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This Week's Headlines

News From ACFAS
Foot and Ankle Surgery
Practice Management
Health Policy and Reimbursement
Technology and Device Trends

News From ACFAS

Call to Residency Directors

ACFAS recently sent letters to all residency directors inviting them to reserve pre-paid, guaranteed positions for residents to attend ACFAS Foot and Ankle Arthroscopy Surgical Skills Courses.

These courses have been so popular that openings are filled almost as soon as registration opens. Because of the importance of this course to podiatric surgical residents, ACFAS will work with residencies to make the course available to every in-training resident who wishes to attend.

If you are a residency director and have not yet received your letter of invitation, please contact Maggie Hjelm at the ACFAS headquarters office.
Heel Pain CPG in National Database

The Diagnosis and Treatment of Heel Pain Clinical Practice Guideline is now part of the archive of objective, detailed clinical practice information for physicians and other health professionals on the website of the National Guidelines Clearinghouse.

This update of the CPG originally published in 2001 appeared as a supplement to the May/June 2010 issue of the Journal of Foot & Ankle Surgery. All current ACFAS CPGs are available on the ACFAS website.
Short Takes on Research for Busy Surgeons

Catch up on research in journals you may not usually read with ACFAS’ Scientific Literature Reviews. Article abstracts are tailored for the interests of foot and ankle surgeons by podiatric residents. Current abstracts include:

Lack of Lower Extremity Hair Not a Predictor for Peripheral Arterial Disease, from the Archives of Dermatology.
Reviewed by Rachel Johnson, RN, DPM, OCPM/UHHS Richmond Medical Center.

Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis, from the New England Journal of Medicine.
Reviewed by Patricia Kim, DPM, Beth Israel Deaconess Medical Center.

Browse the latest entries or the entire archive any time at Scientific Literature Reviews.

Foot and Ankle Surgery

Risk Factors for Incision-Healing Complications Following Total Ankle Arthroplasty

The anterior incision used for the insertion of total ankle arthroplasty systems is at high risk for wound complications. Researchers set out to determine who is at risk for the development of these complications. They conducted a retrospective chart review of 106 total ankle arthroplasties. Independent risk variables included age, sex, body-mass index, diabetes, smoking, medications, preoperative diagnosis, implant size, tourniquet time, closure method, and anticoagulation status. Postoperative office notes were reviewed for wound-related complications. Outcomes were divided into three categories: no complications (uncomplicated wound-healing), minor complications (wounds requiring only local care/oral antibiotics), and major complications (requiring a return to the operating room for treatment). The researchers found that when patients who had no complications were compared with those who had minor complications, a history of diabetes was the only variable that was identified as resulting in a significant risk increase. When patients who had no wound complications or minor wound complications were compared with those who had major wound complications, female sex, a history of corticosteroid use, and underlying inflammatory arthritis were all associated with increased risk. Underlying inflammatory arthritis was found to be the only significant risk factor for major wound complications.

From the article of the same title
Journal of Bone and Joint Surgery (American) (09/15/10) Vol. 92, No. 12, P. 2150 Raikin, Steven M.; Kane, Justin; Ciminiello, Michael E.
Web Link - May Require Paid Subscription | Return to Headlines

Use of US in Examination of the Ankle in Children with JIA Found to Be Inadequate

Researchers conducted a prospective comparison of clinical examination of ankle structure with ultrasound (US) findings on 42 children with juvenile idiopathic arthritis (JIA). The clinical and ultrasonographic assessment of 61 swollen/painful ankles was carried out, and accurate clinical examination of the whole ankle joint was executed, focusing on three regions in particular—the tibiotalar joint and medial and lateral tendons. US uncovered no indications of tibiotalar joint effusion in 14 out of 43 ankles considered clinically involved, while tenosynovitis was revealed in 13 ankles out of 31 deemed to be clinically normal. Less than half of the 19 lateral tendons thought to be clinically involved exhibited involvement on US, and extremely poor correspondence was observed comparing the clinical and US scores for the three regions. Just 39 percent of the subtalar joints deemed clinically involved showed abnormality on US, while only two of the 10 ankles with talonavicular US effusion were considered clinically involved. The researchers concluded that clinical evaluation of the ankle in children with JIA was inadequate in identifying the structures involved, and US examination prior to glucocorticoid injection should be considered to improve the outcome.

From "Prospective Evaluation of Clinical and Ultrasound Findings in Ankle Disease in Juvenile Idiopathic Arthritis: Importance of Ankle Ultrasound"
Journal of Rheumatology (09/10) Pascoli, Laura; Wright, Stephen; McAllister, Catherine; et al.

A Pharmacokinetic Analysis of Diclofenac Potassium Soft-Gelatin Capsule in Patients After Bunionectomy

Researchers analyzed the pharmacokinetic properties of the diclofenac potassium liquid-filled soft-gelatin capsule (DPSGC) and compared them with a commercially available oral diclofenac potassium tablet in 53 patients following primary unilateral first metatarsal bunionectomy. They determined that delayed and/or multiple peaks in the diclofenac plasma concentration-time course profiles happened more often with the commercially available oral diclofenac potassium 50-mg tablet than with a ProSorb-D 12.5-mg liquid drug, a DPSGC 25-mg tablet, or a DPSGC 50-mg tablet. DPSGC exhibited faster and more consistent absorption after bunionectomy. These attributes should be beneficial when quick pain relief is desirable.

From the article of the same title
American Journal of Therapeutics (10/10) Vol. 17, No. 5, P. 460 Kowalski, Mark; Stoker, Douglas; Bon, Charles; et al.

Practice Management

Hopkins Shooting Makes Caregivers Aware of Stresses, Vulnerability

The recent shooting at Johns Hopkins has highlighted the importance of communications skills training to help physicians interact with stressed and grieving patients and families. Pat Thomas, associate dean for curriculum at the Johns Hopkins School of Medicine, says medical schools have beefed up their training since the 1990s. "From year one, the whole theme is relationship-centered care. Stopping periodically and checking with the patient, asking, 'How does that sound to you? Is this what you expected?' Even allowing silence so that a patient can process, not talking through," Thomas says. Tone of voice, use of touch, and being in a good location are important too, notes Thomas.

From the article of the same title
USA Today (09/20/10) Marcus, Mary Brophy

The Fading Art of the Physical Exam

Many physicians are abbreviating physical exams or even skipping them altogether and relying on technology instead to determine a patient's state. Stanford Medical School professor Abraham Verghese is leading the charge to restore the physical exam to what he considers its rightful place and bring doctors' skills up to snuff. "I sometimes joke that if you come to our hospital missing a finger, no one will believe you until we get a CAT scan, an MRI and an orthopedic consult," Verghese says. "We just don't trust our senses."

At Stanford, they're trying to reverse the trend. The school's graduates and trainees have to master 25 different bedside exam skills, from palpating a spleen to testing ankle reflexes.

From the article of the same title
National Public Radio (09/20/10) Knox, Richard

Doctors' Notes Go High-Tech

Some physicians are relying on speech-recognition technology to help them maintain better records, especially as the government pushes for more electronic health data. Under the federal stimulus package passed in 2009, the government made it a goal that everyone in the United States have an electronic health record by 2014. This will need to be an ambitious undertaking, given that records for approximately 80 percent of U.S. physicians and 90 percent of hospitals remain on paper.

As this effort is implemented doctors accustomed to writing down notes and transcribing from a tape recorder have not all been quick to adopt the pointing, clicking, and typing required by electronic-medical-record platforms. This is where speech-recognition technology enters the scene, allowing doctors to speak into a computer and have that recording transcribed by voice-recognition software, and then reviewed by the doctor or tidied up by a manual transcriptionist. This can reduce the traditional manual transcription process by days.

From the article of the same title
Wall Street Journal (09/15/10) Cummings, Jennifer
Web Link - May Require Paid Subscription | Return to Headlines

Health Policy and Reimbursement

Federal Health IT Coordinator Completes Nationwide System to Assist Doctors and Hospitals in Switching to Electronic Health Records

David Blumenthal, national coordinator for health information technology, has announced selection of the final Regional Extension Centers (RECs), completing a national system of 62 organizations that will help physicians and healthcare organizations shift from paper-based medical records to electronic health records (EHRs). “The selection of these final awardees means that Regional Extension Centers are now in place in every region of our country to help health providers make the switch from paper-based medical practice to electronic health records,” said Blumenthal. “For primary care physicians and smaller hospitals in particular, the RECs will be an important resource to help meet the challenges of adopting EHRs and using them to deliver better care.”

From the article of the same title
U.S. Department of Health and Human Services (DC) (09/28/10)

GAO Names First Members of Patient-Centered Research Board

The Government Accountability Office (GAO) has announced the appointment of 19 members to the Board of Governors for the new federal board charged with overseeing comparative effectiveness research as mandated under the Patient Protection and Affordable Care Act. The Patient-Centered Outcomes Research Institute will assist patients, clinicians, purchasers, and policymakers in making informed health decisions by using evidence-based medicine. The full list of members can be found here.

From the article of the same title
BNA Health Care Policy Report (09/24/10) Weixel, Nathaniel

Senators Warn Health Insurers on Premium Increases

Senate Finance Committee Chairman Max Baucus (D-Mont.) and Commerce Committee Chairman John Rockefeller (D-W.V.) are demanding more transparency about premium increases from health insurers and warning them against blaming higher rates on a newly passed reform law. The two senators sent letters to WellPoint Inc, UnitedHealth Group Inc, Aetna Inc, Health Care Services Corp., and Cigna Corp. In their letter, the senators said estimates for the new coverage and other provisions from the law taking effect this year call for an increase for health insurance premiums of 1 to 2 percent. "Health insurers should be transparent about the assumptions they use to arrive at their premium increases," the senators wrote. "If an insurer thinks it can blame the enactment of the Affordable Care Act for its rising premiums, it is surely mistaken."

From the article of the same title
Reuters (09/20/10) Krauskopf, Lewis

CMS Announces Partial Code Set Freeze for ICD-9-CM and ICD-10

CMS has announced that due to the magnitude and complexity of the transition to ICD-10 coding system, the agency will implement a partial code set freeze beginning in October. The ICD-10 coding system is scheduled to replace the ICD-9 coding system for medical diagnosis and inpatient hospital procedures on Oct. 1, 2013.

CMS will suspend issuance of regular annual updates to both ICD-9-CM and ICD-10 code sets starting on Oct. 1, 2011. On Oct. 1, 2012, only a limited number of new technologies and disease codes as required by section 503(a) of Pub. L. 108- 173 will be allowed. On Oct. 1, 2013, only a limited number of code updates to ICD-10 code sets will be permitted to capture new technologies and diagnoses as required by section 503(a) of Pub. L. 108-173. There will be no further updates to ICD-9-CM after Oct. 1, 2013, since it will no longer be used for reporting purposes. On Oct. 1, 2014, regular updates will resume to ICD-10 coding.

From the article of the same title

Technology and Device Trends

Stem Cell Applications in Diabetic Charcot Foot and Ankle Reconstructive Surgery

Researchers sought to determine the clinical efficacy and potential use of stem cell derived bone grafting in diabetic Charcot foot surgery and ankle reconstructive surgery. Eleven patients were evaluated retrospectively. Seven patients had undergone diabetic Charcot foot and ankle reconstructive surgery with a multipotential cellular bone matrix for bone remodeling and repair and four patients had not. The mean clinical healing time and radiographic healing times for the graft group versus non-graft group were 4.9 weeks versus 6.7 weeks and 6.4 weeks versus 9.2 weeks, respectively. There were non-unions and/or delayed unions in each group. Inflammatory and immunogenic rejection symptoms were not noted in the graft group. Complications in the graft group were: hardware/external fixation failure (5); non-union (1); and delayed union (2) in graft group patients with tobacco use and renal disease comorbidities. The control group had two non-unions in patients with comorbidities of tobacco use and renal disease.

From the article of the same title
Wounds (09/01/10) No. 9, P. 226

Yale Medical Group Tightens Conflicts Policy

The Yale Medical Group, part of the Yale University School of Medicine, has adopted a new, comprehensive policy to address financial ties to drug and device manufacturers, as well as gifts, meals and other benefits from industry; ghostwriting; samples; consulting; and continuing medical education (CME). "We wanted to upgrade the guidelines to a full-blown policy so that faculty and others understand that these are no longer electives, because the landscape has changed," said Yale Medical Group CEO David Leffell.

Under Yale's new policy, sales reps will be allowed on site by invitation and appointment only, and industry-sponsored CME will be allowed to continue, as will industry-sponsored meals during CME events, as long as rules established by the Accreditation Council on Continuing Medical Education are followed. "Our view is that we continue to respect the role the pharmaceutical industry plays in contributing to and investing in the health of people, and we firmly recognize most innovation in health-related therapies would not be possible without the pharmaceutical industry," said Leffell. "That doesn’t mean they are angels or all medical schools are angelic. But we try to recognize the pharmaceutical industry as an important partner."

From the article of the same title
Pharmalot (09/16/2010) Silverman, Ed

CT-TOMASD Provides Precise 3D Measurements of Subchondral BMD

Researchers have developed a depth-specific topographic mapping technique, known as computed tomography topographic mapping of subchondral density (CT-TOMASD), for the 3D assessment of subchondral cortical and trabecular bone density in normal and osteoarthritic (OA) human tibiae. Their tests of this new technique found that CT-TOMASD provided precise 3D measurements of subchondral bone mineral density (BMD). For this reason, they believe the technique has the potential to identify and quantify changes in subchondral BMD associated with OA in vivo. The study involved 14 patients categorized as normal or OA. Each participant was scanned using clinical quantitative CT (QCT) three times over two days. Researchers assessed average subchondral bone mineral density (BMD) across three layers measured in relation to depth from the subchondral surface. Regional analyses included: medial plateau BMD; lateral plateau BMD; anterior/central/posterior compartment BMD; medial:lateral (M:L) BMD ratio; and average BMD of a 10-mm diameter “focal spot,” which searched each medial and lateral plateau for the highest focal densities present within each plateau. Precision was assessed using root mean square coefficients of variation (CV%RMS) and intraclass correlation coefficients (ICC). Average CV%RMS precision errors for BMD measures were 2.3 percent, reaching a maximum CV%RMS of 3.9 percent. ICC showed high repeatability above 0.98.

From "In Vivo Precision of a Depth-Specific Topographic Mapping Technique ..."
Skeletal Radiology (09/10) Johnston, James D.; McLennan, Christine E.; Hunter, David J.; et al.

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September 29, 2010