January 2014

Can Subthreshold Depression Put Patients With Diabetes At Risk For Poor Health Outcomes?

By Brian McCurdy, Senior Editor

A recent study in Diabetes Care suggests that subthreshold depressive episodes are a risk factor for poor health outcomes for patients with diabetes and early monitoring of depressive symptoms may lead to better functioning and quality of life.

   The study focused on 1,064 patients. Five yearly assessments between 2008 and 2013 revealed that almost half of the patients experienced at least one episode of subthreshold depressive symptoms. After adjusting for potentially confounding factors, the study notes that for those with four subthreshold depressive episodes, the risk of poor functioning/impaired health related quality was almost three times higher in comparison to people with no or minimal depression.

   Saying there is “absolutely no doubt” that depression is associated with diabetes, Kathleen Satterfield, DPM, says those who are newly diagnosed with diabetes will face many of the realities that cancer patients face. The diagnosis of diabetes, she notes, is going to change everything in that patient’s life, such as traditional family gatherings with fatty holiday foods and birthdays with ice cream.

   “In a very real sense, they feel like outsiders in their own lives,” says Dr. Satterfield, an Associate Professor/Assistant Dean of Pre-Clinical Education and Outcomes Assessment in the College of Podiatric Medicine at the Western University of Health Sciences. “My patients told me this time and time again in their own way. Life isn’t as fun anymore. Trying to decide how to eat is now work. Many had never been active before and their friends and family aren’t too interested in taking up a new activity either. So they are facing this alone. How depressing is that?”

   Andrew Rice, DPM, concurs, saying multiple comorbidities, longstanding illness, a feeling of helplessness or fear of losing employment due to long disability periods from the complications of diabetes can contribute to or may exacerbate depression.

   When choosing medications, Dr. Rice suggests avoiding those medications that may worsen depression, and particularly when treating neuropathy, one should use medications that may have a positive effect to reduce depressive symptoms. Aside from making referrals to mental health professionals, Dr. Rice, an Assistant Clinical Professor in the Department of Orthopaedics and Rehabilitation at the Yale University School of Medicine, suggests podiatric physicians be empathetic and alert family to assist. Dr. Satterfield also suggests getting the help of office staff and nurses to speak to patients and find out how they feel.

   Dr. Satterfield recalls that when she practiced at the Texas Diabetes Institute in San Antonio, there was an outstanding amputee support group that the patients ran with support from her nurse case manager, Sabrina Shoe, and the podiatric residents who rotated through the clinic.

   “One patient told the others a story about slipping out of his prosthetic limb while he was at the grocery store, pushing his cart. He took a step before he realized what had happened. Only his support group members could share in that embarrassment and really understand how a person would feel,” says Dr. Satterfield.

   What red flags for depression should podiatric physicians look for in patients with diabetes? Dr. Satterfield suggests looking for a patient who doesn’t follow instructions and appears unkempt. Both she and Dr. Rice note other red flags are those who are uncommunicative or have sleep disturbances.

CMS Offers Wider Reimbursement For Single-Use NPWT Systems

By Danielle Chicano, Editorial Associate

The Centers for Medicare and Medicaid Services (CMS) recently issued new rules that include increased reimbursement and the new use of a level II HCPCS code for single-use/pocket-sized negative pressure wound therapy (NPWT) system.

   The final rules incorporate an increase in mean reimbursement from $209 in 2013 to $276 in 2014, according to the CMS. The increase in existing reimbursement applies to the Ambulatory Payment Classification 0016 and HCPCS G-codes. The CMS announced that these new rules were effective beginning on January 1, 2014.

   Kazu Suzuki, DPM, CWS, is pleased with the ruling and hopeful about what this could mean for future single-use NPWT system implementation.

   “It is rather rare to get an increase in reimbursement in anything in today’s healthcare climate,” explains Dr. Suzuki. “I’m hoping that this reimbursement increase will facilitate faster implementation of these single-use NPWT systems as the treatment cost is one of the major factors in using disposable medical devices.”

   In his practice, Dr. Suzuki says he regularly uses both the PICO (Smith & Nephew) and SNaP (Spiracur) single-use NPWT systems. Additionally, he sometimes uses Prevena (KCI) for incisions and notes that patients have given positive feedback for this device in terms of comfort.

   Dr. Suzuki mainly uses single-use NPWT systems on elderly patients who may find traditional NPWT “too heavy and cumbersome.”

   “(The single-use NPWT system) is a nice alternative for traditional battery-operated NPWT, which is sometimes too heavy for some of my frail and elderly patients,” adds Dr. Suzuki, the Medical Director of the Tower Wound Care Center at the Cedars-Sinai Medical Towers in Los Angeles.

   Dr. Suzuki will also utilize the single use device as a transition between VAC therapy and a conventional wound dressing. However, the single-use devices are somewhat limited in their draining suction capacity in comparison to larger NPWT devices, explains Dr. Suzuki.

   According to Dr. Suzuki, when using single-use NPWT systems over traditional battery-operated NPWT systems, practitioners will need to purchase single use units ahead of time and keep them on stock in their facility. Secondly, Dr. Suzuki notes that one must change the single-use NPWT systems once or twice a week, which differs from traditional battery-operated systems that require changing three times per week.

   “I was hesitant and skeptical at first, but I found out quickly that single-use NPWT work just as well as the battery-operated NPWT. The ‘negative pressure (suction force)’ is all the same, regardless of the manufacturer,” adds Dr. Suzuki.

Can Hallux Valgus Surgery Improve Balance And Gait In Older Patients?

By Brian McCurdy, Senior Editor

A new study in the Journal of the American Podiatric Medical Association has concluded that in older patients, hallux valgus surgery may have positive effects on gait and balance.

   Researchers obtained gait and static balance data from 40 adults. There were 19 patients with preoperative hallux valgus, 10 patients who recently had successful hallux valgus surgery and 11 control participants. Authors note that despite similar age and body mass index, post-op patients exhibited 29 percent and 63 percent less center of mass sway during double-and single-support balance assessments respectively in comparison with pre-op patients. The patients’ overall gait performance was similar among the groups, except that post-op patients experienced lower speed during gait initiation in comparison with the preoperative group.

   Study co-author Lowell Weil Jr., DPM, FACFAS, notes that the study population consisted of older adults so researchers are not necessarily certain how bunion surgery will affect balance control in those over 65. He says the mean age for the hallux valgus post-op group was 50 ± 9.4.

   “We are not advocating bunion surgery for the sole purpose of restoring or improving balance,” clarifies Dr. Weil, the President of the Weil Foot and Ankle Institute. “The indications for bunion surgery, we believe, should still be foot pain and the inability to ambulate productively and/or comfortably regardless of patient age.”

   Dr. Weil and co-authors Adam Fleischer, DPM, and Erin Klein, DPM, say the study provides preliminary evidence supporting the secondary benefits that patients may experience following hallux valgus surgery. With further supportive evidence, Dr. Weil foresees providers and patients being more inclined in the future to “pull the trigger” and perform hallux valgus corrective surgery for patients who have demonstrated a fall risk (such as a fall within the past year) when DPMs believe the painful bunion is contributing appreciably to this elevated risk.

   Dr. Weil notes that researchers performed a scarf bunionectomy in the study so their results may not necessarily apply generally to all forms of bunionectomy correction. However, he and his co-authors feel any first ray procedure that realigns the first metatarsophalangeal joint (MPJ), promotes or improves upon first MPJ range of motion, reduces foot pain, and/or improves tactile sensation of the foot and/or proprioceptive feedback may potentially improve static balance in patients.

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