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11/06/2019    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2


RE: Time for The New Generation of Podiatrists to Speak Up


From: Dale Feinberg, DPM


 


I’ve followed PM News for quite some time and noticed that there are only a limited number of practicing podiatrists who are either proactive or reactive to the many subjects brought up on the open forums. If you read their current posts, it appears that many are about to hang up their white coats. I can’t believe that out of over 18,000 daily subscribers, the new generation is not stepping up to let us know what they think. 


 


When I was editor of the First Amendment at the California College of Podiatric Medicine, I was tasked with editing, writing, layout, and publishing 95% of each issue. I guess things haven’t changed much in the last 40 years. Please step up and help Barry keep this blog going. He needs new blood and he needs our help. To post a comment or respond to one, simply reply to PM News or send an email to bblock@podiatrym.com.


 


Dale Feinberg, DPM, Yuma, AZ

Other messages in this thread:


08/04/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Richard A. Simmons, DPM


 


The fee is going up from $731 to $888 for the three year registration. I gave up my DEA license more than ten years ago. I first contacted the State Board to see if there was any need for me to have it and there was not. Depending on the amount of controlled substances you prescribe or if you dispense medications from your office could help you decide if it is financially feasible or not. Not having that license has not had any adverse effects on my practice.


 


Richard A. Simmons, DPM,  Rockledge, FL

08/03/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2


RE: Questions to the ABPM BOD 


From: Charles M Lombardi, DPM


 


I recently sat through the BOD meeting of the ABPM last Friday (I am a diplomate). Lee Rogers, DPM stated ABPM is spending 100K to defend the right of an ABPM member to obtain hospital privileges with just the ABPM credential. My hospitals have always allowed ABPM members to obtain admitting privileges and wound care, etc., but not surgical privileges.


 


Does the ABPM Board believe that an ABPM certified person should be given surgical privileges? My residents are getting the insinuation that this is the case, and if they do, how can they claim that their diplomates are trained and evaluated in surgical skill sets without any methodology in their testing? Please answer.


 


These questions are my personal questions that do not represent any organization that I may presently serve or have served in the past.


 


Charles M Lombardi, DPM, Flushing, NY

07/30/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2B



From:  Brian Kiel, DPM


 


Dr. Secord is absolutely correct that this is not really sclerosing. The term is used by podiatrists to describe the injection of 4% alcohol/local anesthetic. We bill this as a CPT 64455, injection of a local anesthetic. I do think this procedure is very effective but it is not sclerosing; the term differentiates this for clinical diagnosis of a neuroma.


 


Brian Kiel, DPM, Memphis, TN

07/30/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A



From: Judith Rubin, DPM


 


Surely, there is a chemist in the profession or in one of the smaller Pharm labs that can make it cheaper. I had a bad neuroma in 1986 in my left foot, third interspace. I used the combo of .5% Marcaine and alcohol 7 times in my left foot. I never had surgery and never had a problem again. This combination has worked on thousands of my patients. I am sounding the alarm for the pharmacologists or chemists that are in our profession to make an affordable denatured alcohol. 


 


Judith Rubin, DPM, Cypress, TX

07/29/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Ron Werter, DPM, David Secord, DPM


 


According to the recent post, a vial is now costing $1,100 each if you can find others to share the box of 10. I figure that one 5ml vial makes 100ml of 5% solution. Medicare allows $60 for a CPT 64455 in my area. So one 5ml vial of the alcohol can bring in about $6,000; not as good as when the vials were $100 each but still financially a win. That being said, it’s also a good idea to offer a surgical alternative to excision such as the decompression procedure to those who want faster relief.


 


Ron Werter, DPM, NY, NY


 


As the 4% alcohol injection meme has come to the fore yet again, I thought I’d reach out and ask those folks doing this for neuritic pain: As a fairly large number of people continue to refer to a 4% alcohol injection as “sclerosing”, when it clearly is not, do these same people bill a code for a “sclerosing injection”, which they are clearly not performing? I’m going to make the assumption here that everyone knows that a 4% concentration of alcohol in a local anesthetic is insufficient to sclerosis anything. Do people simply use the term “sclerosing” because it is in common parlance or because they believe they are sclerosing something at that concentration and bill in like manner?


 


David Secord, DPM, McAllen, TX

07/28/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2B



From: Anthony Hoffman, DPM


 



I have a couple of scenarios in which I like the ability to offer the series of 4% alcohol sclerotherapy injections. The first scenario is for injection of a nerve other than a Morton's neuroma (it happens to be a branch of the lateral calcaneal nerve around the lateral wall of the calcaneus) where there is no need to do a decompression in that there is no entrapment of the nerve. The other scenario is a patient who is not a surgical candidate for various reasons. Having 4% alcohol in our treatment armamentarium is beneficial. By the way, FFF enterprises charges $11,000 for 10 vials (and they will not send only 1 or 2; you have to purchase 10.)


 


Anthony Hoffman, DPM, Oakland, CA


07/28/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A



From: Jeffrey Kass, DPM


 


I have used 4 percent dehydrated alcohol injections in my practice ever since attending the first podiatric dermatology and plastic surgery seminar given by Dr. Dockery in Chicago. This treatment became my primary treatment when steroids were not working consistently and I was seeing patients coming to me for second opinions which MRIs revealed plantar plate ruptures. 


 


Since giving these injections, I think I have done one decompression as there is no need to do surgery due to the effectiveness of this treatment. I have the utmost respect for Dr. Peacock, who is an incredible teacher, and would love for him to expound on the damage caused by this injection. I can’t recall any patient complain of any side-effect from this injection. (I give 1ml, inject directly between met heads, series of three injections every two weeks). There are published articles of radiologists giving much higher concentrations under ultrasound guidance directly into the neuroma. If a patient has pain and the pain is eliminated with no complaint of post-injection pain or numbness, what is the damage to the nerve? I think a patient would have a complaint if the nerve is damaged, no? 


 


Jeffrey Kass, DPM, Forest Hills, NY

07/27/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Martin M Pressman, DPM, Dieter J Fellner, DPM


 


I have a source for alcohol for neurolysis - Compounded Solutions in Pharmacy (Monroe, CT). You can get denatured alcohol for injection in vials that are good for 90 days after opening. A 5ml vial is $70.


 


Martin M Pressman, DPM, Milford, CT


 


I greatly respect the opinion of my esteemed colleague, Dr. Peacock. With his extensive practical experience, I have no reason to doubt the veracity of his personal opinions. It will be germane to supplement a Level 5 professional opinion with supportive substantive research evidence of a higher level to address the view that: 1. Alcohol sclerosing injection provides little benefit and, 2. That nerve decompression with transection of the intermetatarsal ligament can provide a superior outcome. 


 


Dieter J Fellner, DPM, NY, NY

07/23/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2B



From: Elliot Udell, DPM


 



Dr. Roth asks a good question when he questions why certain companies are charging so much money for sclerosing alcohol. He should also ask why the cost of masks and gloves have skyrocketed in price. I took a deep breath when I called a supplier yesterday to re-order disposable masks and was told that the price went from $5.95 a box to $35 a box. Gloves also went up 20%. The question is whether this is allowable supply and demand or are these examples of companies ripping off consumers. If it’s the latter, especially during the pandemic, government agencies need to look into this, and we as consumers need to make these agencies aware of what is happening. 


 


Elliot Udell, DPM, HIcksville, NY 


07/23/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A



From: Howard R. Fox, DPM


 


This whole mess started when Belcher Pharmaceuticals won approval for its version of the drug Ablysinol for use in treating hypertrophic obstructive cardiomyopathy. Because hypertrophic obstructive cardiomyopathy is a rare cardiac illness, Belcher Pharmaceuticals won orphan designation, which means no other pharmaceutical company could manufacture denatured alcohol until Belcher’s patent expires in 2025. Supply companies have run out of their old stock of denatured alcohol and are forced to stock the Blecher product Ablysinol at its ridiculous orphan drug price.


 


I expect denatured alcohol will once again become available at a more reasonable price in 2025.


 


Howard R. Fox, DPM, Staten Island, NY

07/17/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Jeffrey Kass, DPM


 


I, like most readers, have attended both live webinar and in-person lectures. Simply put, they both have pros and cons and I feel they both can be highly effective. The major point to consider and which were missed in prior postings is that podiatry should be pro-choice. The choice to attend an in-person lecture or seminar should be up to the licensed podiatrist. The fact that some posting here feel the need to fraternize with colleagues is truly irrelevant to the critical aspect of this discussion. If that helps you learn, good for you. Then, go to live lectures. The point is to learn. 


 


Learning can be accomplished online just as well as in person. After 25 years of practice, I have learned a lot from both resources. When done correctly, online lectures can be done with amazing engagement. Proof of this is to participate in any lapiplasty webinar. I have participated in these multiple times. Each one is unique and refreshing. It is unfortunate there are states that are not pro-choice and force doctors to get in-person credits, particularly in light of COVID-19. Shame on these states.  


 


Jeffrey Kass, DPM, Forest Hills, NY

07/15/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2


RE: Medical Exemptions to Wearing Face Masks? 


From: Cynthia Ferrelli, DPM


 


This can be a physical issue and not psychological. One of my staff was wearing an N95 mask and getting headaches a couple of hours into the day. After a week or two, she deduced it might be the mask because when she took her mask off, she felt better. We switched to a different type of mask and she did okay. I don't believe this was all in her head. 


 


Cynthia Ferrelli, DPM, Williamsville, NY

07/08/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Steven J. Kaniadakis, DPM


 


I feel that the quote by the Greeks, which has been cited or reported by Leonard Levy, was in fact, updated in podiatry schools to an expression as follows: "The feet don't just walk in to the office, the whole body walks in." It is one among my expressions in my practice I delivered to patients. 


 


Steven J. Kaniadakis, DPM, St. Petersburg, FL

07/07/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Elliot Udell, DPM


 


Dr. Shea gives one good example of why we need to be members of the American Podiatric Medical Association. There are many other reasons ranging from conferences, webinars, and day-to-day ways in which the APMA is only a telephone call away from each of our offices. There is, however, one master reason why in this troubling economic time we need to stay on the saddle and maintain our membership. The APMA represents and defends our right to exist.


 


If we did not have a unified body representing and defending our profession legally and politically, other professions would see to it that we would cease to be in the way we are entitled to exist. If you want to know what that would look like, ask any of us what the practice of podiatry was like thirty-five years plus ago. We have come a long way and will only stay that way if we continue to be unified under a common banner.  


 


Elliot Udell, DPM, Hicksville, NY

07/06/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2


RE: HHS Check and APMA 


From: Timothy P. Shea, DPM


 


How much is membership in the APMA worth? Recently, I was one of the few providers who did not receive stimulus checks from HHS. In spite of fulfilling all the requirements and continuing to work seeing patients, the program for HHS stimulus did not send any of the funds promised. In spite of numerous efforts on my part (contacting banks, local Medicare carrier, local CAC representative, and the HHS hotline provided (to name a few), it was a classic catch-22 where I was advised that I should be receiving the funds but nobody could  do anything about it.


 


I contacted the APMA and they assigned one of their very able attorneys to assist in trying to figure out what happened. Gail M. Reese, JD began to investigate this. After utilizing many avenues, yesterday, I finally received the funds appropriate to those promised. Because I provide care to a fair amount of patients on Medicare, the amount was substantial and will definitely assist in allowing me to continue with keeping the practice open.


 


Over the 40+ years practicing podiatric medicine, I have heard many excuses why podiatrists won't join the APMA. The most common is the dues! I can unequivocally state the amount of this one HHS stimulus check more than offsets the dues for APMA for many years. That is not taking into account all the other numerous other activities provided which benefit us every year. It's time for all podiatrists to join in our common effort spearheaded by the APMA. 


 


Timothy P. Shea, DPM, Concord, CA

06/26/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2



From: Tim Shea, DPM 


 


What a great question Dr. Simmons presents. My associate and I are both above 60+ and we were wondering why we were short of breath after about 4-5 patients, especially if we were talking. I think it is a combination of re-breathing CO2 and not getting as much O2 volume through the masks. We may try to have O2 available in the office. Thank you Dr. Simmons.


 


Tim Shea, DPM , Concord, CA

06/25/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2B



From: Dennis Shavelson, DPM


 


In changing our focus and training towards surgery, as a profession, we are forced to become more and more vestigial regarding closed-chain lower extremity biomechanics. In medicine, a surgeon’s card reads that he/she is a surgical specialist. A physiatrist's card reads rehabilitation specialist, and a dermatologist's reads skin specialist, etc. They can and do consult outside of their specialty at a lesser level, but remain dedicated to one or more specialties. They consult with other specialists when their training and experience falls short of the problem at hand by putting the patient in the hands more expert than their own.


 


I can count the number of biomechanical consultations that I have received from surgeons in my 40+ years of podiatry on nine or ten fingers. Instead, I have fostered relationships where I can confidently refer the few surgical cases I am asked to consult on and in return, I am called upon to assist them biomechanically pre- and post-op. In summary, in becoming podiatric foot and ankle surgeons, we are practicing a stunted version of biomechanics and orthotics without incentivizing non-surgical podiatric consultants in integrative biomechanics, making DPMs like me more and more vestigial.


 


Dennis Shavelson, DPM, NY, NY

06/25/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A



From: Marc A. Benard, DPM



 


I agree with Dr. Ribotsky with respect to a distinct absence in gait analysis and applied biomechanics, as well as his indicating “… are we losing the skill to determine the difference between open chain kinetics and closed chain kinetics pathology? If so, how can correct surgical procedures be explained?” I can attest that I observe this deficiency at close hand through my didactic lectures to residents both in person and recently via webinars, as well as through on-site observation at Operation Footprint (formerly The Baja Project for Crippled Children) during patient screenings, grand rounds, and intra-operatively. I’ve also engaged in discussion with program directors on the problem.


 


In truth, the problem has always existed, if my 43 years of dealing with the issue holds any validity. Fundamentally, the partitioning of “biomechanics” and “surgery” fractionated the...


 


Editor's note: Dr. Benard's extended-length letter can be read here.


06/11/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2B



From: Elliot Udell, DPM


 


Thank you Dr. Markinson for once again reminding us of the non-COVID-19 risks associated with grinding toenails. Several responders have legitimately asked how to adequately soften nails so as to properly debride them without the use of an electrical drill. 


 


As an allergy sufferer, I had to limit nail grinding very early in my career. I coughed and wheezed, even with the use of dust extractors. When papers came out showing that breathing in nail dust was an occupational hazard, I took all of the drills and extractors to the nearest dumpster. Some papers showed that the dust remains in the air for over 11 hours. 


 


There are ways to soften nails so that they can be adequately debrided. Spraying the nails with "Three Way Solution", often works. Another way is to dispense some of the nail softening products and insist that the patients use them daily between visits. We get great results with Bako's 40% urea nail gel as well as other products such as Formula 7. We have found that if the patients use these as well as other urea containing nail products, there is no need to mourn the use of nail grinding devices. 


 


Elliot Udell, DPM, Hicksville, NY

06/11/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A



From: Charles Morelli, DPM


 


You asked to "detail your techniques for reducing toenail hypertrophy". It has nothing to do with technique and all to do with having sharp instruments. If, and only if, your instruments are sharp, can this be done relatively easily and without pain to the patient. A dull instrument will do a less than optimal job and be painful for the patient if you are trying to reduce nail thickness. That being said, I do grind nails, have used a vacuum extractor for the past 30 years, and I now also wear a mask and will continue doing so, long after COVID is gone. I'd be embarrassed to have some patients leave my office without my doing that, but that is just me, as I know others will disagree. 


 


Charles Morelli, DPM, Mamaroneck, NY

05/25/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2B



 


I purchased the Swift immunotherapy device in August of 2019. I found that I had a significant amount of patients, both adult and pediatric, with lesions that often times were referred from dermatologists and colleagues specifically for CO2 laser excision after failing various conservative treatments. I had a 16-year-old patient scheduled for CO2 laser excision in September of 2019. I called his parents after purchasing the device and recommended that we try the Swift procedure before CO2 laser excision. After three treatments, all of the patient’s lesions (greater than 30 on both feet) resolved.


 


The Swift device can cause discomfort. This discomfort is far less than surgical excision. I find it is extremely helpful to prescribe EMLA cream and apply this for 5 to 8 minutes prior to Swift treatment. Patients feel discomfort/pain in the form of heat. Once the treatment is over, the discomfort dissipates. The patient can exercise or go about their activities of daily living immediately post treatment without any discomfort.


 


The device is very easy to use. It is extremely effective in pediatric patients with young, healthy immune systems. I often find that lesions are completely resolved after 3 to 4 treatments. In adult patients, with older immune systems, often times they need between four and six treatments.


 


Disclosure: I recently became a consultant for the Swift device company.


 


Rachel Balloch, DPM, Avon, CT

05/25/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A



From: Richard Goldstein, DPM


 


We have been very pleased with our purchase of the Swift machine. We purchased it in November 2019 and are on track to pay for it in full this year. So far, the results have been incredible, especially on recalcitrant warts. We are still working on our process. Some people need local anesthesia and some have not, but either way they are tolerating it. I was really glad to be an early adopter and I feel that within the next few years, microwave technology will be the treatment of choice for warts. I also feel like we have only touched the surface of what medical microwaves can be used for.


 


Richard Goldstein, DPM, NY, NY

05/25/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2


RE: 40th Anniversary OCPM Class of 1980


From: Tom Silver, DPM


 


I too would like to take a moment to "wax nostalgic" to offer congratulations to all my OCPM classmates on the 40th anniversary of our graduation. It's hard to believe it has been so many years! I hope you too have fond memories from school days and that many of the hopes and dreams for the future that you had back then have been fulfilled! 


 


Tom Silver, DPM, Minneapolis, MN

05/22/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2B



From: Alec Hochstein, DPM


 



I like to consider myself a progressive podiatrist. I try to add something to my practice at least yearly that brings a certain polish and a new technology to the office. This past year after seeing the initial advertisements for the Swift Emblation unit, I just couldn’t resist bringing it into my office, as I find verrucae to be extremely frustrating entities to treat (as I’m sure many podiatrists and dermatologists do as well).


 


I could not be happier with my decision to add this to my treatment armamentarium as the results and adoption by my patients have been nothing short of miraculous. I have no problem stating that my resolution rates for my verruca treatments with Swift Emblation is over 90%. The treatment is extremely well tolerated by my patients. It has been a great addition to the office. 


 


Disclosure: I am a consultant for Saorsa North American distributors of Swift. 


 


Alec Hochstein, DPM, Great Neck, NY


05/22/2020    

RESPONSES/COMMENTS (NON-CLINICAL) - PART 2A



From: Thomas A. Graziano MD, DPM


 


I decided to buy this new modality/technology because I believe in its mechanism, i.e. stimulating one's immune system to "naturally" eradicate the virus. My experience with the modality has been very favorable. Initially, I was seeing patients who had multiple unsuccessful attempts utilizing different modalities (surgical excision, chemo, cryo, etc.). At the onset, I must admit that I was questioning whether or not anything was happening during treatment, for as advertised, there is no smoke, no visible burn, or heating of the tissue. Don't be discouraged though; this is a very powerful therapeutic modality.


 


It is not painless. At times, it is necessary to administer local anesthesia, often a PT nerve block if the warts encompass a large region or subdermally in sensitive areas. Each treatment requires that the operator use a new tip. Each tip costs around $75, so be mindful of that if you’re charging a “case fee.” The mechanism of action relies on an intact immune system, so those patients with compromise in this area may require more treatments or be recalcitrant completely. Typically in patients with healthy immune systems, even those who have been resistant to other forms of treatment, from 3 to 5 sessions may be required. "Virgin" solitary warts can be handled in 1 to 3 treatments.


 


Thomas A. Graziano MD, DPM, Clifton, NJ
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