News From ACFAS

---

Renew your ability to treat the most complex forefoot injuries and deformities in this spring’s ACFAS On the Road program coming to Charlotte April 20–21 and Detroit May 4–5.

Our work “In the Trenches” will begin on Friday night with the presentation, “Controversies and Complications,” followed by a panel discussion during which you can share your own work cases while refreshments are served.

After a series of lectures from expert faculty on Saturday, you will practice your surgical skills in two hands-on sawbones labs on osteotomies and the Big 6 Techniques. Faculty will wrap up the seminar with valuable takeaways you can put to use as soon as you return to the office.

Register now at acfas.org/ontheroad, and watch This Week @ ACFAS for future On the Road dates and locations. Visit the all-new ACFAS Logo Store and show your College pride! New apparel and gifts available in the store include:

• Dress and casual shirts
• Fleece jackets and baseball caps
• Scrubs and surgical caps
• Coffee mugs and water bottles
• Professional pens
• Hoodies, t-shirts, socks and more!
  (Clothing is available in a variety of colors and sizes.)

The ACFAS Logo Store is a 24/7 one-stop shop. Visit anytime to check out all the new products, make your purchases and provide payment. Be the first of your colleagues to show off your pride in YOUR professional association! If you could not make it to the fifth annual ACFAS Job Fair in Nashville, you can still take advantage of the Job Fair virtually. Visit PodiatryCareers.org to post your resume online, view available jobs in your area or take advantage of ACFAS member discounts to post positions you are trying to fill.

Next year's Job Fair at ACFAS 2019 in New Orleans will include everything you have come to expect, including expanded time with a professional resume reviewer. Watch for more details on how to participate as the event gets closer.

Foot and Ankle Surgery

---

A study was conducted in which the carbon-14 ([14C]) bomb pulse method was used to measure lifelong replacement rates of collagen in tendinopathic and healthy Achilles tendons. The healthy tendon collagen had not been replaced during adulthood, but in a tendinopathic tendon, a substantial renewal had transpired. Modeling of the [14C] data suggested 50 percent of the collagen in tendinopathic matrix had undergone continuous slow turnover for years prior to presentation of symptoms. This finding permits a new concept in tendon pathogenesis by suggesting either the symptoms of tendinopathy represent a late phase of a prolonged disease process, or an abnormally high collagen exchange could be a risk factor for tendon disorders rather than a result of disease.


Researchers conducted this study to explore the differences in longer-term gait outcomes and severity of idiopathic toe walking between children treated actively with casting or inactively following recommendations for stretching. Forty-three adolescents and young adults who participated in an idiopathic toe walking classification study as children returned for repeat physical examination and three-dimensional computerized gait analysis. Meanwhile, 23 participants received active treatment with casting and ankle foot orthotics, and 20 participants received inactive treatment with recommended stretching exercises. Results showed that the ankle angle at initial contact, peak dorsiflexion in stance and toe walking severity improved significantly in the active treatment group only at follow-up. Significant improvement in peak ankle power and timing of ankle kinematics and kinetics in the gait cycle were found in both groups; however, greater changes occurred in the active treatment group. The results of this study suggest that improvement in ankle kinematic timing and ankle kinetic gait analysis variables is sustainable, independent of conservative treatment for idiopathic toe walking in childhood.


A study was conducted to determine surface pH, size and surface temperature in noninfected, neuropathic foot ulcers at baseline and at 12 weeks, with the participation of 50 patients. The mean baseline pH of wounds was 6.95, while temperature was 30.91 degrees Celsius and size was 0.82 square centimeters. After 12 weeks, 26 percent of patients were lost to follow-up, and 50 percent had healed. Of the remaining patients, mean pH was 6.72, temperature was 30.88 degrees Celsius and size was 0.13 square centimeters. Baseline values for pH and temperature of noninfected, neuropathic diabetic and nondiabetic foot ulceration have been furnished, and further studies in a larger cohort are needed to determine if temperature and/or pH are indicative of a healing or nonhealing state.

Practice Management

---

Recently, hospitals and doctor offices have pushed patients to sign up for online portals where they can receive medical information. Supporters say electronic medical records can build patient engagement and improve safety. However, there are challenges to receiving medical information using this method. Patients can receive information that can lead to unneeded concern and more work for doctors. For example, an electronic report with too little information or lacking input from a doctor may cause a patient to misinterpret a medical issue or overreact. Studies show this is more common among patients with low health literacy and numerical skills. Patients could also be exposed to very technical reports and information they can have trouble understanding.


The introduction of electronic health records (EHRs) was intended to reduce medical errors, but the use of EHRs has raised the possibility of new kinds of errors for medical practices. Experts say doctors should keep the following three tips in mind to use EHRs safely: When organizations change vendors or record systems, it is important to carefully monitor EHR data during new installations or upgrades. Employees should also be wary about copying and pasting entries into EHRs. This practice can result in entered data that is not up to date or accurate. Finally, experts warn that overuse of premade templates can lead to record duplication and sometimes events being documented before they actually happen.


Change within a healthcare practice can be a disruptive event. However, when handled correctly, change can lead to success. Experts say identifying change agents within an organization will help a plan for change end successfully. However, these individuals must be given the tools to do their jobs and encourage change. Leadership would also do well to clearly explain to employees why change is happening. This will make it easier for employees to accept and support the changes. Successfully changing an organization will also require strong leadership from all executive officers. Other factors to consider include reviewing plans and maintaining good communication.

Health Policy and Reimbursement

---

The mere threat of Amazon getting into the health business is already affecting the industry. Two of the nation's largest pharmacy benefit managers (PBMs)—CVS Health and Express Scripts—have joined forces with two of the largest insurers, Aetna and Cigna. With Amazon's technological prowess, long investment horizon, bottomless appetite for new business and tolerance for thin margins, its long shadow helped instigate these deals. UnitedHealth Group successfully pioneered a strategy of aggressive diversification by buying a large PBM in 2015 and with its Optum health services unit. All three of the biggest U.S. PBMs will be tied to three of the country's biggest insurers. CVS, Express Scripts and UnitedHealth process more than 70 percent of all U.S. prescriptions. After the merger, three companies will insure more than 90 million people in some capacity, process more than 3.5 billion prescription claims and generate more than $500 billion in revenue. Drugmakers and providers will struggle to negotiate with these new giants. As for consumers, drug and provider options may narrow. Aetna and CVS will want to drive people to its own clinics, as UnitedHealth already does with its own provider network.


The spending plan signed by President Trump includes a record $4.6 billion to fight the opioid crisis in the United States. However, some advocates say much more funding is needed. A 2017 report from the White House estimated the cost to the country of the overdose epidemic was more than $500 billion annually. Former U.S. Rep. Patrick Kennedy—who served on the president's opioid commission last year—said while there are clear solutions, Congress needs to allocate more money to them. "We still have lacked the insight that this is a crisis, a cataclysmic crisis," he said. Of the total funding, $1 billion will be distributed to states and American Indian tribes, $500 million will go to opioid-related research and hundreds of millions more will be used to expand treatment availability. The opioid crisis took the lives of 42,000 Americans in 2016.


During his swearing in ceremony, the new director of the U.S. Centers for Disease Control and Prevention, Robert Redfield Jr., stressed the importance of science and data and said the agency's most important public health mission is to protect Americans "from that which we don't expect." Redfield—a longtime AIDS researcher—became emotional as he spoke about the honor of leading the best "science-based, data-driven agency in the world."

Medicine, Drugs and Devices

---

Medicare's plan to deny payment for long-term, high-dose opioid prescriptions has provoked criticism from many people who would be directly affected by it, including those with chronic pain, primary care physicians and experts in pain management and addiction medicine. The new Medicare rule means Medicare would deny coverage for more than a week of prescriptions equivalent to 90 milligrams or more of morphine daily, except for those with cancer or in hospice. The U.S. Centers for Medicare and Medicaid Services estimates that about 1.6 million persons currently have prescriptions at or above those levels. A Medicare official says the limit for monthly high doses was intended not only to catch overprescribing physicians, but also to monitor people accumulating opioid prescriptions from several doctors. Critics say the regulation could make people who lost access to opioids go into withdrawal or force them to buy dangerous street drugs. "The decision to taper opioids should be based on whether the benefits for pain and function outweigh the harm for that [beneficiary]," argues Albert Einstein College of Medicine Professor Dr. Joanna L. Starrels. "That takes a lot of clinical judgment. It's individualized and nuanced. We can't codify it with an arbitrary threshold."


A new report released by U.S. Sen. Claire McCaskill (D-Mo.) says the costs for each of the 20 most prescribed brand-name drugs for seniors have risen dramatically every year for the past five years. The prices rose by an average of 12 percent every year for five years, nearly 10 times higher than the rate of inflation. A dozen drugs had prices increase by more than half, six had increases of more than 100 percent and one drug's cost soared 477 percent. The drug's maker, Pfizer, refuted that number, saying its price increased 228 percent. In addition, prescriptions for top brand-name drugs fell by 48 million and revenue rose by $8.5 billion over the last five years. "This report demonstrates that the pricing decisions made by these drug companies are outrageous," McCaskill said. In 2013, the latest year for which data was available, prescription drugs comprised nearly $1 in every $5 that Medicare beneficiaries spent out-of-pocket on healthcare services. Democrats are demanding that Medicare negotiate directly with drugmakers on prices, while Republicans want to introduce more generic drugs to boost competition in the market. McCaskill is one of several bipartisan sponsors of legislation to ban "pharmacy gag clauses" that can hide potential savings on prescriptions from consumers at the pharmacy counter.


Between 2000 and 2015, human consumption of antibiotics worldwide soared 65 percent, to 42 billion doses a year, according to a new report in the Proceedings of the National Academy of Sciences. The researchers discovered a dramatic increase in antibiotic use over the last 15 years in low- and middle-income countries, and although Western countries did not experience the sharp rise in antibiotics, they nevertheless failed to reduce overall consumption. Antibiotic use more than doubled in India between 2000 and 2015, spiked 79 percent in China, and rose 65 percent in Pakistan. Some of that increase was due to population growth, but overall sales were also up. Meanwhile, hospitals around the world increasingly have been reporting bacterial infections that do not respond to traditional antibiotics. Health officials worry about the rapid growth in antibiotic use in low- and middle-income countries because these drugs are often available there without a prescription, so the potential for misuse is high.