How important is debridement in onychomycosis?

This paper has generated some good discussion:
Study to determine the efficacy of Clotrimazole 1% cream for the treatment of onychomycosis in association with the mechanical reduction of the nail plate
"Onychomycosis is invasion of the nail by dermatophytes yeasts and moulds [Calderon RA, Hay RJ. Fungicidal activity of human neutrophils and monocytes on dermatophyte fungi Tri. Quinckeanum and Tri. Rubrum. Immunology 1986;61:289–95; Degreef H. Onychomycosis. Br J Clin Pract Syn Suppl 1990;71:91–7; Zaias N. Clinical manifestations of onychomycosis. Clin Exp Dermatol 1992;17(1):6–7]. Causative organisms include T. rubrum and T. mentagrophytes. Fungi invade the distal and lateral under surfaces of the nail. The prevalence of onychomycosis approximates to 5–10% of the population and is increasing significantly in recent years [Stutz A. Allylamine derivatives—a new class of active substances in antifungal chemotherapy. Angew Chem 1987;2:320–8].Clotrimazole 1% cream is the most commonly prescribed topical antifungal agent in the United Kingdom although its use on nails has not been widely documented. Past inefficiencies may be due to the thickness of the nail plate. The mechanical reduction of the nail minimises the nail as a barrier to the absorption of the cream and increases the permeability of the nail plate.Subjects were ambulant and healthy with no systemic medication, no past history of anti-fungal agents and an ankle-brachial index indicating sufficient circulation for healing to occur. The infecting organism was identified by microscopy and culture. A total of ninety-two infected nails were isolated over a four-year period. The age range was 60–78 years. Nails were drilled every 14 days by the same operator and the area of infection mapped. Clotrimazole 1% cream was applied twice daily during the trial period and the percentage clearance rate was recorded. After 12 weeks there was an average improvement of 96.2% with the infection in 80% nails completely resolved. "
Discussion

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Feds accuse foot doctor of massive Medi-fraud

This not good:
"Federal prosecutors say a Middlesex County podiatrist bilked the government of hundreds of thousands of Medicare dollars by submitting claims for treatments that were little more than massaging feet and clipping toenails. A civil complaint filed in federal court in Newark said Ming Tung, who lives in East Brunswick and has offices there and in Jersey City, ignored warnings about improper billings, instead filing more claims. Two years ago, authorities say, Tung received $856,000 in Medicare payments, or nearly 24 times the average reimbursement for a New Jersey foot doctor. Last year his filings topped $1.6 million. In many cases, Tung billed for visits to low-income apartment complexes in Middlesex and Hudson counties, where he allegedly gave foot massages in the lobbies. " Full story

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The Mid Tarsal Joint

The midtarsal joints is one of those joints that is subject to so much ongoing debate, discussion, scientific and theoretical modeling. Chris Nester has attempted to, at least, get everyone speaking the same language with this new publication: Clinical and Experimental Models of the Midtarsal Joint Proposed Terms of Reference and Associated Terminology Journal of the American Podiatric Medical AssociationVolume 96 Number 1 24-31 2006. Discussion here.

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The Mid Tarsal Joint

The midtarsal joints is one of those joints that is subject to so much ongoing debate, discussion, scientific and theoretical modeling. Chris Nester has attempted to, at least, get everyone speaking the same language with this new publication: Clinical and Experimental Models of the Midtarsal Joint Proposed Terms of Reference and Associated Terminology Journal of the American Podiatric Medical AssociationVolume 96 Number 1 24-31 2006. Discussion here.

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Comparison of foot orthoses made by podiatrists, pedorthists and orthotists

"Within each discipline there was an extensive variation in construction of the orthoses and achieved peak pressure reductions. Pedorthists and orthotists achieved greater maximal peak pressure reductions calculated over the whole forefoot than podiatrists: 960, 1020 and 750 kPa, respectively (p< .001). This was also true for the effect in the regions with the highest baseline peak pressures and walking convenience rated by patients A and B. There was a weak relationship between the 'importance of pressure reduction' and the achieved pressure reduction for orthotists, but no relationship for podiatrists and orthotists." More information and comments.

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What defines podiatry as a profession

In this discussion on Who Treats Feet?, I posted this message:

That is an issue - what defines "podiatry" as "podiatry" so that it is different from other professions --- in the USA, podiatry is clearly part of the medical model - in the rest of the world it is not, where it is a discipline similar to physiotherapy etc (that is despite limited numbers with surgical qualifications in places like the UK and Australia).

While it is one thing to aspire to the medical model, but is that feasible outside the USA where historical development and educational models are different? One train of thought I have been considering for a while, is just what is it that underpins the 'podiatric model'?

Take nursing as an eg....they used to be the doctors 'hand maidens' - the textbooks of >20 or so years ago reflected that. BUT, now there is no doubt about the very high levels of independence, professionalism and status of nurses as not being the doctors 'hand maidens'. What changed? What gave them this independence as a profession ..... take a look at the current and recent nursing (up to 10 or so years ago) textbooks - the change is obvious....its the concept of a 'nursing diagnosis' that has got nursing to where it is.

For example - the medical diagnosis might be 'chronic obstructive pulmonary disease'. The nursing diagnosis "is a clinical judgment about an individual, family or community response to actual and potential health problems/life processes" - is it will focus on restrictions in ADL's and how they can be facilitated etc. Look at attempts in the physiotherapy literature to define and develop a theoretical model/framework to define the "physiotherapy model'. Look at the plethora of recent textbooks from occupational therapy defining the occupational therpy model with models and frameworks --- they are very well developed and rapidly catching up to nursing in their ability to define their profession in such a way (no wonder they are no longer perceived as basket makers ).

Maybe its time we need to consider the concept of a 'podiatric diagnosis' that needs to be addressed in each patient to better define podiatry as a profession. Those who want to pursue the medical model will disagree with me here...For eg that corn on the fifth toe has a medical diagnosis of hyperkeratosis due to an adductovarus deformity of the fifth digit.... a podiatric diagnosis could be pain due to a pyschosocial problem that prevents them wearing appropriate footwear .... for which problem did the patient really come to us for? Which definition of this problem should we be directing our treatment at? The concept of a nursing diagnosis has defined 'nursing' and directs nursing interventions --- Do we need something similar?

What say you? Comments

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Plantar fasciitis discussions

Podiatry Arena has had a lot of good topics and discussions on plantar fasciitis:
Orthoses vs plantar fasciitis
Is a calcaneal spur in the plantar fascia?
Extracorporeal Shock Wave Therapy:
Ultrasound therapy for plantar fasciitis
Plantar fasciitis and dorsal pain
Nutrition and plantar fasciitis
Botulinum toxin and plantar fasciitis
First-Step Pain
Plantar fasciitis is associated with functional limitation in older people
Growth Factors For Chronic Plantar Fasciitis?
Wheatgrass cream no more effective than placebo for plantar fasciitis
Plantar Fasciitis: Evidence-Based Review of Diagnosis and Therapy

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