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 infec- tion,” 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 conserva- tive 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