Over half of opioid misusers last obtained access to opioids via a friend or relative, a problematic reflection of the opioid reservoir phenomenon, which results from an unused backlog of excess prescription opioids that are typically stored in the American home. We aim to determine if a voluntary educational intervention containing standard opioid and nonopioid analgesic prescribing ranges for common surgeries is effective in altering postoperative prescribing practice. We utilized a mixed methods approach and sent out a questionnaire to American podiatric physicians, including residents (baseline group A), via email in early 2020 for baseline data; then, we interviewed foot and ankle surgeons and the primary themes of these semistructured interviews informed us to target residents for an educational intervention. We repeated the survey 3 years later in summer 2022 (preintervention group B). We created an opioid guide and emailed it to residents in fall 2022. Another repeat survey was done in spring 2023 (postintervention group C). We used the Mann-Whitney U test to examine differences between the groups among their reported postoperative opioid quantities for a first metatarsal osteotomy surgical scenario. Groups A, B, and C had 60, 100, and 99 residents, respectively. There was no significant difference (p = .9873) between baseline group A and preintervention group B. There was a difference (p < .0001; -5 median) between preintervention group B and postintervention group C (same residency year). In postintervention group C, a majority (91/99) reported viewing the guide at least once, and the number of residents that reported supplementing with NSAIDs also doubled compared to preintervention group B. This novel opioid educational intervention resulted in meaningful change in self-reported postoperative prescribing behavior among residents.

Onychomycosis (tinea unguium) and tinea pedis are common, frequently concomitant infections of the nails and feet, respectively, and are often caused by dermatophyte fungi (Trichophyton, Microsporum, and Epidermophyton spp.).1 Antifungal-resistant tinea is an emerging global public health problem.2 A recent, large analysis of toenail samples from US patients with suspected onychomycosis found that nearly 4% of Trichophyton spp samples had squalene epoxidase gene mutations, which are associated with terbinafine resistance.3 Clinicians may be increasingly likely to encounter resistant tinea infections. Therefore, we aimed to assess diagnostic approaches, antifungal resistance testing practices, and treatment practices for treatment-resistant onychomycosis and tinea pedis. A 12-question survey was developed in early 2023 by a working group consisting of a dermatologist with expertize in cutaneous fungal infections (BE), an infectious disease clinician (PP), infectious diseases laboratory scientists, epidemiologists, and other experts. The survey instrument was created using QualtricsXM licensed to The Ohio State University (CTJ). The survey was deemed exempt from full review by the university's Institutional Review Board. Informed consent was included as the initial segment of the survey which gave access to the subsequent survey questions when affirmed. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy (e.g., 45 C.F.R. part 46.102(l)(2), 21 C.F.R. part 56; 42 U.S.C. §241(d); 5 U.S.C. §552a; 44 U.S.C. §3501 et seq.). The survey aimed to query a range of physicians, including podiatrists, who treat dermatophyte infections; the survey was emailed twice to approximately 8000 nonstudent and nonresident American Podiatric Medical Association (APMA) members in February 2023. Other distribution listservs included: dermatologists, the Mycoses Study Group Education and Research Consortium, the FungusCME.org listserv, and social media. SAS (SAS Institute, v. 9.4) was used to produce descriptive statistics. The survey closed on March 31, 2023, with 577 responses. Most responses (n = 498, 86.3%) were from podiatrists, 19 were from primary care practitioners, 23 were from dermatologists, 19 (3.3%) were from infectious diseases physicians, 13 (2.3%) from others, and 5 (0.9%) from pathology/laboratory medicine clinicians. The quantity and completeness of responses from the non-podiatry audiences were low; therefore, we focused on the responses from podiatrists to preserve statistical power. In total, 498 podiatrists began the survey; 200 respondents who did not complete the survey and 1 who did not see patients with dermatophyte infections were excluded from the analysis. Among the 297 included respondents, 106 (36.9%) were from the South; 83 (28.9%) were from the Northeast; 55 (19.2%) were from the Midwest, and 43 (15.0%) were from the West. Most respondents (n = 266, 89.6%) saw > 10 patients with onychomycosis and >10 patients with tinea pedis monthly (n = 171, 57.6%) (Figure 1). The most commonly reported definitions of treatment failure were terbinafine failure (72.4%), failure of multiple topical therapies (71.4%), and infection spreading during treatment (48.1%) (Table 1). Most respondents (53.2%) reported that >20% of onychomycosis cases involve treatment failure; 52.2% reported that <10% of tinea pedis cases involved treatment failure (Figure 2). Cost was a frequently reported (59.6%) barrier to ordering diagnostic testing for dermatophyte infections. The most commonly ordered diagnostic testing included histological examination (81.5%) and molecular testing (59.5%); 21.6% ordered antifungal susceptibility testing, and 30.0% indicated that their laboratory has reported antifungal resistance for treatment failure cases. No regional differences in antifungal resistance were observed (data not shown). For difficult-to-treat or terbinafine-resistant dermatophyte cases, reported management strategies included surgical nail avulsion (59.6%), topical therapy (45.8%), and systemic azole therapy (39.1%) (Figure 3). However, 31.0% reported that some cases remained refractory. Our study demonstrates that antifungal resistant onychomycosis and tinea pedis might be more common than previously appreciated, with nearly one-third of surveyed podiatrists reporting laboratory-confirmed resistance. This proportion might underestimate the true frequency of antifungal resistance because nearly 80% of podiatrists did not routinely order antifungal susceptibility testing. In addition, our study highlights the burden of onychomycosis, as suggested by the high percentage of onychomycosis patients who experience treatment failure, and by the substantial percentage of whom underwent surgical nail avulsion, which is painful and unlikely to be curative. The proportion of podiatrists reporting antifungal resistance in this survey exceeded a 2022 survey in which nearly 20% of 1500 nonspecialist healthcare providers reported clinical experience with antifungal resistant tinea.4 These findings might be attributable to podiatrists ordering diagnostic testing for suspected tinea more frequently than nonspecialists.5 For all clinicians who see patients with tinea, confirmatory laboratory testing is essential for guiding appropriate therapy and avoiding unnecessary antifungal use. Reported treatment failure in this study could be related to several factors besides resistance, including misdiagnosis, patient non-adherence to treatment, or variable definitions of treatment failure. For suspected onychomycosis, the differential is broad, and approximately half of nail disorders seen in clinical practice are not due to fungal pathogens.1 Therefore, the American Academy of Dermatology, as part of the ABIM Foundation's Choosing Wisely campaign, recommends that suspected fungal nail infections be confirmed before starting oral antifungal therapy,6 which we argue should be expanded to include topical antifungals. In addition, inadequate courses of antifungal therapy can lead to treatment failure, particularly for onychomycosis, which requires a long treatment course and can be difficult to completely cure. A treat-to-terminate approach is suggested. The high proportion of laboratory-confirmed antifungal resistance observed could also partly reflect survey response bias in which APMA members who were more familiar with dermatophytes and resistance were more likely to respond to the survey. Other study limitations include that we did not query regarding laboratory-confirmed antifungal resistance for tinea pedis and onychomycosis separately, though tinea pedis almost always precedes onychomycosis. The lack of demographic and training-related information for respondents is another notable limitation. These data could help identify more specific opportunities to address educational gaps in antifungal resistance testing practices. Together with previous studies, our findings suggest that antifungal-resistant tinea is a growing concern. This concern merits increased attention to antifungal stewardship efforts, emphasizing diagnostic testing and judicious antifungal use for suspected superficial fungal infections of the skin and nails. Kaitlin Benedict: Formal analysis; writing—original draft; writing—review and editing. Jeremy A. W. Gold: Conceptualization; methodology; writing—review and editing. Carolynn T. Jones: Conceptualization; methodology; writing—review and editing. Lisa A. Tushla: Conceptualization; methodology; writing—review and editing. Shari R. Lipner: Methodology; writing—review and editing. warren s joseph: writing—review and editing. Dyane E. Tower: Writing—review and editing. Boni Elewski: Conceptualization; methodology; writing—review and editing. Peter G. Pappas: Conceptualization; methodology; supervision; writing—review and editing. This survey was funded in at by a cooperative agreement with the Centers for Disease Control and Prevention (CDC-RFA-CK20-2003) to the University of Alabama at Birmingham and in collaboration with Terranova Medical LLC and The Mycoses Study Group Education and Research Consortium. Shari Lipner has served as a consultant for Ortho-Dermatologics, Moberg Pharmaceuticals, Hoth Therapeutics, and BelleTorus Corporation. Lisa Tushla has received research grant support from Bristol Myers Squibb and Novartis in the area of skin cancer. These financial relationships were not involved with this study. The remaining authors declare no conflict of interest. The lead author Kaitlin Benedict affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained. The data presented in this study are primarily included in this article; however, the full data set and survey instrument may be available on request from the corresponding author.

Background: More than 86,000 Americans with type 2 diabetes mellitus (T2DM) undergo nontraumatic lower-extremity amputations annually. The opioid-prescribing practice of podiatric surgeons remains understudied. We hypothesized that patients with T2DM who undergo any forefoot amputation while using antidepressant medication will have reduced odds of using opioids beyond 7 days. Methods: We completed a retrospective cohort study examining patients with T2DM who underwent forefoot amputation (toe, ray, transmetatarsal). Data were restricted to patients with a hemoglobin A1c level less than 8.0% and an ankle-brachial index greater than 0.8. The out -come was use of postoperative opioids beyond 7 days. Patients received an initial opioid prescription of 7 days or less. We developed simple logistic regression models to identify the odds of a patient using opioids beyond 7 days by patient variables: age, race, sex, amputation level, body mass index, antidepressant medication use, and marital status. Variables with P , .1 in the univariate analysis were included in the multiple logistic regression model. Results: Fifty patients met the inclusion criteria. Antidepressant use and marital status were the only statistically significant variables. Adjusting for marital status, patients with antidepressant use had decreased odds (odds ratio, 0.018; 95% confidence interval, 0.001-0.229; P = .002) of using opioids beyond 7 days after a diabetic forefoot amputation.Conclusions: Patients with T2DM who used antidepressants had significantly reduced odds of using opioids beyond 1 week after forefoot amputations compared with those with -out antidepressant use. We proposed an underlying diabetic foot-pain-depression cycle. To break the cycle, podiatric surgeons should screen this population for depression preoperatively and postoperatively and not hesitate to make a mental health referral if warranted. Nontraumatic amputations can be a traumatic experience for patients; psychiatrists and other mental health providers should be members of limb preservation teams. (J Am Podiatr Med Assoc 113(3), 2023)

BACKGROUND:More than half of opioid misusers last obtained opioids from a friend or relative, a problematic reflection of the commonly known opioid reservoir maintained by variable prescription rates and, notably, excessive postoperative prescription. We examined the postoperative opioid-prescribing approaches among podiatric physicians.METHODS:We administered a scenario-based, anonymous, online questionnaire via an online survey platform. The questionnaire consisted of five patient-foot surgery scenarios aimed at discerning opioid-prescribing approaches. Respondents were asked how many opioid "pills" (dosage units) that they would prescribe at the time of surgery. We divided respondents into two opioid-prescribing approach groups: one-size-fits-all (prescribed the same dosage units regardless of the scenario) and patient-centric and procedure-focused (prescribed varied amounts of opioid dosage units based on the patient's opioid history and the procedure provided in each scenario). We used the Mann-Whitney U test to determine the difference between the opioid dosage units prescribed at the time of surgery by the two groups.RESULTS:Approximately half of the respondents used a one-size-fits-all postoperative opioid-prescribing approach. Podiatric physicians who used a patient-centric and procedure-focused approach reported prescribing significantly fewer opioid dosage units in scenarios 1 (partial toe amputation; -9.1; P = .0087) and 2 (incision and drainage with partial fifth-ray resection; -12.3; P = .0024), which represented minor procedures with opioid-naive patients.CONCLUSIONS:Podiatric physicians who used a one-size-fits-all opioid-prescribing approach prescribed more postoperative opioid dosage units regardless of the scenario. Given that the patient population requiring foot surgery is diverse and may have multiple comorbidities, the management of postoperative pain, likewise, should be diverse and nuanced. The patient-centric and procedure-focused approach is suited to limit excess prescribing while defending the physician-patient relationship.

BACKGROUND:More than 86,000 Americans with type 2 diabetes mellitus (T2DM) undergo nontraumatic lower-extremity amputations annually. The opioid-prescribing practice of podiatric surgeons remains understudied. We hypothesized that patients with T2DM who undergo any forefoot amputation while using antidepressant medication will have reduced odds of using opioids beyond 7 days.METHODS:We completed a retrospective cohort study examining patients with T2DM who underwent forefoot amputation (toe, ray, transmetatarsal). Data were restricted to patients with a hemoglobin A1c level less than 8.0% and an ankle-brachial index greater than 0.8. The outcome was use of postoperative opioids beyond 7 days. Patients received an initial opioid prescription of 7 days or less. We developed simple logistic regression models to identify the odds of a patient using opioids beyond 7 days by patient variables: age, race, sex, amputation level, body mass index, antidepressant medication use, and marital status. Variables with P < .1 in the univariate analysis were included in the multiple logistic regression model.RESULTS:Fifty patients met the inclusion criteria. Antidepressant use and marital status were the only statistically significant variables. Adjusting for marital status, patients with antidepressant use had decreased odds (odds ratio, 0.018; 95% confidence interval, 0.001-0.229; P = .002) of using opioids beyond 7 days after a diabetic forefoot amputation.CONCLUSIONS:Patients with T2DM who used antidepressants had significantly reduced odds of using opioids beyond 1 week after forefoot amputations compared with those without antidepressant use. We proposed an underlying diabetic foot-pain-depression cycle. To break the cycle, podiatric surgeons should screen this population for depression preoperatively and postoperatively and not hesitate to make a mental health referral if warranted. Nontraumatic amputations can be a traumatic experience for patients; psychiatrists and other mental health providers should be members of limb preservation teams.

BACKGROUND:Debridement of toenails is a common procedure that leads to the production of nail dust aerosols in the work environment. Previous studies indicate that inhaled nail dust can cause respiratory distress and eye irritation. This comprehensive review aimed to assess the available literature on the effect of nail dust exposure and to evaluate nail dust as a potential occupational hazard for podiatric physicians.METHODS:A comprehensive literature search was conducted via PubMed, Google Scholar, CINAHL, Cochrane Library, and ClinicalTrials.gov. Risks of bias of the collected studies were evaluated using various assessment tools to match the type of study design. A qualitative analysis of the included studies was performed, from which primary and secondary outcome measures were extracted: prevalence of symptoms and specific microorganisms in nail dust.RESULTS:Of 403 articles screened, eight met the inclusion criteria. The primary outcome measure resulted in a pooled prevalence of eye-related symptoms being the most consistent symptom reported (41%-48%). The secondary outcome measure resulted in a pooled prevalence of Trichophyton rubrum (9.52%-38%) and Aspergillus (11.11%-35.48%) as the most common microorganisms present in nail dust.CONCLUSIONS:From the included eight articles, we found that nail dust is a potential occupational hazard, especially for those exposed more often. Aspergillus and T rubrum are most commonly associated with nail dust leading to development of respiratory illness. It is important to take preventive measures in podiatric medical clinics by using improved and efficient personal protective equipment for workers exposed to nail dust. Detailed health safety guidelines can be developed to decrease respiratory symptoms and diseases from nail dust exposure.

Background: Debridement of toenails is a common procedure that leads to the production of nail dust aerosols in the work environment. Previous studies indicate that inhaled nail dust can cause respiratory distress and eye irritation. This comprehensive review aimed to assess the available literature on the effect of nail dust exposure and to evaluate nail dust as a potential occupational hazard for podiatric physicians.Methods: A comprehensive literature search was conducted via PubMed, Google Scholar, CINAHL, Cochrane Library, and ClinicalTrials.gov. Risks of bias of the collected studies were evaluated using various assessment tools to match the type of study design. A qualitative analysis of the included studies was performed, from which primary and secondary outcome measures were extracted: prevalence of symptoms and specific microorganisms in nail dust.Results: Of 403 articles screened, eight met the inclusion criteria. The primary outcome measure resulted in a pooled prevalence of eye-related symptoms being the most consistent symptom reported (41%-48%). The secondary outcome measure resulted in a pooled prevalence of Trichophyton rubrum (9.52%-38%) and Aspergillus (11.11%-35.48%) as the most common microorganisms present in nail dust.Conclusions: From the included eight articles, we found that nail dust is a potential occupational hazard, especially for those exposed more often. Aspergillus and T rubrum are most commonly associated with nail dust leading to development of respiratory illness. It is important to take preventive measures in podiatric medical clinics by using improved and efficient personal protective equipment for workers exposed to nail dust. Detailed health safety guidelines can be developed to decrease respiratory symptoms and diseases from nail dust exposure. (J Am Podiatr Med Assoc 112(5), 2022)

Acral fibrokeratoma is a rare soft-tissue mass, more commonly found on the hands and rarely on the feet. This case report of a 40-year-old Hispanic man highlights an unusually located acral fibrokeratoma on the second toe, describes the clinical presentation and microscopic and pathologic findings, discusses differential diagnoses, and presents treatment options.

Talocalcaneal joint middle facet coalition is the most common tarsal coalition, occurring in ≤2% of the population. Fewer than 50% of involved feet obtain lasting relief of symptoms after nonoperative treatment, and surgical intervention is commonly used to relieve symptoms, increase the range of motion, improve function, reconstruct concomitant pes planovalgus, and prevent future arthrosis from occurring at the surrounding joints. Several approaches to surgical intervention are available for patients with middle facet coalitions, ranging from resection to hindfoot arthrodesis. We present a series of 4 cases, in 3 adolescent patients, of talocalcaneal joint middle facet coalition resection with interposition of a particulate juvenile hyaline cartilaginous allograft (DeNovo(®) NT Natural Tissue Graft, Zimmer, Inc., Warsaw, IN). With a mean follow-up period of 42.8 ± 2.9 (range 41 to 47) months, the 3 adolescent patients in the present series were doing well with improved subtalar joint motion and decreased pain, and 1 foot showed no bony regrowth on a follow-up computed tomography scan. The use of a particulate juvenile hyaline cartilaginous allograft as interposition material after talocalcaneal middle facet coalition resection combined with adjunct procedures to address concomitant pes planovalgus resulted in good short-term outcomes in 4 feet in 3 adolescent patients.