Dermatology, Diabetes Treatments Addressed in Breakfast Symposium

TheOFFICIAL NEWSPAPER National OF THE APMA ANNUAL SCIENTIFIC Today MEETING

July 24-27, 2014 • Honolulu, Hawaii • Hilton Hawaiian Village and Convention Center Saturday, July 26, 2014 Dermatology, Diabetes Treatments For additional meeting coverage, visit apma-365.ascendeventmedia.com. Addressed in Breakfast Symposium Today’s Schedule n update of the treatment of a variety of common dermatology 6:30–8 a.m. conditions podiatric physicians Breakfast Symposium 1: Overcom- see and a look at treatment ing Onychomycosis: Management advances for type 2 diabetes Update as well as the role the specialty plays in Ballroom A Acontrolling its effects were presented Breakfast Symposium 2: Understand- yesterday in the Breakfast Symposium ing Biologics: Update on Bone Graft “Dermatological Condition Update.” Applications Ballroom C Use of Topical and Steroid Treatments 8–9 a.m. From simple dry skin, to various types of Plenary Lecture: Tackling Tinea Pedis: dermatitis, to fungal infections, podiatric Updates on Latest Treatments physicians see a variety of dermatologic be treated with Yesterday’s Breakfast Symposium ad- Ballroom B conditions, but they need to broaden their steroids, and dressed dermatology issues and Fariba diagnostic and treatment horizons to they are more Rahnema, MD, also discussed treating 9–9:30 a.m. type 2 diabetes. Exhibit Hall Break and CECH Scanning better serve their patients, said G. (Dock) complex.” Kamehameha Exhibit Hall Dockery, DPM. Dr. Dock- “It is a common misconception by ery addressed infections to worsen and slow the treat- 9:30–11 a.m. most practitioners that everything that dermatitis, and ment when added to antifungals. Track 1: Pediatrics is a rash on the foot is a fungal infection, he reminded cli- To better diagnose the condition, a Room 311 and studies show that is not the case,” said nicians that it is punch biopsy is the best option, and Track 2: Controversy Debates Dr. Dockery, International Foot & Ankle an inflammation of the dermis exhibiting ideally a practitioner should get two 2mm Room 312 Foundation. “Sixty percent of rashes are spongiosis or fluid between the cells. The punches instead of one 4mm punch, Dr. eczematous dermatitis and are not fungal. most common spongiotic dermatitis and Dockery said. 9:30 a.m.–Noon “If you find out you have a bacterial eczematous dermatitis are atopic derma- The gold standard for treating spongiot- Assistants’ Program: Practice Man- agement and ICD-10 infection, you treat it with an antibiotic. titis, eczema, allergic contact dermatitis, ic or eczematous dermatitis is topical cor- Room 301B If you find out you have a fungal infec- nummular dermatitis, and dyshidrotic ticosteroids, and he reminded physicians tion, you treat it with an antifungal. If you dermatitis. to use Fitzpatrick skin typing to determine Workshop 2: Ankle Arthroscopy have a viral infection, you treat it with He cautioned against assuming rashes which corticosteroid to use. Workshop an antiviral. Pretty much everything else are a fungus because treating fungal and A recent development in the use of Room 308AB is eczematous dermatitis that needs to yeast infections with steroids can cause the see SYMPOSIUM, page 15 11 a.m.–Noon Track 1: Public Health/Falls Preven- tion Room 311 Interesting Cases Often Turn into Deadly Cases

Track 2: Health-Care Disparities radley W. Bakotic, DPM, DO, Dr. Bakotic reviewed 11 cases and answered large B-cell lymphoma of the leg, and died. Room 312 was forced to deliver his Plenary questions from the audience. He started These lymphomas often are not life-threat- address yesterday from Atlanta, with more ordinary unusual cases, includ- ening, but on the legs they spread rapidly, Noon–1 p.m. but in Honolulu the message ing a man who presented with blotches and and half of patients die, Dr. Bakotic said. Lunch Break and CECH Scanning Kamehameha Exhibit Hall was clear: Don’t hesitate to take bruises on his feet, but was diagnosed with “For some reason, when this occurs biopsies of suspicious lesions. pernio when it was discovered he worked in on the leg, the prognosis becomes much Non-CECH Lunch Symposium: Topical B“Be open-minded to outside viewpoints. a cold environment. In another case, a nine- worse,” he said. “As physicians of the lower Antifungal Therapy: New Options, Be careful not to limit biopsies to cases of year-old girl with a toe nodule was diag- extremities, you need to be aware of this.” New Opportunities obvious malignancy. Don’t forget the mean- nosed with infantile digital inclusion body. Three other cases also involved older Ballroom A ing of ‘atypical,’” said Dr. Bakotic, who pre- Other interesting cases at first appeared women diagnosed with cancers, and a 1–2 p.m. sented “Interesting Case Studies in Podiatric innocuous, but medical investigations fourth involved a man diagnosed with Poster Abstracts Symposium Medicine.” revealed otherwise. A 73-year-old woman metastatic renal cell carcinoma several years Kamehameha Exhibit Hall Using an audio connection and displaying with a nodule that had appeared two after being cleared of cancer, which is not presentation slides on screens in the room, months earlier was found to have diffuse unusual, Dr. Bakotic said. see SCHEDULE, page 5

xx Inside this issue: MRI Provides Comprehensive New Approaches Saving Limbs of Knowing Addiction Medicine 4 Imaging for Ankle and Foot 5 Patients with Vascular Disease 12 a Key in Pain Management

Saturday, July 26, 2014 The National Today • APMA Annual Scientific Meeting 3

The Challenge of Diagnosing, Treating Charcot Joint ne of the most important chal- eration of a weightbearing joint that can discussed its use in “Basic Principles in conditions that usually throw off MRIs, lenges in managing patients be recognized and arrested at “stage zero.” Practice for Imaging in the Face of Acute and so we look for alternative imaging, with diabetes is the early However the lack of widespread awareness and Chronic Infections With and Without such as NMI, to resolve these special cases. diagnosis and treatment of of this condition often results in delayed Ulceration.” “Nuclear medicine imaging using la- Charcot joint because many or even missed diagnoses, which increases NMI tracks a radioactive agent to beled white blood cells can provide insight physicians are unfamiliar with the con- morbidity and mortality associated with identify infection or inflammation in the and allow the differentiation between in- Odition. Despite a plethora of case re- this condition. Part of the problem is body, and Dr. Judge used a series of images fected ulcerations, osteomyelitis, and other ports and numerous published theories that the condition is not well understood to demonstrate the modality and how it more benign conditions.” in pathology mechanics and chemistry, and so is likely to be underreported. That can be used in diagnosis. A “routine bone A detailed history and a through clinical there remains a substantial population means that even the speculated incidence scan” is not an agent used to diagnose exam supplemented by streamlined imag- of physicians who are unaware of those or prevalence for the condition is probably infection. It is used to identify regions of ing are important, and Dr. Judge explained at risk for this condition. estimated lower than it actually occurs, Dr. inflammation that may be associated with when to use which agents and how to Judge said. infection. In cases where an infection is order imaging. For those who are aware of the condi- suspected, a positive bone scan indicates “Nuclear medicine imaging is the go-to tion of neuroarthropathy, also known as that infection cannot be ruled out. imaging modality in the complex cases Charcot joint, the condition often pres- “There are white blood cell imaging where a patient has had previous surgery, ents as a profound single-limb swelling, agents that can identify infection in people a history of chronic or repeatedly infected warmth, and history of trivial trauma, who have had previous surgery or who ulcerations, or when suffering from the if any. The challenge for physicians is have had previous ulcerations and infec- degenerative changes of neuroarthropa- differentiating Charcot joint from infection,” she said. “These are complicated thy,” she said. tion. Podiatric physicians can play a role in improving knowledge of the condition by participating in group discussions with Ultrasound Workshop colleagues and other practitioners who may be unaware of this condition, she said. Dr. Judge discussed a profile of a patient with Charcot joint, but said that treatment strategies should be focused on conservative management when possible. Molly Judge, DPM: ‘There is not a lot of hard “Ultimately, the people who have done evidence as to how and why this may evolve.’ the most surgery for Charcot joint and have tracked their own long-term follow- Molly Judge, DPM, director of research up are saying, ‘If you can avoid surgery on and publications for CHP—Healthspan these people, do it,’ because their morbid- physician group—Cleveland Clinic ity and mortality is important. Foundation, discussed those challenges “The most important element in treating in her presentation, “The Science Behind the Charcot joint is awareness of those Charcot Joint and Use of Nuclear people at increased risk for neuroarthrop- Medicine Imaging to Differentiate athy and early identification of the acute Infection from Acute Charcot Breakdown.” process. To identify these people early “People lean toward the anecdotal when and prevent them from needing surgery is it comes to managing the Charcot joint, perhaps the greatest power of modern-day and that is because there is not a lot of podiatric medicine. That is the pathway to hard evidence as to how and why this may saving lives one limb at a time.” evolve,” she said. “Even in the current lit- erature there is far more reported via case Nuclear Medicine Imaging reports and, essentially, in their summary Nuclear medicine imaging (NMI) is a Glenn Kleezens, regional sales manager for Universal Imaging, tests an ultrasound is almost always an anecdotal comment or unique, useful modality that can help machine yesterday during the ‘Hands-On Ultrasound Workshop.’ The annual workshop suggestion regarding management.” differentiate between serious infections is designed to teach podiatrists to use the equipment for diagnosis and treatment in Charcot joint is the progressive degen- and more benign conditions. Dr. Judge their offices. Question of the Day QuestionWhat have you learnedof theduring the meetingDay that you can put to Q: use in your practice? “The osteomyelitis “I liked Dr. Bakotic’s “The diabetes session “The use of embryonic lecture Thursday advice to biopsy early Thursday was interest- tissue in wound care. stands out. You had if suspicious. If you ing. What I picked up My practice is at the VA, everybody saying you have a suspicious was to push operating to so we will take that back are supposed to use lesion, find out early reduce the foot pressure. and discuss it further.” antibiotics for six to what it is.” It is not very common eight weeks, and he in Australia to do that; suggested that two we tend to stick to the weeks is perfectly adequate.” conservative therapy.” Howard Weinstein, DPM, Carrollton, TX Peter John Sardella, DPM, Providence, RI Tran T. Luc, Kew, VIC, Australia Glenn S. Gold Jr., DPM, Bountiful, UT 4 The National Today • APMA Annual Scientific Meeting Saturday, July 26, 2014

MRI Provides Comprehensive Imaging for Ankle and Foot ifferent imaging modalities ing with a radiologist who specializes in fascia and removal of calcifications within done at an imaging center because the may work best for different musculoskeletal imaging is a great advan- tendons.” equipment is relatively new. injuries, but MRI remains a tage when possible, Dr. Levine said. Training greatly decreases or eliminates comprehensive modality for “MRI is the most powerful and com- the learning curve, he said. Imaging Tumors of the Foot and Ankle the ankle and foot, said Ben- prehensive imaging modality, but other “The key is obtaining a good picture, Even though most tumors are nonspe- jamin D. Levine, MD, who presented modalities are complementary to each which is dependent on probe manipula- cific on imaging, several of them do have “MRID of the Ankle and Foot,” yesterday other,” he said. “Ultrasound is excellent for tion,” Dr. Schwartz said. specific imaging features, which were during the Radiology track. looking at a targeted area around the ankle reviewed by Dr. Levine in his presenta- “Studies demonstrate that using MRI as and foot, particularly tendon pathology. Advantages of CT tion “Imaging Tumors of the Foot and a diagnostic imaging tool for evaluation X-ray is inexpensive and fast, and should Computed tomography (CT) is similar to A n k l e .” of the ankle and foot has been shown to always be the baseline imaging modality X-ray and should be used to obtain images Dr. Levine used a series of images to change treatment and management deci- to choose. CT can characterize a com- of bone trauma or bone pathology of any illustrate many of the tumors that can sions,” said Dr. Levine, assistant professor plex fracture. Dual-energy CT is newer kind, said Albert Armstrong Jr., DPM, develop around the ankle and foot. Most of radiology in the Musculoskeletal Sec- and provides the ideal imaging modality MS, associate professor of radiology and of these tumors are benign, but it is im- tion at the David Geffen School of Medi- for the diagnosis of gout with its ability interim dean, Barry University School of portant to get a baseline of all suspected cine, University of California, Los Angeles to uniquely identify monosodium urate Podiatric Medicine, Miami. tumors using X-ray, he said. Health System. crystals.” CT is an advanced X-ray imaging mo- If a tumor is osseous, further imaging dality that is useful in imaging intra-artic- with CT is the best step. However, if you Update on Imaging Ankle Injuries ular fractures and bone tumors. It also is need to determine if a tumor is a cyst or a Dr. Levine also expanded his discussion better than MRI for imaging cortical bone. solid, ultrasound is a good imaging option. of when to use different modalities in his CT equipment produces images that are Ultimately, MRI excels at defining the lo- presentation “Ankle Injuries: Update on much sharper than X-rays because they cal extent of disease, Dr. Levine said. Imaging.” He used a variety of images to use an X-ray beam that is thinly collimated explain which imaging tests to order for and has less scatter radiation. An X-ray Tendon Evaluation using Power Doppler the most common ankle injuries seen in a has a greater amount of scatter radiation Ultrasound imaging is useful in diagnosis podiatric or orthopedic practice. that grays out the image, Dr. Armstrong because it provides dynamic images in Among the injuries he reviewed were said. real time, which cannot be done using CT ligament and tendon injuries, osseous or MRI. A practitioner can evaluate the injuries, osteochondral injuries, and im- Advances in 3D Weightbearing CT movement of a tendon in real time using pingement syndromes. A cutting-edge advancement in imaging ultrasound. “Impingement syndromes around the is the development of weightbearing CT, Power Doppler is a form of ultrasound ankle are clinical diagnoses, but they have which is used for biomechanical evalua- that detects and measures blood flow by imaging features, particularly on MRI, tion, and preoperative and postoperative recording changes in the frequency of the that can suggest and help confirm the surgical evaluation. Images are three-di- ultrasound wave. Power Doppler can im- diagnosis,” Dr. Levine said. “If the patient mensional and help to detect biomechani- age very small blood vessels in damaged is presenting clinically with an impinge- cal bone abnormalities better than X-rays tendons. If neovessels are detected, they ment syndrome, and then you have the or MRI. are a sign the tendon is injured and trying MRI features to go along with it, it can The equipment is designed so the to heal itself, Dr. Armstrong said. Ultra- confirm the diagnosis.” patient can stand in it to produce images sound also can be used to look at tendon showing the effect of weight on the lower shape, texture, and disruptions. Foot and Ankle Ultrasound extremities. It also is useful in the diagno- “A lot of podiatrists still do not have The cost of ultrasound imaging equip- sis and treatment of a collapsed arch in a diagnostic ultrasound equipment,” he said. ment has decreased as digital technol- patient with Charcot foot, Dr. Armstrong “The equipment is much cheaper than Benjamin D. Levine, MD, reviewed the ad- ogy has replaced analog technology, so said. weightbearing CT, but it is not widely used vantages of MRI as a diagnostic tool. podiatric physicians should take advan- A 3D weightbearing CT is more expen- even though it should be. Diagnostic ultra- tage of that evolution to use diagnostic sive than an X-ray machine and is usually sound has many advantages over MRI.” Dr. Levine discussed different types of ultrasound, said Nathan H. Schwartz, MRI sequences to use in specific situations DPM, who presented “Foot and Ankle when imaging the ankle and foot, but the Ultrasound.” type of MRI also can affect the quality “X-rays are a part of most every podia- of the scan. There are different magnetic trist’s practice, and they supply valuable strengths of MRI machines such as 0.5, information. However, X-rays give little 1.5, and 3T, which provides the highest to no soft-tissue information. Ultrasound resolution. does, and it gives unique bone and joint Because they are the latest generation information. It is safe; there are no con- and most expensive, 3T scanners are not traindications,” he said. as common, and are likely not available at Other advantages to adding digital smaller, private radiology centers, he said. ultrasound equipment include improved “For routine diagnosis around the ankle processes, such as providing images in and foot, a good 1.5 scanner does the job,” real time so the equipment can be used he said. “For more detailed cartilage imag- during procedures. ing, higher resolution, and better diag- “There are a lot of computer-based nostic performance, 3T outperforms 1.5T. enhancements with ultrasound that make There are certain pathologies that you will the images much clearer and eliminate only be able to see on 3T. Those usually the guesswork in the interpretation,” Dr. revolve around intra-articular pathologies; Schwartz said. “If one wants to give an however, even routine tendon tears will be injection accurately into one specific area, better characterized with 3T. ultrasound not only will guide the clini- “We used to do arthrograms of the an- cian, but also verify that it has been given kle. With the advent of 3T, we only rarely in the right location. need to perform an arthrogram procedure “There are procedures that can be per- on the ankle.” formed percutaneously under ultrasound Nathan H. Schwartz, DPM: ‘The key is obtaining a good picture, which is dependent on probe In addition to using 3T scanners, work- imaging, such as the release of the plantar manipulation.’ Saturday, July 26, 2014 The National Today • APMA Annual Scientific Meeting 5

New Approaches Saving Limbs of Patients with Vascular Disease

ew approaches are helping to The Sherman Oaks Amputation Preven- algorithm, he said, that starts with treating with the same outcomes as conventional reduce amputations in patients tion Center has a staff of three podiatric an infection, determining if there is any endovascular interventions done through with vascular disease. Two physicians who were trained during underlying vascular disease preventing the femoral artery.” presentations during Friday’s fellowships in limb salvage, two vascu- healing, and addressing any abnormal Patients with critical limb ischemia Society for Vascular Surgery lar surgeons, a hyperbaric management pressures or biomechanical issues. most often have pain in their feet at rest, Young Surgeons Committee/APMA Young specialist, a general surgeon, and a plastic “This is a true multidisciplinary ap- nonhealing foot ulcers, or toe gangrene. If NPhysicians’ Vascular Disease Symposium surgeon. It operates in a newly renovated proach in an area where the patient is they do not undergo limb revasculariza- looked at how one specialty center is expe- facility that opened in 2013. The center, a in need of multidisciplinary care,” Dr. tion, these patients face a major amputa- diting treatment to salvage limbs and the pioneer in the technology of painless epi- Pougatsch said. “By acting quickly, we are tion, he said. use of pedal access for minimally invasive dermal skin grafting, also uses biological able to preserve as much tissue as we can The most durable revascularization op- procedures to clear occluded arteries. tissues available to help heal wounds, Dr. to heal/close the wound. The quicker one tion is a surgical bypass, but these patients Pougatsch said. Its hyperbaric facility is addresses and intervenes with respect to are often too frail to withstand surgery. Time is Tissue: The Urgency of currently being upgraded with monoplace the patient’s underlying vasculopathy, the Clearing the occluded vessel with a mini- Revascularization hyperbaric chambers. greater the presence of healthy tissue and mally invasive procedure is safer for sick Time is of the essence in any medical “There is no longer a need for patients the higher the success rate at preserving patients, but it is not as durable a treat- treatment, but particularly when trying to to bounce around from one specialist to the patient’s foot and functionality. ” ment, Dr. Chaer said. avoid leg amputations in patients with an another to treat their wounds,” he said. “There is a high rate of recurrence of ischemic diabetic foot. The processes of a “The concept of our physicians working Pedal Access for Endovascular the blockages, but this is unaffected by center that has a limb salvage rate of more as a team to heal our patients is the reason Interventions the access route and is the natural history than 90 percent were discussed in “Time Is we have a high success rate. We are able to Podiatric physicians often are the first following percutaneous interventions,” he Tissue: The Urgency of Revascularization provide for our patients a true multidisci- health-care professionals to diagnose criti- said. “Sometimes you have to accept that in the Ischemic Diabetic Foot.” plinary, multimodal limb salvage center. cal limb ischemia in patients, so they need these interventions are not as durable as “A lot of leg amputations due to vascular “The time frame in which our patients to be aware of treatment options that can a surgical bypass because they are safer in disease could be avoided if the patients are treated for underlying vascular disease help these patients avoid amputation. patients who have multiple other medical were revascularized in an adequate time is much faster than at most facilities. By Traditionally, the most common inter- problems and cannot tolerate a bypass. frame. We try to do everything in less having other specialists available under ventions to revascularize limbs have been “Vascular surgeons are often not the first than three or four days, from getting them one roof, we are able to work together and a surgical bypass or endovascular inter- physicians who see patients who present admitted to the hospital, to getting them expedite whatever needs to be done.” ventions with percutaneous access through with critical limb ischemia. Oftentimes cleared by a medical team, to getting an The key is to prevent any further tissue the femoral artery in the groin. However, it is their podiatrist or their primary care angiogram, to surgical intervention. We loss in the ischemic limb. accessing occluded vessels through the physician. Sometimes the general im- work as a team,” said David A. Pougatsch, “If you can re-establish blood flow in a foot is a newer option that is being used pression is that these patients often are DPM, associate medical director at the timely manner to an area you are trying more often, said Rabih A. Chaer, MD, too sick to undergo surgery, so they are Amputation Prevention Center at Sher- to salvage, further necrosis can be pre- MSc, associate professor of surgery at the not referred for revascularization. But man Oaks Hospital, Los Angeles. vented. Surrounding healthy tissue will be Division of Vascular Surgery, University of most of the time there are alternatives to When symptoms of vascular disease preserved and the attempt at limb salvage Pittsburgh Medical Center. surgical bypass. The key is to educate all are first recognized in patients, they often will not be in jeopardy,” Dr. Pougatsch “This is an added avenue we can offer specialties that treat patients with vascular wait weeks before a diagnosis is confirmed said. “The problem lies in the fact that it patients who have critical limb ischemia,” disease about these minimally invasive and appropriate vascular intervention is is difficult to re-establish blood flow in an said Dr. Chaer, who presented “Transpedal approaches. Through a multidisciplinary scheduled, he said. adequate time frame in the traditional way Endovascular Interventions for Critical collaboration among podiatrists and vas- “During this time frame, if tissue is dy- medical practices operate, going from one Limb Ischemia.” “What we have learned cular surgeons, improved limb salvage can ing, it will continue to die and this necro- doctor to another.” over the past few years is that when this still be achieved in this challenging patient sis will spread,” Dr. Pougatsch said. The center follows a “common sense” technique is done right it provides patients population.”

SCHEDULE Tools of the Trade Continued from page 1 Scanning Schedule 2–4 p.m. Risk Management Seminar: Lessons Learned From a Podiatric Malpractice Today Settlement 9–9:30 a.m. Scanning in the exhibit hall Ballroom B 2.5 contact hours

Sunday’s Schedule Noon–1 p.m. 7:30–9 a.m. Scanning in the exhibit hall Breakfast Symposium: Surviving the 2.5 contact hours Changing Health-Care Landscape: Gen- erational and Legal Challenges 1–2 p.m. Hilton Hawaiian Village, Coral 3 Poster Abstracts Symposium Scanning in poster exhibit 9–10:30 a.m. 1 contact hour The Ultimate APMA Coding Seminar: ICD-10—It May Be Delayed, but You Still 2–4 p.m Need to Get Ready Risk Management Seminar Hilton Hawaiian Village, Coral 4 Ballroom B Scanning immediately following the con- clusion of the seminar 10:30–11 a.m. 2 contact hours CECH Scanning Break Hilton Hawaiian Village Coral 4 Sunday 10:30–11 a.m. 11 a.m.–12:30 p.m. Scanning outside lecture hall The Ultimate APMA Coding Seminar: Hilton Hawaiian Village, Coral 4 ICD-10—It May Be Delayed, but You Still 3 contact hours Need to Get Ready (continued) Hilton Hawaiian Village, Coral 4 12:30–1 p.m. A National attendee examines surgical tools in the exhibit hall yesterday. The Scanning outside lecture hall exhibit hall will be open from 9 a.m. to 2 p.m. today, the last day it is open during 12:30–1 p.m. Hilton Hawaiian Village, Coral 4 the meeting. CECH Scanning 1.5 contact hours Hilton Hawaiian Village Coral 4 6 The National Today • APMA Annual Scientific Meeting Saturday, July 26, 2014

Variety Spices Up Education Program is that for some people they’re great, for many others with medical and biome- Sessions Address Clinical, review the fundamental principles of tablish the diagnosis because many people chanical issues, they are not. The studies Legal, and Ethical Issues bone healing and the cutting-edge tech- who come in with chronic heel pain don’t have indeed shown injuries in long bones nology of bone grafts. have that classic plantar fasciitis at the of the feet and shins, the Achilles, etc., but oday’s education program will origin. If you put a probe on it, which they have shown promise in reducing knee address a variety of clinical, 6:30–8 a.m. in Ballroom A, Overcoming takes two seconds, you can tell where it is pain and impact trauma to the knee.” legal and ethical issues in several Onychomycosis: Management Updates in the fascia, so it helps with the diagnosis different presentation formats. for Podiatrists of plantar fasciitis.” 9:30 a.m.–noon in Room 308AB Ankle Breakfast symposia will fea- Warren S. Joseph, DPM, said the FDA Emily A. Cook, DPM, MPH, CPH, will Arthroscopy Workshop ture updates on bone grafts and treating has not approved any new onychomy- discuss how the overuse of ultrasound can This cadaveric workshop presents an Tonychomycosis, and a plenary lecture will cosis treatments in almost 15 years, but add costs and delay treatment. “Plantar introduction to ankle arthroscopy. look at tinea pedis. If you are in the mood approved two new topical agents in July. fasciitis is really a clinical diagnosis, and Presenters will introduce attendees to for a debate, you can hear the pros and They will give podiatrists and their pa- ultrasound is not necessary to make that the instrumentation required, and a new cons of minimalist shoes and ultrasound tients new options for the treatment of this diagnosis. Utilizing ultrasound to diag- set of terms and skills, with a focus on diagnosis for heel pain. Other sessions will infection. nose common conditions that we treat on superficial anatomy, the portals, and how look at health-care disparities and how a regular basis adds unnecessary exami- to navigate the equipment, said Patrick R. to prevent falls. In the afternoon, see the 8–9 a.m., Plenary Lecture, in Ballroom B, nation time, increases overall health care Burns, DPM, who will lead the session. latest research at the Poster Abstracts Sym- Tackling Tinea Pedis: Update on Latest costs and should not be used to substitute (Preregistration required.) posium and hear the details of a podiatric Treatments a thorough clinical examination.” malpractice lawsuit. Tracey C. Vlahovic, DPM, will discuss • “Minimalist/Barefoot Versus Tradi- 11 a.m.–noon in Room 301B, Track 1: Public how the disease is spread and the newest tional Running Shoes,” Nicholas A. Health/Falls Prevention 6:30–8 a.m. in Ballroom C, Understanding topical treatments that have been devel- Campitelli, DPM, will discuss the • “Falls Risk Assessment,” Jeremy J. Cook, Biologics: Update on Graft Applications oped and analyze the products used to development of shoe gear, the biome- DPM, MPH, will discuss the devel- • “Understanding the Science of Bone prevent tinea pedis. She also will address chanics of different types of feet, and opment of a reliable falls-prevention Grafts,” Aprajita Nakra, DPM, will the consequences of not treating the con- their influence on injuries in runners. assessment tool to identify those elderly discuss autograft, allograft, and xenograft dition until it is completely cured. “How one runs is probably more im- who have a higher risk of sustaining one bone grafts. She also will discuss the pros portant than what is on one’s feet, but or more falls in a one-year period and to and cons of each, their clinical applica- 9:30–11 a.m. in Room 312, Controversy what is on one’s feet may affect how one help minimize the risk of fractures that tions in foot and ankle surgery, and their Debates runs,” he said. can lead to a long-term inability to walk. physiology. • “Diagnostic Ultrasound for Heel Pain?” Jeffrey Ross, DPM, MD, said evidence- • “What Can Podiatrists Do to Prevent • “Clinical Applications in Foot and Ankle Adam E. Fleischer, DPM, MPH, will based studies have shown injuries with Falls?” Dr. Fleischer will discuss the Procedures,” David A. Yeager, DPM, will take the pro position: “It can help you es- minimalist shoes: “The moral of the story importance of podiatrists in influencing Saturday, July 26, 2014 The National Today • APMA Annual Scientific Meeting 7

the overall health of patients and the YOUNG PHYSICIANS’ PROGRAM PROVIDES PRACTICE MANAGEMENT ADVICE role of using a “foot visit” as an opportunity to exert that influence. The Young Physicians’ Program, “Insuring Suc- must comply. In this highly regulated environ- but was destroyed by Hurricane Katrina. His ex- cess—Practice Survival,” provided vital ment, practitioners who fail to gain a basic perience formed the basis of his presentation. 11 a.m.–noon in Room 312, Health-Care information for podiatrists trying to establish understanding of health-care law concepts “Unless you have experienced it firsthand, Disparities themselves in practice. run great risks of audits, licensure discipline, it is hard to really understand what happens • “Introduction to Health-Care Dispari- As part of the program, Kevin West, JD, loss of privileges, lawsuits, government fines during a disaster such as I experienced with ties,” Joseph M. Caporusso, DPM, MPH, partner, Parsons Behle & Latimer, discussed and penalties, and other potentially career- Katrina,” he said. “My staff was scattered. will discuss the perceptions of dispari- basic health-care law for podiatrists. “This threatening events. Health-care law is rapidly I had to balance my personal life and my ties and their ramifications. [presentation] is a primer on many topics evolving, and the past 10 years have seen worries about my family along with caring for • “Cultural and Linguistic Competency,” about which podiatric physicians should have huge changes at every level on each of the my staff, and I had very little to no access to Klaus J. Kernbach, DPM, will discuss a basic understanding,” West said. The talk topics that we covered.” money. It took me more than three years to the importance of understanding the so- covered several topics, including employment Also during the program, Jon Goldsmith, return to my previous level of income.” cial, cultural and linguistic needs of the contracts, insurance contracts, the Stark law, DPM, presented on career opportunities for Dr. Dabdoub shared the lessons he patient, and address the needs of some the Anti-Kickback Statute, malpractice insur- young physicians. The lecture focused on the learned so young physicians can be prepared patient groups. ance, fraud and abuse laws, Medicare and variety of different employment arrangements should the worst happen. “You need to look private insurance audits and investigations, that are available to the young physician. at your insurance,” he said. “Not just against 1–2 p.m., Poster Abstracts Symposium, HIPAA, licensure and privileging issues, the “[Options] include starting a practice, being an floods or other natural disasters, but business Kamehameha Exhibit Hall Affordable Care Act, and medical malpractice associate, entering a partnership, a multi- interruption insurance as well. [These events] Attendees will have the opportunity to risk management. specialty group, hospital employment, and can happen to any practice along a coast, or review the latest cutting-edge foot and Learning from West is an invaluable academic positions,” he said. in a tornado or earthquake zone.” ankle research and ask questions of the experience for young physicians. He has Dr. Goldsmith is only a year removed from The program was rounded out by Harry authors of around 80 posters during represented health-care providers, particularly young physician status himself. He practices Goldsmith, DPM, and his presentation, “What today’s Poster Abstracts Symposium. podiatrists, for more than 25 years and wrote in Omaha, NE. “My hope is that my experi- You Need to Know about Coding and Reim- Pick up a Poster Abstracts booklet at the APMA’s HIPAA manual and its two subse- ence with a variety of these options ben- bursement.” Dr. Goldsmith is a renowned cod- Registration Desk. quent updates. efits young physicians as they are planning ing expert and APMA consultant. Although the “The world of health care is one of the to graduate residency and begin their profes- ICD-10 transition has been delayed for one 2–4 p.m., Risk Management Seminar, most, if not the most regulated industry in the sional careers,” he said. year, this topic remains incredibly important Ballroom B United States,” West said. “New practitioners Also presenting during the session was Wil- for young physicians. Alan S. Banks, DPM, will present “Les- must not only be well-trained from a medical liam H. Dabdoub, DPM. Dr. Dabdoub practices Young physicians can find valuable materi- sons Learned from a Podiatric Malpractice standpoint, but also well-informed of the legal in Slidell, LA. However, that wasn’t always the als and resources at www.apma.org/young- Settlement.” and regulatory framework with which they case. Until 2005, his practice in New Orleans— physicians.

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It’s Never Too Soon to Plan Ahead: Register for Next Year’s National in Orlando! e are halfway through If roller coasters aren’t your thing or For all that Orlando has to offer, arts and crafts, face painting, pool games, the APMA 2014 Annual you are planning to leave the kids at you and your family can even enjoy a and more! Scientific Meeting (The home, Orlando has you covered. You can complete vacation without leaving the Do you like to slow down on vacation National), but it isn’t too see musical performances at the House grounds of the Marriott Orlando World instead of packing in a lot of activity? early to think about next of Blues in Downtown Disney and Hard Center (www.marriott.com/hotels/travel/ The spa at the Marriott Orlando World year’s premier foot and ankle confer- Rock Live at Universal CityWalk. Is deli- mcowc-orlando-world-center-marriott). Center offers all of the services you could ence.W Come to the APMA booth (#623) cious food a priority when you travel? Along with the aforementioned golf want: facial, massage, manicures/pedi- to register for The 2015 National, July Orlando is a true culinary hot spot with course, the property boasts numerous cures, body wrap, and more. Take some 23–26 in Orlando, FL, at the Mar- award-winning restaurants and celebrity dining options, a luxurious spa, and a time for yourself and enjoy a peaceful, riott Orlando World Center, and pay chefs who cater to visitors from around range of recreation activities for children relaxing treatment. the lowest possible rate: only $295 for the globe. There’s an extensive menu of of all ages. Keep your taste buds happy by sam- APMA members! fine-dining establishments, international The Marriott Orlando World Center is pling all of the property’s dining options. Orlando is the perfect destination for eateries, casual cafés, and chic wine bars practically a water park all unto itself. For Have a hankering for steak? Pick from professional development and family fun. for just about any taste or budget. Look- younger children, the Splash Zone with a traditional steakhouse (Hawk’s Land- With a little bit of something for everyone, ing for an upscale steakhouse or a new Zero Entry Pool and Water Playground ing Steakhouse & Grille) or Japanese it is no surprise Orlando is one of the cities neighborhood bistro? Want to check out featuring water trees, spray jets, and more (Mikado). For Italian, try Siro Urban visited most often by both domestic and where the locals wine and dine? Orlando will provide entertainment for hours. For Italian Kitchen, voted the 2013 Best New international travelers. With seven of the has it all. For more information, visit the more daring, the Plunge Zone with Restaurant for Central Florida by Florida world’s top 20 theme parks, not to men- www.VisitOrlando.com. Slide Tower is a must-do. Choose from Trend magazine. Need to get something tion nearly 100 other attractions, the city Orlando may lack Florida’s famous three slides, including a 90-foot super- in a hurry? Stop by the Mangrove food certainly knows how to entertain. beaches, but it does have plenty of the speedy drop-slide. When your children court for a quick bite on the go! After a day of lectures and walking the Sunshine State’s other well-known at- need to dry out, send them to the Gam- After the meeting, you may register on- exhibit hall floor, you will feel refreshed and traction: golf courses. With 176 courses, ing Recreational Interactive Destination, line at www.apma.org/TheNational. Enter inspired by a leisurely escape to a world of Orlando was recently named the North or GRID. the coupon code SUNSHINE to guarantee imagination and fantasy. Our host property, American Golf Destination of the Year You will want to take a look at the daily the best possible registration rate. Be on the Marriott Orlando World Center, is the by the International Association of Golf scheduled resort activities. Parents can let the lookout for information about this ideal launching pad for all of your Orlando Tour Operators. Play 18 holes on courses loose and kids can get silly with ongo- meeting in the coming months. adventures. The resort is advantageously lo- designed by golf legends including ing, ever-changing activities and events We’ll see you in Orlando! cated across the highway from Walt Disney Palmer, Watson, Nicklaus, and Norman. at the Activity Center. Activities range World Resort and is just a short drive from Be sure to book a tee time before or after from LEGOLAND-themed events and *The National Today gratefully acknowledges Visit Universal Studios Resort and the Wizarding the meeting at our host property’s on-site Gatorland animal appearances featuring Orlando and the Marriott Orlando World Center World of Harry Potter. golf club, Hawk’s Landing. alligators and snakes, to fun and festive for providing information used in this article.

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Sunday Sessions to Look at Legal and Practices Issues, ICD-10 racticing medicine involves “You need to comply with both HIPAA Oct. 1, 2015, but physicians and their staffs smith, DPM, Lawrence A. Santi, DPM, more than seeing patients in and Meaningful Use,” West said. “I will still need to be working hard to be ready and Phillip E. Ward, DPM, will present an exam room. Dealing with talk about how those rules intersect, and to make the change. It will take time to “ICD-10 Coding of Clinical Scenarios.” personnel matters and follow- how important compliance with those train staffs, refine the resources for the James Christina, DPM, will present “PQRS ing federal regulations are rules has become in today’s environment. transition to using new codes, and test all and Meaningful Use.” In the presentations, important parts of health care that will be the processes. Failure to be ready at the they will discuss the additional codes in Pexamined in the Sunday Breakfast Sympo- ICD-10 Seminar deadline will violate federal regulations ICD-10 and how they need to be recorded, sium and the APMA Coding Seminar. The deadline for implementing ICD-10 and endanger reimbursements. and the role of the Physician Quality Re- “Surviving the Changing Health-Care may have been pushed back one year, to In the ICD-10 seminar, Harry Gold- porting System. Landscape: Generational and Legal Chal- lenges” will be presented from 7:30 to 9 a.m. Sunday at Hilton Hawaiian Village, Coral 3. “The Ultimate APMA Coding Seminar: ICD-10—It May Be Delayed But You Still Need to Get Ready” will be presented in two parts from 9 to 10:30 a.m. THE SINGLE BEST PODIATRIC and 11 a.m. to noon in Hilton Hawaiian Village, Coral 4. CODING RESOURCE

A Wealth of Generations From the Silent Generation to Baby Boomers to Gen X to Millennials, four generations are working together for the first time, and they have different approaches to work and life. “It’s not that people in the different generations are not motivated, it’s that you CODING have to understand what motivates them, RESOURCE CENTER and engage them based on their own motivation,” said Barry L. Scurran, DPM, chief compliance officer for the Perma- Your single online resource for: nente Medical Group. “Understanding how people of different generations view diversity, themselves, or the future makes #04s)#$ s)#$ s(#0#3s##)%$)43s it possible to understand what motivates different people.” -%$)#!2%,#$S"934!4% s$-%2%&%2%.#%3s Dr. Scurran will discuss such topics as -%$)#!2%',/"!,$!93 .%%$&/2!33)34!.4352'%/. the influence of social media and how the Silent Generation and Baby Boomers !.$265Ss9/523/52#%&/2&//4!.$!.+,% want to see details on a written page while 30%#)&)#)#$ 4/)#$ $)!'./3)3#2/337!,+3 younger generations avoid paper and want to see emails or texts. “I will discuss the concept that your history and your influences shape your emotions, actions, and perceptions of institutions, careers, and life.

Changes to HIPAA and Meaningful Use HIPAA has been part of the health-care world in the US since 2003, but it was up- dated in 2010 and 2013, and is now being enforced more strictly than ever. An expert on health-care law, J. Kevin West, JD, will discuss those updates and the current HIPAA enforcement environment during Sunday’s Breakfast Symposium, “Surviv- ing the Changing Health Care Landscape: Generational and Legal Challenges.” “In the past two years we have seen a record number of audits, fines, penalties, and investigations, none of which we saw in the early years of HIPAA. Now, it has exploded into a very aggressive enforcement situation,” said West, of Parsons Beh- le & Latimer, Boise, ID, who is the author SUBSCRIBE TODAY! of the APMA HIPAA manuals, practices health-care law and teaches a health-care Visit the APMA booth (#623) or www.APMACODINGRC.org law course at Boise State University. In his presentation, “The 2013 Changes to HIPAA; HIPAA Audits; Meaningful Use Audits,” West will discuss the HIPAA security risk analysis and the interaction with Meaningful Use standards and audits. 10 The National Today • APMA Annual Scientific Meeting Saturday, July 26, 2014

Shoes Can Play Key Role in Sports Injuries

different prescriptions and devices made. malist shoe,” said Dr. Werd, the session The goal is to come up with best practices presenter. “Several shoe companies are at based on evidence-based medicine,” said the other extreme of minimalism, creating Howard E. Kashefsky, DPM. maximum-cushion shoes. Dr. Kashefsky, director of podiatry “My take-home on running shoes services at University of North Carolina is that there is a specific shoe for each Hospitals, presented “Innovations in patient. Choice needs to be individualized Orthotics” Friday. His meta-analysis of based on running mechanics, the level data collected in several studies since 2009 of the athlete, the goals of the athlete, the found a lack of level 1 evidence when distances in training, and whether this is reviewing about 20 commonly prescribed an elite athlete or a middle-of-the-pack uses for orthotics. runner.” “We are trying to determine when The treatment of Achilles tendon something would be custom versus over- injuries has changed, and now includes the-counter,” he said. “There are more extracorporeal shockwave therapy, cobla- devices that are more cost-efficient for tion therapy, platelet-rich plasma, and patients that are over-the-counter, and the high-speed ultrasonic ablation. Future data support when it is appropriate to be treatments being studied include the use using that and still have a good outcome of growth factors for tendon repair and for patients.” regeneration, marrow-derived stem cell- The analysis also looked at developing seeded collagen implants, and low-energy trends in managing ankle instability and balance, and the use of 3D CAD/CAM technologies that will affect prescribing, dispensing, and modifying orthotics over the next decade or more, Dr. Kashefsky It is difficult to see said. “Some of the orthotics we use now are consistency with Matt Werd, DPM, who participated in several triathlons, polls the audience to see how many rigid, but is rigid best? Some of the newer attendees had been in triathlons. devices and some of the data show that not prescriptions because everyone needs to be in a rigid device and you go to five people he treatment of triathlon par- “There has been a trend from traditional that flexible devices have their indications ticipants’ injuries, a compari- running shoes, to minimalist to a maxi- as well,” he said. “This newer technology, and you get five son of over-the-counter versus malist shoe, and each has led to differing even though it can control the foot, is not custom shoe orthotics, and the injuries,” Dr. Werd said. “There is a poten- rigid.” different prescriptions effect of minimalist shoes and tial to trade one set of injuries for another One new device he discussed is a pre- and devices made. The stretching exercises on Achilles tendon set of injuries by switching shoes or chang- fabricated, ultra-thin interactive carbon Tinjuries were examined yesterday in ing training techniques.” insole from Germany that can be custom- goal is to come up with the Biomechanics and Sports Medicine Other issues he discussed included ized. It is designed so adjustments can be track. training, overtraining, and environmental made to gradually increase changes to a best practices based issues, such as extreme heat and difficult patient’s gait and posture in stages. on evidence-based Diagnosing and Treating running surfaces. The most common “This is a new concept in orthotics. Triathlon Injuries lower extremity injuries are orthopedic in If someone has a deformity, you don’t medicine. Podiatric physicians treat many patients nature, but fatal cardiac injuries do occur, have to correct it with one device that is suffering from injuries that occur during primarily during the swim portion, he custom-made,” Dr. Kashefsky said. “This long runs that test athletes’ endurance. Fri- said. Deaths are rare, but occur at a rate of allows you to gradually bring the patient Howard E. Kashefsky, DPM day, they heard about identifying, diagnos- 15 per 1 million participants in triathlons. to what they can maximally tolerate and ing, and treating lower extremity injuries The most common swimming-related allows their body to adapt to it gradually. suffered during triathlons, including one problems for triathlon participants are “It also allows more normal foot function of the most grueling races in the world, shoulder injuries and cardiac issues. For because it is not rigid. With the adjust- photostimulation. the Hawaii Ironman. the bicycling portion of triathlons, trauma ments, you can target specific joints, which Dr. Werd also discussed the controversy A finisher of the Hawaii Ironman, Matt injuries are most common, while lower ex- is a new paradigm. Before, with the custom, over stretching, which arose after a study Werd, DPM, discussed the variety of inju- tremity overuse injuries are most common semi-rigid orthotic, we were locking up on the potential detriments of stretching. ries—from traditional running injuries to for the run. Twenty-two percent of injuries and controlling all the joints of the foot and “It was misinterpreted by some people,” death—that participants may suffer during are trauma/orthopedic, and 72 percent altering gait and normal muscle pattern.” he said. “In general, regular stretching taxing triathlons, and that podiatrists may of injuries are related to dehydration or is a good thing, but static stretching just be called upon to treat. Dr. Werd is chief exhaustion. Role of Minimalist Shoes, Stretching before exercise may not be the best time. A of podiatric surgery at Lakeland Regional in Achilles Injuries dynamic pre-activity warm-up is recom- Medical Center, Lakeland, FL, and is a past Innovations in Orthotics An Achilles tendon injury is the third mended. Studies show that stretching president of the American Academy of Traditionally, the only consistency in most common lower extremity injury, and before exercise can temporarily weaken a Podiatric Sports Medicine. prescribing orthotics has been the incon- 18 percent of running injuries involve the muscle, but in general, regular stretching The Hawaii Ironman started in 1978 and sistency among practitioners. However, Achilles tendon. The role of minimalist is still something we do recommend, and includes a 2.4-mile swim in rough Pacific a meta-analysis of several studies of the shoes in these injuries, newer approaches it may be best performed after exercise.” Ocean water, a 112-mile bike race, and a effectiveness of over-the-counter (OTC) on stretching, and treatment trends were Finally, Dr. Werd looked at new surgical 26.6-mile marathon through blackened devices versus custom devices and the discussed Friday during “Achilles Tendon options for tendon repair, and reviewed lava fields. It serves as the Ironman World development of more flexible devices may Injuries in Sports.” case studies. Championship competition, and each of help standardize approaches to orthotic “The minimalist shoe has increased the “For the young healthy athlete with an the 1,900 participants must qualify for prescriptions. potential strain on the Achilles. In the Achilles tendon rupture, surgical repair is entry. “The main thing we found is that it is running shoe industry, the pendulum is still the recommended treatment,” he said. The types of shoes worn in the race are not clear how orthotics work. It is difficult swinging from the minimalist/barefoot “For the less active, older, sedentary pa- tracked by the annual “Kona Shoe Count,” to see consistency with prescriptions be- trend in the last several years to the other tient, non-operative treatment is the more and range from 15 to 20 types. cause you go to five people and you get five end of [the spectrum] to more of a maxi- likely recommendation.” Saturday, July 26, 2014 The National Today • APMA Annual Scientific Meeting 11

Plantar Fasciitis Study Finds Custom Orthotics Speed Healing atients with planar fasciitis fasciitis randomized patients into three are more active during their groups, one that received custom foot recovery when using custom orthotics, one that received prefabricated foot orthotics compared to orthotics, and one that received a sham. prefabs and sham devices The study followed participants for three according to a study funded by APMA. months, and charted pain relief with the PThe study also found common threads first steps in the morning and at the end of to help predict which patients respond the day, and measured quality of life using better to specific treatments. surveys and activity monitoring. “We found that people who had a se- “We also looked at the biomechanical verely contracted Achilles tendon seemed findings. We recognized we had a great data to do best with a regimen that centered set and we had one examiner with a great on stretching, supportive shoe gear, and deal of experience doing these biome- insoles,” said Adam E. Fleischer, DPM, chanical exams that podiatrists do,” Dr. MPH. “We know that a contracted Achilles Wrobel said. “We wanted to see which of tendon is a risk factor for developing heel the findings might be predictive of people pain, but we didn’t know that the greater who respond to orthotic therapy or did not the contraction the more likely you are to respond. benefit from stretching and conservative “We did the same thing with our radiol- treatment.” ogy measures, and Dr. Fleisher looked at James S. Wrobel, DPM, MS, (left) and Adam E. Fleischer, DPM, MPH, answer questions about Dr. Fleischer and James S. Wrobel, DPM, ultrasound and radiographic changes to see an APMA-funded study of plantar fasciitis. MS, presented “The APMA-Funded Plantar if any of those [changes] predicted response Fasciitis Study” Friday. Dr. Fleisher is an to orthotic therapy.” custom-made foot orthotics. There was a who had a biconvexity plantar fascia associate professor at the Dr. William M. Many study participants changed their 5.6-fold improvement over the people who appearance were five times less likely to Scholl College of Podiatric Medicine at shoe sizes, did stretching and ice massage got prefabricated foot orthotics, over three respond to orthotic therapy. Rosalind Franklin University of Medicine at home, received a pad they could remove, months. People who got custom devices “We found that people whose plantar and Science, and Dr. Wrobel is an associ- and wore house slippers, Dr. Wrobel said. were 120 percent more active after three fascia had swelling and a circular appear- ate professor of internal medicine in the “Those therapies alone resulted in months than the people who had prefabri- ance at the origin simply did not do well Metabolism, Endocrinology and Diabetes significant improvement within the first cated orthotics.” with a mechanical treatment regimen,” Dr. Division at the University of Michigan couple of weeks,” he said. “We found a Using ultrasound to measure the thick- Fleischer said, adding that the use of injec- Medical School. great deal of improvement in spontane- ness of the plantar fascia, echostructure, tions or anti-inflammatory medications The study of 77 patients with plantar ous physical activity in the people who got and inflammation, the study found patients might be better options.

ETHICALLY SPEAKING 2014 Annual Meeting Sponsors As of June 27, 2014 Attendees debated the nuances of medical conduct in each of the scenarios. Sce- ethics during yesterday’s “Track 2: narios covered such topics as treating DIAMOND SILVER PEWTER Applying the APMA Code of Ethics to family members, engaging in sexual Practice Situations.” relationships with patients, addressing APMA Deputy Executive Direc- suspected substance abuse among tor and COO Jay Levrio, PhD, kicked colleagues, negotiating relationships off the session with a review of the with industry, and being transparent in six core concepts of medical ethics, advertising. including patient autonomy, physi- In one scenario, a young physician beneficence, non-maleficence, cian is under pressure from his senior justice, dignity, and honesty. Dr. Levrio partners in practice to perform more reminded the audience that a profes- surgeries and increase his contribution sional code of ethics pertains not only to the bottom line. An elite college ath- to a physician’s public, but also his or lete presents with an injury he wants PLATINUM her private life. He also explained that treated quickly—with surgery. The although APMA maintains a detailed physician knows, however, that this pa- code of ethics, the association de- tient could respond well to conserva- pends on the state components to tive care. The audience discussed the adjudicate ethical violations. many facets of the case, including the Scott Haag, JD, MSPH, APMA’s unethical behavior of the young physi- director of Health Policy and Practice cian’s senior partners; the importance and a licensed attorney, underscored of informed consent to help the patient the potentially severe consequences understand the nature of his condition, GOLD of an ethical violation, including loss of the proposed treatment and alterna- license and legal ramifications. tives, and the potential for success The speakers then injected some and complications; and HIPAA issues PHARMACEUTICALS COPPER levity, as Jim Christina, DPM, APMA that can arise in treating athletes who director of Scientific Affairs, led the sometimes have trainers involved in BRONZE audience through a review of several their care. humorous but relevant ethical cases, For more information about APMA’s allowing participants to share their Code of Ethics, visit www.apma.org/gov- input about appropriate physician ernance and click on “Code of Ethics.” 12 The National Today • APMA Annual Scientific Meeting Saturday, July 26, 2014

Knowing Addiction Medicine a Key in Pain Management ain is the most common rea- medications with boundary settings, said, adding that 3 percent to 16 percent including addictive disorders; and docu- son patients visit physicians, according to Howard A. Heit, MD. of the population has the disease of ad- ment all evaluation. but the majority of physicians “To do good pain management, you diction, exclusive of nicotine addiction, “The treatment agreement—it is an are not familiar with how to need to be at least a talented amateur which affects about 20 percent of the agreement, not a legal contract—puts in treat pain using appropriate in addiction medicine,” said Dr. Heit, population. writing the responsibilities of the doctor an expert on pain both professionally “The goals of pain management are to to the patient and the patient to the doctor P and personally, who presented “Defen- decrease pain, increase function, and use who prescribes a controlled substance, sible, Rational, and Compassionate Pain medicines that do not have unacceptable such as an opioid,” Dr. Heit said. Management” yesterday during Track 3, side effects,” said Dr. Heit, who reviewed “You need exit strategies if the opioids Pain Management. “Most physicians and his 2005 paper, “Universal Precautions in are not improving the pain syndrome, health-care professionals do not know the Pain Medicine: A Rational Approach to the source of the pain is resolved, or the difference between addiction and physical the Treatment of Chronic Pain.” It outlines patient is displaying aberrant behavior. dependence.” 10 principles in treating chronic pain with In an exit strategy, you can abandon the Dr. Heit, an assistant clinical professor at scheduled medications, such as opioids. molecule, but never abandon the pa- Georgetown University, is board-certified Those principles in working with tient,” he said. in internal medicine and gastroenterol- patients in pain are to make a diagnosis The bottom line in treating a patient ogy/hepatology, and is a diplomate in with an appropriate differential; make a with pain is that management should addiction medicine. He moved into pain psychological assessment, including risk always be patient-centered, Dr. Heit said. and addiction medicine while spending of addictive disorders; get an informed “Pain management is what you are more than 20 years in a wheelchair for a consent; develop a treatment agreement; doing for the patient not to the patient,” rare, painful muscle disorder following conduct a pre- and post-intervention of he said. “You should focus on improving an accident. In 2008, he was treated with assessment of pain level and function; outcomes and managing risk. You have a deep brain stimulation and now functions conduct an appropriate trial of opioid responsibility to make sure these medi- with a marked decrease in pain, and no therapy with or without adjunctive cines are prescribed safely to the patient, longer uses a wheelchair or other assistive medication; regularly assess the pain and the patient has a responsibility once devices. score and level of function; regularly medicines are dispensed from the phar- Howard A. Heit, MD: ‘Most physicians and Physical dependence is a neuropharma- assess the ‘four A’s” of pain medicine— macist to take care of these medicines so health-care professionals do not know the cological phenomenon, while addiction analgesia, activity, adverse effects, and they are not lost or stolen. Pain manage- difference between addiction and physical is both a neuropharmacological phenom- aberrant behavior; periodically review ment should be defensible, rational, and dependence.’ enon and a behavioral phenomenon, he pain diagnosis and comorbid conditions, compassionate.”

Attention Young Physicians!

Come to the APMA booth (#623) today to learn more about how APMA is meeting your needs:

Ȉ Sign up for Friday’s Young Physicians’ Program Ȉ Register for the 2014 Young Physicians’ Institute, October 10–12 Ȉ Learn about the Young Physicians’ Reception Ȉ Explore APMA’s new online career center and eAdvocacy center Ȉ Meet your young physician leaders

Be sure to add to the conversation on social media throughout the meeting with our hashtags #ASMHawaii and #youngdocsrock. Saturday, July 26, 2014 The National Today • APMA Annual Scientific Meeting 13

Podiatry’s Public Health Crisis APMA Luau Reception odiatrists’ membership in the This morning, Dr. Simon will moderate American Public Health As- the Public Health/Falls Prevention track at sociation (APHA) is reaching an 11 a.m. in Room 311. all-time low, despite podiatric APMA encourages state component medicine’s role in public health. societies to consider sponsoring member- James DiResta, DPM, MPH, the cur- ship for the state’s executive director and Prent chair of the APHA Podiatric Section, one additional member. Individual APMA is asking each APMA component to fund members, visit www.apha.org and click on membership for its executive director and “About Us,” and “Membership Informa- one additional member (who is not a cur- tion” for links to renew your current APHA rent APHA member). “If our membership membership or join as a new member. in APHA continues to dwindle, the status of our Podiatric Section will be in jeopardy,” Passionate about Public Health? Dr. DiResta warned. “If we lose our section, If you have an interest in public health we will lose our seat at the table and will re- or know a podiatrist who does, consider duce our effectiveness in many public health the APMA/The Dartmouth Institute for initiatives that should concern us all.” Health Policy and Clinical Practice (TDI) Janet Simon, DPM, chair of APMA’s Pub- Public Health Fellowship. lic Health and Preventive Podiatric Medi- The fellowship curriculum is designed cine Committee, echoed Dr. DiResta’s call to to provide the fellow with fundamental action. “Much of what we do as podiatrists skills, knowledge base, and philosophical on a daily basis is public health,” she said. foundation in health policy and clini- Everything from screening patients cal practice, with specific attention paid More than 1,100 attendees were on hand Thursday evening at APMA’s Luau Reception to for diabetic peripheral neuropathy and to public health, clinical/health services peripheral arterial disease to encouraging enjoy a stunning performance of traditional Polynesian music and dances. Guests enjoyed research, and health-care leadership. smoking cessation and assisting elderly tiki cocktails and hors d’oeuvres as they took in the breathtaking scenery of Oahu from the The application period for the 2015–16 patients to prevent falls qualifies as public Great Lawn of the Hilton Hawaiian Village. APMA gratefully acknowledges the sponsors of APMA/TDI Fellowship is now open. The health practice, Dr. Simon said, particularly the Luau Reception, Anacor Pharmaceuticals, Inc.; Bako Integrated Physician Solutions; as the population ages and more and more deadline for applications is November 7. MediTouch EHR/HealthFusion; the Podiatry Insurance Company of America; and Spenco podiatrists participate in meaningful use To learn more and apply, visit www.apma. Medical Corporation. and quality reporting initiatives. org/tdi.

Your premier foot & ankle meeting… your family’s destination for fun!

APMA is pleased to announce the 2015 Annual Scientiﬁc Meeting, The National, will be hosted in Orlando, Florida. Register today at www.apma.org/thenational. 14 The National Today • APMA Annual Scientific Meeting Saturday, July 26, 2014

Exhibit Hall Map

H Hawaiian Moon...... 522 Hawaiian Museum...... 923 Henry Schein MicroMD...... 814 Hilo Hattie...... 1133 Horizon Pharma, Inc...... 403 Hush Puppies Footwear...... 912 I IM Custom...... 918 J JM Orthotics...... 417 K Kerasal...... 714 M Medi USA, LP...... 704 MediTouch EHR/HealthFusion...... 503 Medline Industries, Inc...... 915 Merz North America...... 603 Metasurg...... 818 Midmark Corporation...... 622 Mile High Orthotics Lab., Inc...... 719 MiMedx Group, Inc...... 723 Multi Radiance Medical...... 525 N NEUROGENX, Inc...... 815 New Balance Athletic Shoe, Inc...... 502 Nomir Medical, Inc...... 419 Northwest Podiatric Laboratory...... 528 O Organogenesis Inc...... 709 Osiris Therapeutics, Inc...... 518 P Pedorthic Footcare Association...... 429 Association of Extremity Nerve Surgeons...... 418 DG Instruments...... 415 PharmaDerm, a part List of Exhibitors athenahealth, Inc...... 612 DJO Global...... 624 of Fougera Pharmaceuticals, Inc...... 402 Axxess Compounding...... 727 DOLA...... 928 Physician Claim Corp...... 628 # Dr. Comfort...... 626 Physician Web Pages/Eppointments...... 810 1st Providers Choice-DPM EMR...... 715 B Dr. William M. Scholl College of Podiatric Podiatry Insurance 20/20 Imaging...... 825 Medicine at the Rosalind Franklin University of Company of America (PICA)...... 703 Bako Integrated Physician Solutions...... 803 Podiatric Medicine and Science...... 425 Podiatry Management Magazine...... 826 A Biofreeze/Performance Health...... 817 Podiatry Today...... 917 Biomet Bone Healing...... 710 E Premier Shockwave, Inc...... 829 ABL Medical, LLC...... 819 Bonapeda Enterprises LLC...... 616 ACell, Inc...... 618 Brooks Running...... 914 European Footcare Supply...... 713 Air Force Recruiting Services...... 412 Brymill Cryogenic Systems...... 516 R American Association of Colleges BSN Medical Inc...... 605 F Renewed Nail/Keratone...... 922 of Podiatric Medicine...... 416 RTI Surgical Inc...... 900 American Board of Foot and Ankle Surgery...... 717 C Fight 4 My Feet...... 711 American Board of Podiatric Medicine...... 725 Foot Karma...... 511 American College of Foot and Ankle Surgeons.. 913 California School of Podiatric FootBalance System, Inc...... 822 S American Podiatric Medical Association, Inc...... 623 Medicine at Samuel Merritt University...... 422 Footmaxx...... 823 Samuel Merritt University American Society of Podiatric Dermatology...... 414 Cardiovascular Systems, Inc...... 813 Health Sciences Simulation Center (HSSC)...... 423 American Society CareCredit...... 514 G Sarapin-High Chemical Company...... 827 of Podiatric Medical Assistants...... 427 Crealta Pharmaceuticals...... 804 SIUI America...... 513 Amerx Health Care Corporation...... 608 Good Feet Worldwide...... 916 Smith & Nephew...... 705 Amniox Medical...... 716 D SOLS Systems, Inc...... 812 Anacor Pharmaceuticals Inc...... 409 Spenco Medical Corporation...... 619 ASICS America Corporation...... 800 Derma Sciences...... 405 Saturday, July 26, 2014 The National Today • APMA Annual Scientific Meeting 15

SYMPOSIUM ing patients during her presentation, “The About 85 percent of all diabetes-related Continued from page 1 Physiology of Dermatological Conditions lower extremity amputations are preceded in Diabetes.” by foot ulcers steroids is a new classification scheme with Research shows that optimal glycemic Foot ulcers are a major complication in SteriShoe by Shoe Care Innovations, Inc...... 609 four classes, down from the seven or five control greatly decreases the risk for the patients with diabetes and remain one of Stryker Foot and Ankle...... 408 classes that used to be followed. development of chronic sequelae of diabe- the most common causes for hospitaliza- Superfeet Worldwide Inc...... 529 “My approach is to have just one drug tes, including macrovascular disease and tion and the high costs associated with this Support the Foot...... 614 SureFit...... 610 for each of the four classes so you only its complications, she said. Every 1 percent disease, she said. Swede-O, Inc...... 523 have to remember four drugs. This is a reduction in A1C levels is associated with The latest guidelines for treatment of pa- new concept not talked about much,” Dr. a 36-percent reduction in microvascular tients with diabetes stress the importance T Dockery said. complications and a 16-percent reduction of a multidisciplinary team, including He also recommended showing patients in macrovascular complications. infectious disease specialists, podiatrists, Televere Systems/TigerView...... 729 The Tetra Corporation...... 509 the “fingertip unit” as the correct amount The lack of any comprehensive podiatry surgeons, and orthopedists, in providing Timberland PRO...... 527 of corticosteroid to apply. The patient service in most countries is a major barrier optimal care for this widespread problem, should squeeze a line of medicine the to improved care of people with diabe- she said. U length of the index finger—the bigger the tes, said Dr. Rahnema, director of Valley Dr. Rahnema discussed new directions person, the longer the index finger. Endocrinology, Las Vegas. in the management of patients with type 2 U.S. Jaclean, Inc...... 708 Universal Imaging...... 504 The American Diabetes Association has diabetes, including: Upsher-Smith Laboratories, Inc...... 809 Podiatry a Key in Controlling stated that podiatrists play a key role in • a focus on earlier diagnosis, such as US Wound Registry...... 426 Effects of Diabetes providing appropriate foot care for people monitoring A1C levels; The latest National Diabetes Statistic with diabetes and that a person with diabe- • earlier, more intensive interventions, V Report said that 9.3 percent of the US tes should have an annual comprehensive including multiple drugs; Valeant Pharmaceuticals North America LLC..... 613 population—29.1 million people—had diabetic foot examination by a podiatrist. • focusing on treat-to-goal, not treat-to- Vasamed, Inc...... 611 diabetes in 2012, and more than one-quar- Depending on the findings on the compre- failure; VIONIC with Orthaheel Technology...... 908 ter of them will have foot ulcers, which hensive diabetic foot examination based • a greater emphasis on weight control illustrates the important role podiatric on the risk status of the person, a regular and using treatments that avoid weight W physicians must play in controlling the schedule of foot care should be established. gain; Western University of Health effects of this epidemic. More than 8,000 amputations are per- • greater individualization of therapy; and Sciences-College of Podiatric Medicine...... 424 Fariba Rahnema, MD, discussed the formed on patients with diabetes each year • focusing on reducing complications/ Wright Medical Technology...... 515 latest treatment advances for patients with in the US, and almost 50 percent of ampu- costs through more rigor in perfor- diabetes and the role of podiatry in treat- tations are preventable, Dr. Rahnema said. mance assessment.

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