microscopy with potassium hydroxide preparation, histopathology with periodic acid–Schiff staining, fungal culture, and polymerase chain reaction) is important; however, more podiatric physicians rely solely on clinical signs than do dermatologists. These dissimilarities may be due, in part, to differences between specialties in training, reimbursement patterns, or practice orientation, and to explore these differences further, a joint podiatric medicine–dermatology roundtable was convened. In addition, treatment options have been limited owing to safety concerns with available oral antifungals and relatively low efficacy with previously available topical treatments. Recently approved topical treatments—efinaconzole and tavaborole—offer additional options for patients with mild-to-moderate disease. Debridement alone has no effect on mycologic status, and it is recommended that it be used in combination with an oral or topical antifungal. There is little to no clinical evidence to support the use of lasers or over-the-counter treatments for onychomycosis. After a patient has achieved cure (absence of clinical signs or absence of fungus with minimal clinical signs), lifestyle and hygiene measures, prophylactic/maintenance treatment, and proactive treatment for tinea pedis, including in family members, may help maintain this status.
Google Trends proves to be a novel tool to ascertain the level of public interest in pathology and treatments. From anticipating nascent epidemics with data-driven prevention campaigns to identifying interest in cosmetic or bariatric surgery, Google Trends provides physicians real-time insight into the latest consumer trends.
We used Google Trends to identify temporal trends and variation in the search volume index of four groups of keywords that assessed practitioner-nomenclature inquiries, in addition to podiatric-specific searches for pain, traumatic injury, and common podiatric pathology over a 10-year period. The Mann-Kendall trend test was used to determine a trend in the series, and the Wilcoxon signed-rank test was used to determine whether there was a significant difference between summer and winter season inquiries. Significance was set at P ≤ .05.
The terms “podiatrist” and “foot doctor” experienced increasing Search Volume Index (SVI) and seasonal variation, whereas the terms “foot surgeon” and “podiatric surgeon” experienced no such increase. “Foot pain,” “heel pain,” “toe pain,” and “ankle pain” experienced a significant increase in SVI, with “foot pain” maintaining the highest SVI at all times. Similar results were seen with the terms “foot fractures,” “bunion,” “ingrown toenail,” and “heel spur.” These terms all experienced statistically significant increasing trends; moreover, the SVI was significantly higher in the summer than in the winter for each of these terms.
The results of this study show the utility in illustrating seasonal variation in Internet interest of pathologies today's podiatrist commonly encounters. By identifying the popularity and seasonal variation of practitioner- and pathology-specific search inquiries, resources can be allocated to effectively address current public inquiries. With this knowledge, providers can learn what podiatric-specific interests are trending in their local communities and market their practice accordingly throughout the year.
A retrospective analysis of 878 articles published in JAPMA from 1991 to 2000 was conducted to investigate changing patterns of publication activity in podiatric medicine. Most of the articles published in JAPMA were case reports (37%), followed by literature reviews (33%) and original research (30%). The Journal has covered a wide range of topic areas, with the most common being foot surgery (14%). A breakdown of the proportion of original research versus review articles and case reports for each topic area revealed that while orthotic therapy and biomechanics attract considerable attention from researchers, other important specialty areas such as foot surgery, dermatology, pediatrics, and rheumatology continue to be represented primarily by literature reviews and case reports. Two significant trends were observed: a gradual increase in the proportion of original research articles and a steady increase in the number of articles by authors outside the United States. These findings provide valuable insight into patterns of publication in podiatric medicine and raise a number of issues regarding the ongoing development of the profession. (J Am Podiatr Med Assoc 92(5): 308-313, 2002)
The Society for Vascular Surgery (SVS) and the American Podiatric Medical Association (APMA) recognize the beneficial impact of a multidisciplinary team approach on the care of patients with critical limb ischemia, especially in the diabetic population. As a first step in identifying clinical issues and questions important to both memberships, and to work together to find solutions that will benefit the shared patient, the two organizations appointed a representative group to write a joint statement on the importance of multidisciplinary team approach to the care of the diabetic foot. (J Am Podiatr Med Assoc 100(4): 309–311, 2010)
This historical perspective highlights some of the pioneers, milestones, teams, and system changes that have had a major impact on management of the diabetic foot during the past 100 years. In 1934, American diabetologist Elliott P. Joslin noted that mortality from diabetic coma had fallen from 60% to 5% after the introduction of insulin, yet deaths from diabetic gangrene of the lower extremity had risen significantly. He believed that diabetic gangrene was preventable. His remedy was a team approach that included foot care, diet, exercise, prompt treatment of foot infections, and specialized surgical care.
The history of the team approach to management of the diabetic foot chronicles the rise of a new health profession—podiatric medicine and surgery—and emergence of the specialty of vascular surgery. The partnership among the diabetologist, vascular surgeon, and podiatric surgeon is a natural one. The complementary skills and knowledge of each can improve limb salvage and functional outcomes. Comprehensive multidisciplinary foot-care programs have been shown to increase quality of care and reduce amputation rates by 36% to 86%. Development of distal revascularization techniques to restore pulsatile blood flow to the foot has also been a major advancement.
Patients with diabetic foot complications are among the most complex and vulnerable of all patient populations. Specialized diabetic foot clinics of the 21st century should be multidisciplinary and equipped to coordinate diagnosis, off-loading, and preventive care; to perform revascularization procedures; to aggressively treat infections; and to manage medical comorbidities. (J Am Podiatr Med Assoc 100(5): 317–334, 2010)
At the end of an anatomical peninsula, the foot in diabetes is prone to short- and long-term complications involving neuropathy, vasculopathy, and infection. Effective management requires an interdisciplinary effort focusing on this triad. Herein, we describe the key factors leading to foot complications and the critical skill sets required to assemble a team to care for them. Although specific attention is given to a conjoined model involving podiatric medicine and vascular surgery, the so-called toe and flow model, we further outline three separate programmatic models of care—basic, intermediate, and center of excellence—that can be implemented in the developed and developing world. (J Am Podiatr Med Assoc 100(5): 342–348, 2010)