January 2011

Are Silver Dressings Worth The Expense?

By Brian McCurdy, Senior Editor

While there are a fair number of wound dressings that utilize the antibacterial properties of silver, a new study in Advances in Skin and Wound Care suggests the only difference between silver dressings and a less expensive gauze dressing may be the cost.

   Researchers compared the antimicrobial effects of AmeriGel Hydrogel Saturated Gauze Dressing (Amerx Healthcare), which contains Oakin, with three silver dressings: Acticoat 7 (Smith and Nephew), Aquacel Ag (Convatec) and Prisma (Systagenix Wound Management). The control was a sterile gauze pad.

   The study authors used an in-vitro corrected zone of inhibition (CZOI) test to measure the antibacterial properties of the dressings. This involved the placement of 1 cm2 strips of these dressings on bacterial cultures of Staphylococcus aureus, methicillin resistant S. aureus (MRSA) and Pseudomonas aeruginosa.

   The study determined there were no substantial differences in the CZOI among the four dressings. The authors suggest that “the biggest differences between many antimicrobial dressings on the market may be more in cost than in antimicrobial efficacy.” The study cites a per application cost of $2.74 for AmeriGel in comparison to $9.70 for Aquacel Ag, $16.39 for Prisma and $33.53 for Acticoat 7.

   While lead study author Jonathan Moore, DPM, MS, does not advocate AmeriGel as a “catchall” dressing, he feels the product can hydrate wounds and its antimicrobial barrier is comparable to silver dressings.

    “(AmeriGel) is an excellent case in point regarding how we often have a ‘knee-jerk’ reaction to choosing wound care products,” says Dr. Moore. “We limit ourselves to products that often have the biggest marketing budgets or products that have the familiar brand names. While there is nothing wrong with using these types of products when they are indicated, we often may not consider other lesser known products from smaller companies.”

   Dr. Moore cautions that AmeriGel would not be indicated in wounds that have exudate or wounds with any substantial depth. Although he does use Prisma, Silvercel and other silver antimicrobial dressings, he cautions that these dressings are often not the best options for many types of ulcerations that need antimicrobial properties.

    “Choosing the wrong dressing at the wrong time can lead to increased wound care costs and slower healing times,” notes Dr. Moore, a member of the Adjunct Faculty of the Ohio College of Podiatric Medicine.

   As Kazu Suzuki, DPM, CWS, notes, the study’s dressing comparisons are not 100 percent equal as authors compared several dressing types: contact layer (Acticoat 7); hydrofiber (Aquacel Ag); a blend of collagen, cellulose and silver (Prisma) and hydrogel impregnated gauze (AmeriGel). Dr. Suzuki does note the validity of the authors’ cost analysis and “real life” impact on running wound clinics. While Dr. Suzuki says it does make sense from a business standpoint to use the least expensive dressing, he does note some caveats.

    “It is probably premature to say that the cheapest antimicrobial product (in this case the AmeriGel product) would supersede all the other products mentioned here,” says Dr. Suzuki, the Medical Director of Tower Wound Care Center at the Cedars-Sinai Medical Towers in Los Angeles. “In reality, one would want to match the wound size, location and, most importantly, drainage amount to choose the most appropriate dressing type, with or without an antimicrobial agent.”

Study Notes Link Between Plantar Fasciitis And Limb Length Discrepancy

By Brian McCurdy, Senior Editor

A recent study in the Journal of the American Podiatric Medical Association draws a correlation between limb length discrepancy (LLD) and plantar fasciitis.

   Researchers evaluated 26 patients and measured them for limb length discrepancy from the anterior superior iliac spine to the medial malleolus and from the umbilicus to the medial malleolus, and performed the block test. The study authors also assessed body mass index (BMI) for all patients.

   Seven patients who had a longer left limb had plantar fascia pain in the left foot while 14 patients who had a longer right limb had plantar fasciitis in the right foot, according to the study. The researchers conclude there is enough evidence to support a link between the location of pain and a longer limb, but not enough evidence to link pain with BMI.

   In his practice, David Levine, DPM, CPed, has seen a relationship between plantar fasciitis and LLD, but says it is not present in all cases of those with LLD. Although patients may contract plantar fasciitis from overuse, poor shoe selection, excessively worn out shoes and other factors, he notes the mechanical etiology of plantar fasciitis “seems to be well established.” Dr. Levine says limb asymmetry is definitely a contributing factor to plantar fasciitis and notes this is particularly true in patients who struggle with chronic plantar fasciitis or those with chronic foot, knee and hip complaints and back pain on one side.

   Effective treatment of LLD begins with taking a history of the complaint and performing a subsequent biomechanical exam of the entire body including posture, according to Dr. Levine, who is in private practice and is also the director and owner of Walkright in Frederick, Md. For patients with either a recurring pattern or associated complaints, he says physicians can gain additional insight from gait analysis, using video and pressure mapping.

Assessing The Security And Malpractice Risks Of EHRs

By Brian McCurdy, Senior Editor

Podiatry practices are increasingly turning toward electronic health records (EHRs) to streamline documentation procedures. However, there are pitfalls to be aware of and a recent article in the New England Journal of Medicine (NEJM) highlights the risk for malpractice liability due to shared electronic technologies.

   As the article notes, some electronic systems share health information about patients via a health information exchange network, which the authors note is becoming more common. The biggest security issue with access to information, says Bruce Werber, DPM, is ensuring all computers, including laptops and iPads, have secure passwords for each employee, adding that staff should not share user names and passwords. He suggests securing computer servers that are in the office and encrypting hard drives in case of theft or vandalism.

   Dr. Werber says doctors must ensure unauthorized personnel do not access patient data. To that end, he recommends using systems that are Web-based so the data is off-site and is the vendor’s responsibility. Along the same lines, offices should use online fax machines or machines that convert faxes to PDFs that only go to specific e-mails. Dr. Werber says this prevents people who are walking by from picking up sensitive faxes.

   Most if not all certified systems have layered security, according to Dr. Werber. He says this provides the administrator the ability to limit which employees have access to certain patient information and also limits the inadvertent disclosure of personal health information. Dr. Werber suggests that employees’ job descriptions document who should have access to which parts of the medical record.

   When it comes to potential malpractice issues, Dr. Werber says it is imperative to customize each note for each patient. He says this shows that one has evaluated the patient and that each note is different and contemporaneous for that specific visit. Similarly, the NEJM article notes the danger of copying and pasting patient histories instead of taking new histories at each visit, saying one might miss new information or perpetuate previous errors.

    “It will be hard to stand up in a malpractice situation if the attorney can show every note is a copy of the one before and there are no specific differences in the chart note to indicate you actually saw the patient on that visit and did a full evaluation,” says Dr. Werber, a Fellow and Past President of the American College of Foot and Ankle Surgeons who is in private practice in Scottsdale, Ariz.

Online Poll: Opinions Split On CPME Residency Changes

By Brian McCurdy, Senior Editor

The podiatry community seems divided over the recent decision by the Council on Podiatric Medical Education’s (CPME) decision to implement a standard three-year residency program.

    Of the 146 people who responded to a Podiatry Today online poll, 42 percent said the residency changes would benefit the profession while another 42 percent said changes would not be beneficial. Another 15 percent said it was too early to tell.

    “I do not believe every podiatrist needs to be a surgeon,” said one commenter. “I do not think that every podiatrist wants to be a surgeon. Not every dentist is forced to be an oral surgeon. There is a great need for non-surgical podiatry. A busy surgical podiatrist hasn’t the time for all the routine foot care. There can be a great referral pattern between the two.”

    “A three-year residency should be the standard,” said another commenter. “Anyone who does not want to become a surgeon should not become a podiatrist. They should look for another profession.”

   For access to more comments for this online poll, visit http://tinyurl.com/29n9gjd . For access to this and other online polls, visit www.podiatrytoday.com/poll.

In Brief

Organogenesis, Inc. announced that Apligraf®, which is FDA approved for the treatment of both diabetic foot ulcers and venous leg ulcers, will have two new procedure codes assigned by the Centers for Medicare and Medicaid Services (CMS) as of January 2011. For more information, see page 32 of this month’s Wound Care Q&A column, “What You Should Know About Skin Grafts And Skin Substitutes.”

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