Managing diabetic foot in times of COVID-19: time to put the best 'foot' forward

Managing Diabetic Foot Complications During COVID-19 Lockdown in India: A Survey

To understand the management of diabetic foot complications by the Diabetic Foot Research India (DFRI) members during the lockdown period. An online survey link was created in "Survey Monkey", and the link was sent to all the members of Diabetic Foot Research India (DFRI) who are staying in different parts of India and data were collected from May 2020 to June 2020. The survey included questions on the type of consultation they provided to their patients, management of a patient with an active foot ulcer, and the various difficulties encountered by the doctors during the lockdown. A total of 33 diabetologists from all over the country participated in this survey. Among them, 26 doctors had attended to active diabetic foot infection at the time of the online survey. Almost three fourth of the (n = 24; 72.7%) doctors recorded difficulties during the inpatient consultations. Difficulty in regular follow-ups, the facility's workforce shortage was reported to be a significant concern. In managing active foot ulcer cases, 15 doctors (45.5%) opted for in-person consultation in their hospital as they felt the infection cannot be handled over a tele-consultation. Amputation was not performed by 78.7% of doctors, 15% (n = 5) of the doctors performed less than five amputations, and 6% (n = 2) of the doctors performed more than five amputations during the lockdown period. In the case of SMBG (Self-monitoring blood glucose) values, the regularity of patients reporting the values varied significantly. Only 8 (24.2%) doctors reported that 75% of their patients regularly shared their SMBG values while all the others mentioned that their patients were not performing SMBG regularly. Most of the physicians were able to manage the diabetic foot complications by tele-consultation during the lockdown and only a few asked the patients to get hospitalized for surgical intervention. All doctors should recommend SMBG to continuously monitor patients' blood glucose levels and prevent complications of hyperglycemia, particularly during pandemic situations.

A collagen-based theranostic wound dressing with visual, long-lasting infection detection capability

Continuous wound monitoring is one strategy to minimise infection severity and inform prompt variations in therapeutic care following infection diagnosis. However, integration of this functionality in therapeutic wound dressings is still challenging. We hypothesised that a theranostic dressing could be realised by integrating a collagen-based wound contact layer with previously demonstrated wound healing capability, and a halochromic dye, i.e. bromothymol blue (BTB), undergoing colour change following infection-associated pH changes (pH: 5-6 ➔ >7). Two different BTB integration strategies, i.e. electrospinning and drop-casting, were pursued to introduce long-lasting visual infection detection capability through retention of BTB within the dressing. Both systems had an average BTB loading efficiency of 99 wt% and displayed a colour change within 1 min of contact with simulated wound fluid. Drop-cast samples retained up to 85 wt% of BTB after 96 h in a near-infected wound environment, in contrast to the fibre-bearing prototypes, which released over 80 wt% of BTB over the same time period. An increase in collagen denaturation temperature (DSC) and red shifts (ATR-FTIR) suggest the formation of secondary interactions between the collagen-based hydrogel and the BTB, which are attributed to count for the long-lasting dye confinement and durable dressing colour change. Given the high L929 fibroblast viability in drop-cast sample extracts (92 %, 7 days), the presented multiscale design is simple, cell- and regulatory-friendly, and compliant with industrial scale-up. This design, therefore, offers a new platform for the development of theranostic dressings enabling accelerated wound healing and prompt infection diagnosis.

Cardiovascular/Stroke Risk Stratification in Diabetic Foot Infection Patients Using Deep Learning-Based Artificial Intelligence: An Investigative Study

A diabetic foot infection (DFI) is among the most serious, incurable, and costly to treat conditions. The presence of a DFI renders machine learning (ML) systems extremely nonlinear, posing difficulties in CVD/stroke risk stratification. In addition, there is a limited number of well-explained ML paradigms due to comorbidity, sample size limits, and weak scientific and clinical validation methodologies. Deep neural networks (DNN) are potent machines for learning that generalize nonlinear situations. The objective of this article is to propose a novel investigation of deep learning (DL) solutions for predicting CVD/stroke risk in DFI patients. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) search strategy was used for the selection of 207 studies. We hypothesize that a DFI is responsible for increased morbidity and mortality due to the worsening of atherosclerotic disease and affecting coronary artery disease (CAD). Since surrogate biomarkers for CAD, such as carotid artery disease, can be used for monitoring CVD, we can thus use a DL-based model, namely, Long Short-Term Memory (LSTM) and Recurrent Neural Networks (RNN) for CVD/stroke risk prediction in DFI patients, which combines covariates such as office and laboratory-based biomarkers, carotid ultrasound image phenotype (CUSIP) lesions, along with the DFI severity. We confirmed the viability of CVD/stroke risk stratification in the DFI patients. Strong designs were found in the research of the DL architectures for CVD/stroke risk stratification. Finally, we analyzed the AI bias and proposed strategies for the early diagnosis of CVD/stroke in DFI patients. Since DFI patients have an aggressive atherosclerotic disease, leading to prominent CVD/stroke risk, we, therefore, conclude that the DL paradigm is very effective for predicting the risk of CVD/stroke in DFI patients.

Telehealth has comparable outcomes to in-person diabetic foot care during the COVID-19 pandemic

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has posed obstacles to the delivery of diabetic foot care. In response to this remote healthcare services have been deployed offering monitoring, follow-up, and referral services to patients with diabetic foot ulcers and related conditions. Although, remote diabetic foot care has been studied before the COVID-19 pandemic as an alternative to in-person care, the peculiar situation of the pandemic, which dictates that remote care would be the sole available option for healthcare practitioners and patients, necessitates an evaluation of the relevant knowledge obtained since the beginning of the severe acute respiratory syndrome coronavirus 2 outbreak.

AIM

To perform a thorough search in PubMed/Medline and Cochrane to identify original records on the topic.

METHODS

To identify relevant peer-reviewed publications and gray literature, the authors searched PubMed-MEDLINE and Cochrane Library-Cochrane Central Register of Controlled Trials starting September 27 till October 31, 2021. The reference lists of the selected sources and relevant systematic reviews were also hand–searched to identify potentially relevant resources. Otherwise, the authors searched Reference Citation Analysis (https://www.referencecitationanalysis.com/).

RESULTS

A number of randomized prospective studies, case series, and case reports have shown that the effectiveness of remote care is comparable to in-person care in terms of hospitalizations, amputations, and mortality. The level of satisfaction of patients’ receiving this type of care was high. The cost of remote healthcare was not significantly lower than in - person care though.

CONCLUSION

It is noteworthy that remote care during the COVID-19 pandemic appeared to be more effective and well - received than remote care in the past. Nevertheless, larger studies spanning over longer time intervals are necessary in order to validate these results and provide additional insights.

Breakdown of Diabetic Foot Ulcer Care during the First Year of the Pandemic in Poland: A Retrospective National Cohort Study

The COVID-19 pandemic revealed a breakdown of the system of DFU patient care. This retrospective national cohort study analyses the epidemiological status of DFU patients in relation to urgent and elective hospitalizations, amputation rates, and deaths in Poland from 2017 to 2019, and during 2020 when the COVID-19 pandemic began. The data were obtained from national medical records gathered by the National Health Fund (NHF). Discharge diagnoses were categorized according to ICD-10 and ICD-9 codes. Analysis of the data showed a statistically significant decrease in elective hospital admissions (from 29.6% to 26.3%, p = 0.001). There was a decrease in the percentage of hospitalizations related to limb-salvage procedures (from 79.4% to 71.3%, p = 0.001). The opposite tendency was observed among urgent hospital admissions (from 67.0% to 73.2%, p = 0.01), which was related to a significant increase in the number of minor amputations (from 3146 to 4269, p = 0.017). This rise was in parallel with the increase in the percentage of patients who died during hospitalization due to DFU (from 3.9% to 4.8%, p = 0.03). The number of deaths has not changed significantly (from 590.7 to 668.0, p = 0.26). The results of the conducted analyses confirm the negative tendencies in the medical care of patients with DFU during the first year of the pandemic in Poland. Changes in therapy schemes and stronger patient support following this period are necessary to avoid further complications in patients with DFU.

Characteristics of Diabetic Foot Ulcer Patients Pre- and During COVID-19 Pandemic: Lessons Learnt From a National Referral Hospital in Indonesia

Background:

Diabetic foot ulcer (DFU) is one of the most terrifying diabetic complications for patients, due to the high mortality rate and risk for amputation. During the COVID-19 pandemic, many diabetic patients limited their visits to the hospital, resulting in delays for treatment especially in emergency cases.

Objective:

This study aimed to compare the characteristics of patients with DFU pre- and during COVID-19 pandemic period. Methods: This study was a retrospective cohort study using foot registry data. We compared our patients’ characteristics pre-COVID-19 pandemic period (1 March 2019-28 February 2020) and during COVID-19 pandemic period (1 March 2020-28 February 2021).

Results:

Cohorts of 84 and 71 patients with DFU pre- and during COVID-19 pandemic period, respectively, were included in this study. High infection grade (66.7% vs 83.1%, P = .032), osteomyelitis event (72.6% vs 87.3%, P = .04), leukocyte count (15 565.0/μL vs 20 280.0/μL, P = .002), neutrophil-to-lymphocyte ratio (7.7 vs 12.1, P = .008), waiting time-to-surgery (39.0 h vs 78.5 h, P = .034), and number of major amputation (20.2% vs 39.4%, P = .014) were significantly higher during the COVID-19 pandemic period.

Conclusion:

During the COVID-19 pandemic, patients with DFU had more severe infection, higher proportion of osteomyelitis, longer waiting time for getting surgical intervention, and higher incidence of major amputation.

Major Lower-Limb Amputation During the COVID Pandemic in South India

People with diabetes have a higher risk of lower-limb amputations than people without diabetes. The risk of avoidable lower-limb amputations has increased in the coronavirus disease 2019 (COVID-19) lockdown period. Hence, we conducted a retrospective, single-centered study on major amputations during the prepandemic period (March 25, 2019-December 31, 2019) and pandemic period (March 25, 2020-December 31, 2020). During the prepandemic period, 24 major amputations (below-knee and above-knee amputations) were performed and during the pandemic period, 37 major amputations were performed. There was a 54.1% increase in major amputations noted in the pandemic period more than the prepandemic period. This increase may also be due to irregular/missed hospital visits, improper diet, nonadherence to the medications, and physical inactivity. This study shows the indirect effect of the COVID-19 pandemic on people with diabetes, resulting in the increased incidence of lower-extremity amputations (below-knee and above-knee amputations) which might cause a drastic impact on their quality of life. This study also emphasizes the importance of easy and routine access to foot-care specialists to prevent avoidable amputations.

ICAM-1 levels in patients with covid-19 with diabetic foot ulcers: A prospective study in southeast asia

BACKGROUND

Viral infection can compound the severity of pre-existing inflammation caused by underlying diseases. For those with a chronic, immune-related condition such as diabetic foot ulcers (DFUs), the coronavirus disease (COVID-19) serves to exacerbate the inflammatory burden. Serum levels of intracellular adhesion molecule-1 (ICAM-1), a primary mediator of cell adhesion express in the inflammatory process, are often used to indicate the gravity of all inflammatory conditions. Therefore, the purpose of this study was to investigate serum ICAM-1 levels before and after debridement in patients with DFUs who were also diagnosed as COVID-19 positive compared with those who were COVID-19 negative.

METHODS

20 patients with DFUs were screened for COVID-19 and then divided into COVID-19 positive and negative groups according to the results. Before debridement, chest x-rays and blood analysis, including ICAM-1 serum levels, were performed in both groups. Only ICAM-1 serum levels were measured after debridement.

RESULTS

Of the 20 patients included in this study, 55% were male (n = 11) and 45% were female (n = 9). The mean age was 52.9 ± 1.9 years. ICAM-1 levels in patients with DFU in the COVID-19-positive group were significantly higher than those in the COVID-19-negative group (median 317.2 vs 149.2, respectively; p < 0.001). Serum levels of ICAM-1 reduced significantly in patients with DFU in the COVID-19-positive group were significantly higher than those in the COVID-19-negative group after debridement (median 312.5 vs 130.3; p < 0.001).

CONCLUSION

ICAM-1 serum levels represent an additional, initial screening marker for COVID-19.