PRESENT Facilitates International Exchange Of Education And Experience

By Brian McCurdy, Associate Editor

   Podology in Spain has evolved from a subspecialty of nursing into its own undergrad degree. As a result, Juan Goez, DPM, says the profession is undergoing the same “growing pains” that American podiatry suffered in the 1960s and ‘70s. As the profession grows, PRESENT (Podiatric Residency Education Services Network) Courseware, an online provider of lecture content to U.S. podiatric residency programs, is expanding its series of lectures into Spain to provide podologists with insights into the medical and surgical experience of American DPMs.     “I have found that our Spanish colleagues have a high standard of care for their patients,” notes Dr. Goez, the PRESENT Español International Editor. “They are always trying to improve and increase their knowledge base and skills by participating in continuing medical education programs.”    Podologists receive three years of undergrad training as opposed to the approximate 10 years of training of U.S. podiatrists, notes Alan Sherman, DPM, Chief Executive Officer of PRESENT. He notes the practice of Spanish DPs (Diplomado en Podologia) is mostly unregulated and many are performing elaborate surgery and trauma care as American podiatrists did in the 1960s and ‘70s when they could not get on hospital staffs.     “The standards of education and practice as it refers to the podologist, although different in Spain, require the same base knowledge of medicine and surgery,” says Dr. Goez. “This is what makes PRESENT Español so valuable to the Spanish podologist.”    Speakers from various podiatric colleges in the U.S. have been providing training lectures in Spain for a few years but Dr. Sherman notes the process of translating their lectures into Spanish simultaneously was not efficient. PRESENT organizers tackled the challenge of translating English lectures into Castillian Spanish and Dr. Goez emphasizes that the academic value of the lectures has not been lost in translation.    Vincent Hetherington, DPM, Dean of the Ohio College of Podiatric Medicine, who has been well known to DPs, has helped tailor lectures to the Spanish market. In addition to providing educational opportunities, Dr. Hetherington says PRESENT Español facilitates greater interaction between American DPMs and Spanish DPs through its self-directed Internet programs. He says PRESENT will develop “a readily available, broad-based resource of educational programming for all podologists throughout Spain.”

What The Future Holds

   As DPs learn from the American body of knowledge, DPMs may learn a few things from their Spanish counterparts as well. Dr. Goez says PRESENT Español aims to solicit the perspectives of foot medicine and surgery of Spanish podology leaders and share such knowledge with foot specialists throughout the world. When Dr. Goez began working with DPs in 1991, he found these nurses/podologists had a broad range of medical and surgical experience.     “They brought this knowledge into their practices and there were many different ideas as to how to treat foot maladies or how to select surgical procedures,” notes Dr. Goez.    Dr. Sherman says PRESENT is working to bring the program to Great Britain and Canada.     “We believe PRESENT Courseware will change the international foot care world, helping to equalize the playing field among countries much the way it helped equalize the training in U.S. podiatric residency programs,” says Dr. Sherman.

Can Surveillance Of Drug-Resistant Infections Have An Impact?

By Brian McCurdy, Associate Editor    With the continually rising prevalence of multidrug-resistant infections acquired in the hospital and those acquired in the community, identifying those at risk for infection can go a long way toward facilitating appropriate treatment. A recent study in Clinical Infectious Diseases emphasized that community surveillance may aid clinicians in choosing empiric antibiotic therapy.    The study involved a three-year prospective surveillance of community-acquired Staph aureus infections among children at Texas Children’s Hospital. Researchers discovered the percentage of methicillin-resistant S. aureus (MRSA) infections increased from 71.5 percent to 76.4 percent during the three years. While the researchers reported yearly increases in community-acquired MRSA isolates and community-acquired methicillin-susceptible Staph aureus (MSSA) isolates, they found a greater rate of increase among the MRSA isolates.    Researchers recommended community surveillance of S. aureus infections to determine the appropriate empiric antibiotic treatment. Such surveillance is of use only if one uses the results to guide therapeutic choices, says Benjamin Lipsky, MD, a Professor of Medicine at the University of Washington School of Medicine.    For example, he says if one knows the percentage of S. aureus isolates that are resistant to methicillin exceeds a certain threshold, one may consider empiric therapy directed at MRSA for an infection that likely has a staphylococcal etiology. Although there are varying opinions on the threshold of MRSA isolates, many set it at 20 to 30 percent, notes Dr. Lipsky, a Fellow of the Infectious Diseases Society of America.     “Certainly, the more serious the infection, the more likely a clinician would feel the need for empiric therapy to cover MRSA, pending the results of culture and sensitivity,” says Dr. Lipsky, the Director of the General Internal Medicine Clinic and Head of the Antibiotic Research Clinic of the VA Puget Sound Health Care System in Seattle.    Dr. Lipsky adds that community surveillance of these infections may also help prevent overuse of antibiotic agents.     “If specific demographic or clinical features help predict which patients are more or less likely to have MRSA as the cause of their infection, this would help constrain excessive use of these agents, thus reducing the risk of developing resistance to these agents as well,” notes Dr. Lipsky.    When it comes to types of surveillance for reviewing MRSA infections, Dr. Lipsky suggests looking at factors like the clinical syndrome, anatomic area, ward or service. At his facility, Dr. Lipsky says the staff has determined there are more nosocomial MRSA infections than community-acquired strains, and adds that more MRSA infections are acquired in intensive care as opposed to the regular wards.

What The IDSA Guidelines Recommend

   Dr. Lipsky co-authored the Infectious Diseases Society of America (IDSA) Diabetic Foot Infection Guidelines that were published last year (also see “A Closer Look At Diabetic Foot Infections” on page 56). As per the IDSA guidelines, Dr. Lipsky says the following recommendations would be effective.    • Culture most infections but not clinically uninfected wounds. Dr. Lipsky says this is the only way to know the pathogens and their sensitivities in the infected site.    • When treating empirically, use relatively broad-spectrum agents tailored to the demographic, clinical and any culture information available.    • Treat with the narrowest spectrum agent appropriate after culture and sensitivity results are available.    • Treat only long enough to control the signs and symptoms of infection, not until the wound is healed. Limit the duration of treatment according to the recommendations.

Physician Program Urges Multidisciplinary Effort For Diabetes

By Brian McCurdy, Associate Editor    Podiatrists have long emphasized that it takes a multidisciplinary team effort to manage patients with diabetes. To this end, the American College of Physicians recently launched a $10 million project to provide education tools for patients with diabetes and the physicians who treat them.    At the end of the three-year project, reportedly the largest of its kind, the college will analyze data, which it hopes will show an improvement in treatment outcomes, according to    Engaging the entire medical team in treating diabetes is vital, says David G. Armstrong, DPM, MSc, PhD, a member of the National Board of Directors of the American Diabetes Association. He emphasizes better communication among specialists.     “The specific step I would take is to ensure that all members are speaking the same language in regard to risk,” says Dr. Armstrong, a Professor of Surgery, Chair of Research and Assistant Dean of the William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science. “Whether this is cardiovascular, amputation, ulcer, retinal or renal risk, the issues are the same. All clinicians should know where their patients stand on these various spectra. If they don’t, then the team is not working as well as it could.”    Both Dr. Armstrong and Lawrence Harkless, DPM, participated several months ago in a roundtable discussion of diabetes care, along with practitioners from various medical specialties, at the Diabetic Foot Global Conference 2005 (DFCON05), which Dr. Armstrong chairs. Dr. Harkless agrees DPMs are vital in treating the systemic disease of diabetes.     “The foot can tell you what is going on in the entire body as related to blood flow,” says Dr. Harkless, the Louis T. Bogy Professor of Podiatric Medicine and Surgery at the University of Texas Health Science Center at San Antonio.

Raising Pertinent Questions

   The ACP meeting acknowledged that many experts are more aggressive in treating patients with poor control of diabetes but treat those with well-controlled diabetes like non-diabetics. Doctors also questioned what special measures non-podiatric physicians should take when treating those with well-controlled diabetes.    Dr. Armstrong says being an effective triage agent is key in treating such a patient population. He says it important to ensure other members of the multidisciplinary team follow up on these patients.    Doctors at the ACP session also asked how to treat those with impaired glucose tolerance or pre-diabetes. Dr. Harkless, Director of the Residency Training Program at the University of Texas, urges physicians to emphasize lifestyle, self-management changes, diet and exercise. For many with impaired glucose tolerance or pre-diabetes, Dr. Harkless says it is a “short timeline to developing diabetes.”

New Legislation May Prevent Cuts In Medicare Reimbursement

By Brian McCurdy, Associate Editor    The House and Senate have each introduced bills that aim to stave off projected cuts in Medicare reimbursement for physicians. Congress had enacted a temporary reprieve in cuts over the last several years but doctors had feared cuts beginning in 2006 unless the government acted (see “Will Medicare Slash Reimbursement In 2006?,” page 6, May issue).    House Bill 2356 and Senate Bill 1081 each would update the Medicare single conversion factor for next year by no less than 2.7 percent. The bills provide a formula to update for physician services for 2007, including the establishment of an input price index and a productivity adjustment factor.    The Medicare funding system is based on the complex sustainable growth rate and unless issues with the rate are resolved, Lloyd Smith, DPM, feels there will not be a permanent solution to thwart potential reimbursement cuts in the future.    The Centers for Medicare and Medicaid Services could fix some of the funding issues by removing the costs of drugs from the physician payment formula, as some groups have advocated, according to Dr. Smith, the Immediate Past President of the American Podiatric Medical Association.     “Physicians will not continue to participate in Medicare if this issue is not solved,” says Dr. Smith. “If we see several years of fee reductions, the system will be in total crisis. I foresee Congress doing something this year but, once again, it will probably only be a temporary fix.”

In Brief

Organogenesis announces that Apligraf® now has a 10-day shelf life. The company says DPMs may use its Standing Order Program to have Apligraf on hand for patients when needed. • Healthpoint has announced the launch of, an online resource for accredited wound care education for physicians and non-physician clinicians.

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