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Laser treatment for nail fungus

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  #541  
Old 21st May 2014, 03:50 AM
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Default Re: Laser treatment for nail fungus

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Originally Posted by newsouth View Post
Yes indeed and it does make sense cause it is the most important part of a laser for this application, it's power.
Do you have a link to this so called peer reviewed rigorous clinical trial which is the most complete in the world?

The only reason I ask is at 10W 1064nm I can put a hole in gyprock wall from 3 feet away (ok slight exaggeration but you get what I am saying.....)

...and i'm pretty sure I have data which shows conclusively that at 1064nm 10.0W 700-1000J application we can eradicate onycomycoses - so I doubt the study shows "anything below" 40W doesn't work, and if it does I am pretty sure we can prove it wrong.
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  #542  
Old 21st May 2014, 05:16 AM
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Default Re: Laser treatment for nail fungus

What do you believe the mechanism is for the effect that you are talking about ? When you talk about power what power are you measuring? Power output of the device doesn't necessary translate into any specific effect which is why your statement is questionable. I can shine a 100 watt light bulb or blast the nail with 1000W sound system it won't kill the fungus. I could contrain that energy within different beam widths and cause localized heating which might then be harmful to the fungus but effect will be a function of time as well as power delivered per unit volume to cause temperature change per unit time or possibly rate of heating. Also a factor is tolerance of host to effect particularly pain. That is why I remain skeptical regarding your comment so far. In a nutshell power output doesn't translate into dose delivered.

cheers Martin

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  #543  
Old 21st May 2014, 06:16 AM
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Default Re: Laser treatment for nail fungus

Quote:
Originally Posted by Paul Bowles View Post
Do you have a link to this so called peer reviewed rigorous clinical trial which is the most complete in the world?

The only reason I ask is at 10W 1064nm I can put a hole in gyprock wall from 3 feet away (ok slight exaggeration but you get what I am saying.....)

...and i'm pretty sure I have data which shows conclusively that at 1064nm 10.0W 700-1000J application we can eradicate onycomycoses - so I doubt the study shows "anything below" 40W doesn't work, and if it does I am pretty sure we can prove it wrong.
10W does not work at all. And he can prove it scientifically. Next saturday he is giving a conference in Portugal regarding this. Once the study is published (there is only a white paper now) you will be very surprised. A well known University like Barcelona's (which gives master degress to podiatrists from all over the world and is number second in Europe for its studies in podiatry) would not be involved on this. They are currently on a study on plantar warts using this laser.
Once the study is published ...no rebates
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  #544  
Old 21st May 2014, 06:18 AM
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Default Re: Laser treatment for nail fungus

Quote:
Originally Posted by Mart View Post
What do you believe the mechanism is for the effect that you are talking about ? When you talk about power what power are you measuring? Power output of the device doesn't necessary translate into any specific effect which is why your statement is questionable. I can shine a 100 watt light bulb or blast the nail with 1000W sound system it won't kill the fungus. I could contrain that energy within different beam widths and cause localized heating which might then be harmful to the fungus but effect will be a function of time as well as power delivered per unit volume to cause temperature change per unit time or possibly rate of heating. Also a factor is tolerance of host to effect particularly pain. That is why I remain skeptical regarding your comment so far. In a nutshell power output doesn't translate into dose delivered.

cheers Martin

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it seems that you do not understand very well how laser diods work. Power is measured at the end of the fiber.Are you related with podiatry or with engineering?
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  #545  
Old 21st May 2014, 06:37 AM
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Default Re: Laser treatment for nail fungus

Some users:

http://www.clinicamayral.com/podolog...r-therapy.html

http://www.youtube.com/watch?v=H9XCn...ature=youtu.be

On the web there are moe than 100 reference centers
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  #546  
Old 21st May 2014, 07:45 AM
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Default Re: Laser treatment for nail fungus

Quote:
Originally Posted by newsouth View Post
it seems that you do not understand very well how laser diods work. Power is measured at the end of the fiber.Are you related with podiatry or with engineering?

The marketing info you posted when translated stated

"Thanks the outpost / advanced technology, S30 PODYLAS causes a controlled thermal effect mycotic infections That delete from the nails. The lenergy from the light penetrates the nail trough, raising up the temperature from the microorganism and fungi without reaching deeper Causing damage to surrounding tissue. That's a safe treatment, comfortable and very fast, you can treat a complete foot in only 15 minute"

This provided no evidence let alone scientific discussion - purely marketing from your link. This is legitimately seen as self serving if you make claims that your product if somehow effective when other aren't without substantiation. Also you cited Bernstein's work which speculated that mechanism is likely associated with mechanisms which are independent of heating - so your comment is inconsistent.

I am a podiatrist - I do understand the technology at a clinical level - I am concerned about the unsubstantiated claims which are broadcast and feel that this forum response should be critical of that.

We know that lasers can heat tissue - that doesn't make them effective therapies. We can heat nail and kill microorganisms inside nails using many different methods and technologies. The question is does this heat cause host damage and does host tolerate the heat exposure required to kill microorganism? Measured power output at fiber end doesn't get close to answering that issue because it doesn't address how efficiently that energy is absorbed by the microorganism compared to the host. It also doesn't address the range of effective exposure needed for efficacy.

Should we focus this thread on plausible speculation and evidence or blind faith and nice looking pictures?

Cheers

Martin

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  #547  
Old 21st May 2014, 07:51 AM
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Default Re: Laser treatment for nail fungus

Sorry, im stating what I have bought, simple as that and why I did it.
When the scientifical evidence is published...then you can rebate whatever you think. You should visit the university and ask, ask and keep asking...
Other professionals can state other opinions, these are my simple thoughts on why I bought it.

PD: you should not translate, you should learn spanish in order to understand it better and properly cause it is not correct.
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  #548  
Old 21st May 2014, 08:02 AM
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Default Re: Laser treatment for nail fungus

Martin's point is that "40 W" is meaningless without specifying the area of the spot. I.e., it's power density, not total power, that matters.

EDIT: I hadn't read to the current end of the thread when I posted the above. Of course the other objections to the 40-W assertion are also valid: the energy must be absorbed and somehow kill the organism so not only power density but also other characteristics are important. Nevertheless, "power" is not a sufficient characteristic without defining an area.

EDIT2: BTW, the "incorrect" translation that's quoted above was provided on the referenced website.
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  #549  
Old 21st May 2014, 08:05 AM
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Default Re: Laser treatment for nail fungus

Quote:
Originally Posted by TPeterson View Post
Martin's point is that "40 W" is meaningless without specifying the area of the spot. I.e., it's power density, not total power, that matters.
I do not agree at all. Everything matters
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  #550  
Old 21st May 2014, 08:22 AM
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Default Re: Laser treatment for nail fungus

Quote:
Originally Posted by newsouth View Post
Sorry, im stating what I have bought, simple as that and why I did it.
When the scientifical evidence is published...then you can rebate whatever you think. You should visit the university and ask, ask and keep asking...
Other professionals can state other opinions, these are my simple thoughts on why I bought it.

PD: you should not translate, you should learn spanish in order to understand it better and properly cause it is not correct.
What is incorrect about the translation I posted?

Perhaps we should consider the scientific evidence BEFORE we market to our patients and be candid with them about what that amounts to.

Universities are were we get our basic training and are then expected to demonstrate competency which then implies a reliable level of trust. Universities are also expected to provide high quality research.

As clinicians we should adopt lifelong learning which includes being able and taking time to review theory and evidence as it shifts enabling us to form well considered opinions. This can happen in many arenas including Universities and podarena.

Sermon over:)

Cheers

Martin

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Winnipeg Manitoba R3M 1Z8
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  #551  
Old 21st May 2014, 12:57 PM
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Default Re: Laser treatment for nail fungus

Quote:
Originally Posted by newsouth View Post
10W does not work at all. And he can prove it scientifically.
This statement alone, combined with no peer reviewed evidence leads me to think that either: a) We have a communication issue here b) The figures you quoted in content don't amount to anything c) Marts point stands or d) a combination of a and c....

Isn't the author of that paper going to be very confounded when he publishes this data and other studies start citing their results at 1064nm 10W at 700J-1000J application.

You don't have to look far back in this thread to see actual clinical photos of patients who have been treated at 1064nm 10W 700J-1000J to see results - yet you are blanket stating it doesn't work? I'm with Mart on this.... the (W) measure alone means nothing out of context - the light globes in my office are 100W, we have 8 of them in the reception area - all my patients still seem to make it to my office with fungus! How about you provide some more information on your "said" laser system such as peer reviewed evidence or clinical patient cases/information with photos or even said white paper you keep referencing (did I miss you post this?) - because at the moment it looks like you either work for the company, or have just spent alot of money on one of these machines and really want it to work!!!!

Also I find it borderline offensive to tell someone to "learn" a language so they can understand a reference you posted. In a worldwide community where many of us are bi-lingual we should all do our best to help each other understand the literature presented. Your ignorance of this fact makes me.....

...think I am smelling a rat!
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  #552  
Old 26th May 2014, 01:27 AM
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Default Re: Laser treatment for nail fungus

I have only had one patient who tried laser treatment SIX times with the same provider without any benefit. She is now taking Terbinafine, and is making good progress.

Last edited by zsuzsanna : 26th May 2014 at 01:37 AM. Reason: delete duplicate
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  #553  
Old 26th May 2014, 01:31 AM
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Default Re: Laser treatment for nail fungus

I have only had one patient who tried laser treatment. She had SIX treatments without any effect and gave up. She is now taking Terbinafine (Lamisil) and making good progress.
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  #554  
Old 26th May 2014, 02:10 PM
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Default Re: Laser treatment for nail fungus

Quote:
Originally Posted by zsuzsanna View Post
I have only had one patient who tried laser treatment. She had SIX treatments without any effect and gave up. She is now taking Terbinafine (Lamisil) and making good progress.
N=1 isn't really indicative of anything. The next person may post in this thread and say that they only had one patient try laser and it worked after 2 treatments. Again their N=1 clinical view means very little.

Laser - like terbinafine - is a treatment option/tool. It should be used as such. It is not the be all and end all.

Management options differ between patients and what works for one person may not necessarily work for others. Even oral terbinafine has a failure rate.
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  #555  
Old 26th May 2014, 04:28 PM
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Default Re: Laser treatment for nail fungus

Im not sure if these articles have been shared but they are relatively new,
I have not fully evaluated the methodological rigor of these studies so I can not comment on their quality.

Choi, Zheng, Goo, and Cho (2014) completed a non-randomised controlled trial on the anti-fungal effects of a 1444-nm neodymium(Nd): Yttrium–aluminum–garnet(YAG) laser on onychomycosis.

They conclude that Nd:YAG lasers with a wavelength of 1444 nm are effective at reducing mycotic colony-forming units (CFUs).

Hees, Jäger, and Raulin (2014) conducted a single blinded study on the treatment of onychomycosis using a 1 064 nm Nd:YAG laser.

They Concluded that the treatment of onychomycosis with the Nd:YAG laser without removing mycotic nail material can lead to a temporary clinical improvement, a reduction of positive fungal cultures and an improvement of the Onychomycosis Severity Index.

A quick look a these studies displays limitations of the methodology but they are still worth a read.


Choi, M.J., Zheng, Z., Goo, B., & Cho, S.B. (2014). Antifungal effects of a 1444-nm neodymium:Yttrium–aluminum–garnet laser on onychomycosis: A pilot study. Journal of Dermatological Treatment, 25(4), 294-297. doi: doi:10.3109/09546634.2012.714455

http://informahealthcare.com/doi/abs...34.2012.714455

Hees, H., Jäger, M.W., & Raulin, C. (2014). Treatment of onychomycosis using the 1 064 nm nd:Yag laser: A clinical pilot study. JDDG: Journal der Deutschen Dermatologischen Gesellschaft, 12(4), 322-329. doi: 10.1111/ddg.12292

http://onlinelibrary.wiley.com/doi/1...12292/abstract
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  #556  
Old 12th June 2014, 07:28 AM
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Default Re: Laser treatment for nail fungus

Lack of efficacy with 1064-nm neodymium:yttrium-aluminum-garnet laser for the treatment of onychomycosis: a randomized, controlled trial.
Hollmig ST, Rahman Z, Henderson MT, Rotatori RM, Gladstone H, Tang JY.
J Am Acad Dermatol. 2014 May;70(5):911-7.
Quote:
BACKGROUND:
Laser therapies have been Food and Drug Administration approved for temporary nail plate clearance; however, there is minimal evidence of their long-term efficacy.
OBJECTIVE:
We sought to evaluate the clinical and mycological clearance of toenails treated with 1064-nm neodymium:yttrium-aluminum-garnet laser versus no treatment.
METHODS:
This was a randomized, controlled, single-center trial comparing 2 treatments with 1064-nm neodymium:yttrium-aluminum-garnet laser (fluence of 5 J/cm(2), rate of 6 Hz) spaced 2 weeks apart versus no treatment in 27 patients (N = 125 affected nails) with clinical and mycological diagnosis of onychomycosis. At 3 months, patients were assessed with mycological cultures and proximal nail plate measurements. Patients treated with laser were also assessed with proximal nail plate measurements at 12 months.
RESULTS:
At 3 months, 33% of patients treated with laser achieved a negative mycological culture compared with 20% of the control group (P = .49), and had more proximal nail plate clearance compared with control subjects (0.44 vs 0.15 mm, P = .18), which was not statistically significant. At 12 months, there was no difference in nail plate clearance between laser versus control subjects (0.24 vs 0.15 mm, P = .59).
LIMITATIONS:
Our study was limited by the small sample size and number of treatments.
CONCLUSIONS:
There was no significant mycological culture or clinical nail plate clearance with 1064-nm neodymium:yttrium-aluminum-garnet laser compared with control.
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  #557  
Old 12th June 2014, 07:49 AM
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Default Re: Laser treatment for nail fungus

.....just down the street from my office....

http://www.toelaser.com/
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  #558  
Old 15th June 2014, 06:39 AM
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Default Re: Laser treatment for nail fungus

in spain at Zaragoza conference some of our collegue said that they are using laser terapy for onicomicosis with good result, but GOD knows.....
so yet there are no studies about that right?!

sincerely, Alessandro
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  #559  
Old 9th July 2014, 08:20 PM
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Default Re: Laser treatment for nail fungus

What I like about using a laser is it gives me another tool to add to my belt. I am not saying it will definitely work on every patient however there is not a definitive treatment available for onychomycosis any way.








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  #560  
Old 9th July 2014, 09:01 PM
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Default Re: Laser treatment for nail fungus

Can you speculate why your results are so variable?

cheers Martin

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  #561  
Old 9th July 2014, 09:30 PM
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Default Re: Laser treatment for nail fungus

Quote:
Originally Posted by Mart View Post
Can you speculate why your results are so variable?

cheers Martin

Send from my Iphone
I think it improves every nail that I treat but it is hard to speculate why some become clear while others require ongoing treatment. Each patient I have found tolerates the laser differently. Some will say that they did not have any discomfort while another will say it got very hot. How they tolerate the treatment does not always correlate with how the nail responds down the track. I wish it would so I could give a better answer.
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  #562  
Old 9th July 2014, 09:39 PM
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Default Re: Laser treatment for nail fungus

Thanks that's interesting observation

cheers Martin
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  #563  
Old 11th July 2014, 09:53 AM
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Default Re: Laser treatment for nail fungus

Hi - we have made a little "quiz" app for Android that has some very basic questions to determine if someone might have a need for a consult re nail fungus.

We are marketers, not podiatrists, and so this app is not very clinical - but it does spur some people to request a consult where we leave it up to you pros to help them further, if it seems appropriate to you and the patient.

The app is intended to generate some new leads/referrals and as we're testing the model we'd appreciate feedback. So far we've had good feedback from consumers, which is the target audience.

Oh and we have a few leads to give out, as we're starting to get a few coming in but have no one to send them to (they are 90% US and some outside USA).

We'd be happy to connect these prospects with members who might be looking for new patients.

I don't mean to hijack this thread so for more details and a current list of the leads pls see our thread here.

Thanks,
Peter
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  #564  
Old 30th September 2014, 08:43 AM
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Default Re: Laser treatment for nail fungus

just read a good recent systematic review.

http://www.jfootankleres.com/content/7/1/34/abstract


mentioned within paper is what has been speculated in this thread

"Studies on fungal nail clippings
have demonstrated this to have a direct thermal killing
effect on fungal mycelia when treatment temperatures
exceed 50° centigrade [18]."

This idea is consistent with the wide variability of anecdotal outcomes reported in this thread. I have speculated within my own experience, (which was primarily with "severe" infection) that the dose limiting factor of intolerance to heating was likely reason for failure. Because of extremely poor outcomes (no cure) I rejected using this technology in my clinic and will not recommend to patients unless further evidence showing reasonable efficacy emerges.

In his review, Bristow pointed to the poor methodology used in majority of studies. I believe that we may not find good outcomes (high cure rates) unless we can overcome understanding the dose issue. Whilst anesthetizing toe would likely allow tolerance of a reliably heat destroying dose to dermatophytes it would likely have an unacceptable risk for host injury.

I have speculated that if the effect of onychomycosis causes separation of nail from nail bed there may be a sufficiently heat insulating air layer present to allow adequately destructive temperature within the nail plate without host injury. This might explain why Tim Foran had success in the examples he posted.

Another idea that I have not seen discussed is to investigate the effect a very short interval (ms) temperature exposure to in vitro onychomycosis. Because laser might be selectively "tuned" for photon energy absorption according to the pigmentation created within/around the dermatophyes it may be possible to heat those elements to very high temperature for very short time intervals with good effect without sufficient heat conduction to adjacent skin to cause injury to host. To achieve this might be largely a function of optimizing balance of pulse width and power output. Anyone aware if this approach has been considered or if it seems logically flawed?



Cheers

Martin

Foot and Ankle Clinic
1365 Grant Ave.
Winnipeg Manitoba R3M 1Z8
phone [204] 837 FOOT (3668)
fax [204] 774 9918
www.winnipegfootclinic.com

Last edited by Mart : 30th September 2014 at 08:45 AM. Reason: typo
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  #565  
Old 30th September 2014, 02:21 PM
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Default Re: Laser treatment for nail fungus

Quote:
Originally Posted by Mart View Post



I have speculated that if the effect of onychomycosis causes separation of nail from nail bed there may be a sufficiently heat insulating air layer present to allow adequately destructive temperature within the nail plate without host injury.

[/url]

I think you may find we discussed this many moons ago in this thread somewhere. We have data that shows debriding any onycolytic nail and applying the laser directly to the nail bed has very little success. Leaving the nail in place even in its lytic state seems to provide better outcomes.
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  #566  
Old 30th September 2014, 02:49 PM
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Quote:
Originally Posted by Paul Bowles View Post
I think you may find we discussed this many moons ago in this thread somewhere. We have data that shows debriding any onycolytic nail and applying the laser directly to the nail bed has very little success. Leaving the nail in place even in its lytic state seems to provide better outcomes.
Hi Paul

Indeed we did, although I am unaware that this was reported by anyone but myself. I am canvassing opinion to see if anyone else has anything to add to that conversation at this stage given the apparent stagnation in well designed published studies in this area over the past year.

Cheers

Martin

Foot and Ankle Clinic
1365 Grant Ave.
Winnipeg Manitoba R3M 1Z8
phone [204] 837 FOOT (3668)
fax [204] 774 9918
www.winnipegfootclinic.com
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Old 30th September 2014, 06:53 PM
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Paul Bowles Paul Bowles is offline
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Default Re: Laser treatment for nail fungus

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Hi Paul

Indeed we did, although I am unaware that this was reported by anyone but myself. I am canvassing opinion to see if anyone else has anything to add to that conversation at this stage given the apparent stagnation in well designed published studies in this area over the past year.

Cheers

Martin

Foot and Ankle Clinic
1365 Grant Ave.
Winnipeg Manitoba R3M 1Z8
phone [204] 837 FOOT (3668)
fax [204] 774 9918
www.winnipegfootclinic.com

We have all data collected, analyzed and reviewed - just needs writing up. You want the job?
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Old 30th September 2014, 07:03 PM
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Default Re: Laser treatment for nail fungus

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We have all data collected, analyzed and reviewed - just needs writing up. You want the job?
Haha ...... I would love to be able to responsibly say yes but if I did there would be yet another unfinished task relegated to the "en route to oblivion list" ....... But look forward to reading whoever does ... Good luck
cheers Martin
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Old 1st October 2014, 02:01 PM
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Haha ...... I would love to be able to responsibly say yes but if I did there would be yet another unfinished task relegated to the "en route to oblivion list" ....... But look forward to reading whoever does ... Good luck
cheers Martin

LOL - thats the excuse I keep using. Everyone tells me its wearing thin!
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