VA Provider Equity Act Passes House Of Representatives
The VA Provider Equity Act would make podiatrists eligible for the same supervisory positions in the VA as other physicians. As this issue went to press, the bill, sponsored by Ohio Rep. Brad Wenstrup, DPM, in the House of Representatives, had been referred to the Senate Committee on Veterans Affairs.
Passage of the act would put podiatrists into the same category as other physicians and surgeons in the VA system, notes Matthew Garoufalis, DPM, FASPS.
“Podiatrists have, for a very long time, done the same thing for their patients that other physicians and surgeons have done in terms of writing orders, prescribing a full range of medications, submitting consults to other providers, doing surgery and seeing patients in clinics,” says Dr. Garoufalis, a Past President of the American Podiatric Medical Association (APMA), who is in private practice in Chicago. “Podiatry clinics are among the busiest in the VA system. Parity in this system is long overdue.”
Both Dr. Garoufalis and Patrick DeHeer, DPM, FASPS, say the VA Provider Equity Act would improve the recruitment and retention of podiatric physicians in the VA. For veterans, both say the act would increase access to lower extremity healthcare, equating to shorter wait times for patients to see a provider.
“This is particularly important for at-risk patients, such as diabetic and peripheral arterial disease patients,” says Dr. DeHeer, the Chairman of the APMA Legislative Committee. “The literature is crystal clear that preventative care is preferred to pathology treatment but also treating a pathological condition (diabetic foot ulcer, for example) sooner rather than later is critical for optimal patient outcomes. Podiatric services are currently one of the most outsourced specialty services within the VA system, resulting in increased cost to the system.”
In addition, the act will ensure a raised pay grade for podiatric physicians, whose VA compensation package (including basic pay and locality rate adjustments) has remained unchanged since 1976, according to Dr. DeHeer. He adds the raise may have a positive ripple effect for podiatrists in general. Dr. DeHeer maintains that podiatric physicians are frequently excluded from programs that provide such workforce development incentives as performance bonuses, loan repayment and scholarship opportunities within the VA system, but the VA Provider Equity Act would open up such opportunities to DPMs.
The bill would also open up leadership roles to podiatric physicians that were previously reserved for “physicians,” notes Dr. DeHeer.
“This increase in opportunities for career advancement is representative of the increased education, training and experience of today’s podiatrists,” adds Dr. DeHeer, who is in private practice in Indianapolis.
In July, the APMA noted the American Academy of Orthopaedic Surgeons (AAOS) and American Orthopaedic Foot and Ankle Society (AOFAS) indicated their support of the bill. Dr. DeHeer says the APMA’s Legislative Department and Committee are “cautiously optimistic” about the Senate passing the act this session, mostly due to the AAOS/AOFAS letter of support. He notes APMA President Ira Kraus, DPM, “worked tirelessly with AAOS/AOFAS to build relationships that resulted in this support.” Dr. DeHeer salutes Dr. Kraus, Dr. Wenstrup, Benjamin Wallner, the APMA’s Director of Legislative Advocacy, and the APMA Political Action Committee.
“We will need every podiatric physician to call their senators asking for their support of the bill once it is introduced the senate,” says Dr. DeHeer. “Grassroots activism will ultimately lead to monumental victory for the profession.”
What Is The Most Specific Method Of Osteomyelitis Detection?
By Brian McCurdy, Managing Editor
A new review in Diabetes Care finds that fluorodeoxyglucose positron emission tomography (18F-FDG–PET) and 99mTc-hexamethylpropyleneamine oxime (HMPAO)-labeled white blood cell (WBC) scintigraphy had the highest specificity among the modalities studied to detect osteomyelitis.
The review selected 27 full articles and two posters for analysis. Authors noted the following performance characteristics of the various diagnostic modalities: 18F-FDG–PET had an 89 percent sensitivity and a 92 percent specificity, WBC scan with 111In-oxine had a 92 percent sensitivity and a 75 percent specificity, WBC scan with 99mTc-HMPAO had a 91 percent sensitivity and 92 percent specificity, and magnetic resonance imaging (MRI) had a 93 percent sensitivity and a 75 percent specificity.
Molly Judge, DPM, cites advantages of 18F-FDG–PET, including its high sensitivity and high resolution. However, Dr. Judge notes that the test is not widely available (especially for osteomyelitis).
One would use 18F-FDG–PET in university hospitals or research centers, according to Dr. Judge, who is in private practice at North West Ohio Foot and Ankle Institute and an adjunct faculty member at Ohio University and the Kent State University College of Podiatric Medicine. She says the test is principally for tumors in the study of metastatic disease.
Dr. Judge says 99mTc-HMPAO–labeled WBC scintigraphy is effective to diagnose acute infection issues when there is little time for study before performing an incision and drainage. She says this test takes 24 hours to attain results and the half-life of technetium (six hours) is desirable.
However, with 99mTc-HMPAO, Dr. Judge says the target to background ratio is lacking so resolution is not perfect, especially when dealing with very small lower extremity bones. In patients who are neutropenic or otherwise immune-compromised, she notes white cell margination is slower and therefore the half-life of this radio isotope is not optimal.
Dr. Judge says technetium has 140 KeV gamma rays of emission with a half life of six hours versus 18F-FDG–PET, with a half-life of 118 minutes. However, she cautions that 18F-FDG–PET is an alpha emitter, which imparts a higher radiation dose. When using CT in combination with 18F-FDG–PET, she notes the CT scan contributes between 54 and 81 percent of the total combined radiation dose.
The average dose of 18F-FDG–PET is 370 MBq and in combination with a diagnostic CT protocol, Dr. Judge says this results in a dose of 32.18 millisieverts (mSv). She explains the whole body PET/CT radiation dose has a substantial risk/benefit ratio in the patient’s favor when evaluating for cancer staging and restaging.
Study: Lasers And ESWT Better Than Ultrasound For Plantar Fasciitis
By Brian McCurdy, Managing Editor
A recent randomized trial in the Journal of Foot and Ankle Surgery finds that lasers and extracorporeal shockwave therapy (ESWT) are superior to ultrasound in treating heel pain.
The study compared low-level laser therapy, therapeutic ultrasound therapy and ESWT using magnetic resonance imaging (MRI) in 60 patients. Authors evaluated patients with measures such as the visual analog scale (VAS), heel tenderness index, American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score, Roles-Maudsley score and MRI with one-month follow-up. The study notes success rates of 70.6 percent in the laser group, 65 percent in the ESWT group and 23.5 percent in the ultrasound group.
Jeffrey Ross, DPM, MD, FACFAS, says his results with ESWT are pretty close to the results the study achieved as he cites approximately 60 percent success in patients with plantar fasciitis.
“It’s a good intervention but not a sure bet,” he says of ESWT. “It works well for some and not for all. I believe the thicker the plantar fascia (from 2 mm to 10 mm), the less positive the results. But for patients who have attempted a variety of modalities and have failed, ESWT is a very viable alternative.”
Although Dr. Ross has not had much experience with laser treatment for plantar fasciitis, he cites colleagues who have had success with the modality.
Ultrasound is helpful but “not a significant intervention for chronic plantar fasciitis,” says Dr. Ross, an Associate Professor at Baylor College of Medicine. He says ultrasound helps with decreasing scar tissue and adhesion formation, and improving blood supply. Although it is a good adjunct treatment, Dr. Ross says ultrasound treatment is “by no means a cure.”
Dr. Ross cites success in treating chronic plantar fasciitis patients with platelet rich plasma and amnion stem cells. His results with PRP were at least as good as the results in the study and maintains that stem cells “seem to have even better results at this early stage” in his experience.