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Jain SN, Choi JY, Cooper B, Renwick B, Mohamed MM, Makris SA. Long-Term Impact of COVID-19 Related Disruption of National Health Service Elective Services on Emergency Major Lower Limb Amputations. Ann Vasc Surg 2024; 102:84-91. [PMID: 38280485 DOI: 10.1016/j.avsg.2023.11.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 10/29/2023] [Accepted: 11/05/2023] [Indexed: 01/29/2024]
Abstract
BACKGROUND The COVID-19 pandemic has affected the healthcare systems worldwide since the dawn of 2020. In March 2020, the United Kingdom government announced the first national lockdown which severely disturbed all National Health Service (NHS) healthcare elective services. Our aim is to assess the long-term impact of COVID-19 related disruption of NHS elective services on emergency major lower limb amputations (MLLAs). METHODS Patients' data for emergency MLLA for critical limb-threatening ischemia and diabetic foot infections performed at Aberdeen Royal Infirmary was collected through Trakcare and divided into the control prepandemic group (April 2018-March 2020) and the pandemic group (April 2020-March 2022). The statistical analysis was conducted using the IBM SPSS software (v28.0.1.1 [14]). RESULTS A total of 358 patients underwent MLLA and 206 (57.5%) of these had diabetes mellitus. There was a 17% increase in the number of urgent referrals and every 1 in 5 of these finally underwent an amputation. There was an increase in the absolute number of Above- and Below-Knee amputations. There was a statistically significant increase by 33% in emergency MLLAs during the pandemic period (P < 0.05). A total of 165 postoperative deaths up to December 2022 were recorded with 30-day mortality rate of 7.26% (n = 26). CONCLUSIONS NHS vascular management groups should update themselves with evolving technologies to optimize the care provided during future unprecedented times. Furthermore, more effective measures should also be implemented to avoid delayed presentations, which can potentially lead to higher rates of major limb amputations.
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Affiliation(s)
- Shubham N Jain
- Department of Vascular Surgery, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | - Jean Y Choi
- Department of Vascular Surgery, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | - Benjamin Cooper
- Department of Vascular Surgery, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | - Bryce Renwick
- Department of Vascular Surgery, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | - Mirghani M Mohamed
- Department of Vascular Surgery, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | - Sotirios A Makris
- Department of Vascular Surgery, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK.
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2
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Hartmann-Boyce J, Highton P, Rees K, Onakpoya I, Suklan J, Curtis F, O'Mahoney L, Morris E, Kudlek L, Morgan J, Lynch R, Marpadga S, Seidu S, Khunti K. The impact of the COVID-19 pandemic and associated disruptions in health-care provision on clinical outcomes in people with diabetes: a systematic review. Lancet Diabetes Endocrinol 2024; 12:132-148. [PMID: 38272607 DOI: 10.1016/s2213-8587(23)00351-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 11/10/2023] [Accepted: 11/13/2023] [Indexed: 01/27/2024]
Abstract
The COVID-19 pandemic triggered disruptions to health care and lifestyles that could conceivably impact diabetes management. We set out to identify the impact of disruptions caused by COVID-19 on clinical outcomes in people with diabetes. We performed a systematic review of the available literature in the MEDLINE and OVID databases from Jan 1, 2020, to June 7, 2023, and included 138 studies (n>1 000 000 people). All but five studies were judged to be at some risk of bias. All studies compared prepandemic with pandemic periods. All-cause mortality (six studies) and diabetes-related mortality (13 studies) showed consistent increases, and most studies indicated increases in sight loss (six studies). In adult and mixed samples, data generally suggested no difference in diabetic ketoacidosis frequency or severity, whereas in children and adolescents most studies showed increases with some due to new-onset diabetes (69 studies). Data suggested decreases in hospital admissions in adults but increases in diabetes-related admissions to paediatric intensive care units (35 studies). Data were equivocal on diabetic foot ulcer presentations (nine studies), emergency department admissions (nine studies), and overall amputation rates (20 studies). No studies investigated renal failure. Where reported, the impact was most pronounced for females, younger people, and racial and ethnic minority groups. Further studies are needed to investigate the longer-term impact of the pandemic and the on potential differential impacts, which risk further exacerbating existing inequalities within people with diabetes.
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Affiliation(s)
- Jamie Hartmann-Boyce
- Department of Health Promotion and Policy, University of Massachusetts Amherst, Amherst, MA, USA; Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
| | | | | | - Igho Onakpoya
- Department for Continuing Education, University of Oxford, Oxford, UK
| | - Jana Suklan
- National Institute for Health and Care Research Newcastle In Vitro Diagnostics Co-operative, Newcastle University, Newcastle, UK
| | - Ffion Curtis
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | | | - Elizabeth Morris
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Laura Kudlek
- Medical Research Council Epidemiology Unit, University of Cambridge, Cambridge, UK
| | - Jessica Morgan
- Medical Sciences Division, University of Oxford, Oxford, UK
| | - Rosie Lynch
- Medical Sciences Division, University of Oxford, Oxford, UK
| | | | - Samuel Seidu
- Diabetes Research Centre, University of Leicester, UK
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3
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Diabetes Care for You: leadership, followership, partnership. PRACTICAL DIABETES 2023. [DOI: 10.1002/pdi.2436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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4
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Narres M, Claessen H, Kvitkina T, Rosenbauer J, Scheider M, Morbach S, Icks A. Hospitalisation rate and mortality among people with and without diabetes during the COVID-19 pandemic year 2020. Eur J Epidemiol 2022; 37:587-590. [PMID: 35674859 PMCID: PMC9175520 DOI: 10.1007/s10654-022-00865-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 03/19/2022] [Indexed: 11/03/2022]
Abstract
Most studies reported reduced health care use among people with diabetes during the COVID-19 pandemic. This may be due to restricted medical services or people avoiding health care services because they fear being infected with COVID-19 in health care facilities. The aim of our study was to analyse hospitalisation and mortality in people with and without diabetes in Germany during the COVID-19 pandemic year 2020 compared to 2017-2019. The data were sourced from a German statutory health insurance company covering 3.2 million people. We estimated age-sex standardised rates of mortality, all-cause hospitalisation, hospitalisation due to coronary heart disease (CHD), acute myocardial infarction (AMI), stroke, diabetic foot syndrome (DFS), and major and minor amputations in people with and without diabetes. We predicted rates for 2020 using Poisson regression based on results from 2017-2019 and compared these with the observed rates.In people with diabetes, the hospitalisation rate for major amputation was significantly increased, while all-cause hospitalisation rate and hospitalisation due to CHD, AMI and DFS were significantly decreased compared to the previous period. Moreover, we found a significantly increased mortality and hospitalisation rate for minor amputation in people without diabetes while all-cause hospitalisation and hospitalisation due to CHD and AMI was significantly lower during the COVID-19 pandemic year 2020.We observed changes in health care utilisation and outcomes during the COVID-19 pandemic compared to previous years in people with and without diabetes. Concerning diabetes care, the increase of hospitalisations due to amputation in people with diabetes with a simultaneous reduction in DFS needs special attention.
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Affiliation(s)
- Maria Narres
- Institute for Health Services Research and Health Economics, German Diabetes Centre (DDZ), Leibniz Centre for Diabetes Research at Heinrich-Heine-University Düsseldorf, Auf´m Hennekamp 65, 40225, Düsseldorf, Germany.,Institute for Health Services Research and Health Economics, Center for Health and Society, Faculty of Medicine, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.,German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
| | - Heiner Claessen
- Institute for Health Services Research and Health Economics, German Diabetes Centre (DDZ), Leibniz Centre for Diabetes Research at Heinrich-Heine-University Düsseldorf, Auf´m Hennekamp 65, 40225, Düsseldorf, Germany. .,Institute for Health Services Research and Health Economics, Center for Health and Society, Faculty of Medicine, Heinrich Heine University Düsseldorf, Düsseldorf, Germany. .,German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany.
| | - Tatjana Kvitkina
- Institute for Health Services Research and Health Economics, German Diabetes Centre (DDZ), Leibniz Centre for Diabetes Research at Heinrich-Heine-University Düsseldorf, Auf´m Hennekamp 65, 40225, Düsseldorf, Germany.,Institute for Health Services Research and Health Economics, Center for Health and Society, Faculty of Medicine, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.,German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
| | - Joachim Rosenbauer
- German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany.,Institute for Biometrics and Epidemiology, German Diabetes Center (DDZ) Leibniz Center for Diabetes Research at Heinrich Heine University Dusseldorf, Düsseldorf, Germany
| | - Maria Scheider
- Department of Health Management, AOK Rheinland/Hamburg - die Gesundheitskasse, Düsseldorf, Germany
| | - Stephan Morbach
- Institute for Health Services Research and Health Economics, Center for Health and Society, Faculty of Medicine, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.,Department of Diabetes and Angiology, Marienkrankenhaus, Soest, Germany
| | - Andrea Icks
- Institute for Health Services Research and Health Economics, German Diabetes Centre (DDZ), Leibniz Centre for Diabetes Research at Heinrich-Heine-University Düsseldorf, Auf´m Hennekamp 65, 40225, Düsseldorf, Germany.,Institute for Health Services Research and Health Economics, Center for Health and Society, Faculty of Medicine, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.,German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
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5
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Bonnet J, Macioce V, Jalek A, Bouchdoug K, Elleau C, Gras‐Vidal M, Pochic J, Avignon A, Sultan A. Covid-19 lockdown showed a likely beneficial effect on diabetic foot ulcers. Diabetes Metab Res Rev 2022; 38:e3520. [PMID: 35080096 PMCID: PMC9015270 DOI: 10.1002/dmrr.3520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 11/29/2021] [Accepted: 01/18/2022] [Indexed: 11/11/2022]
Abstract
AIMS During the Covid-19 epidemic, many countries imposed population lockdown. This study aimed to analyse diabetic foot ulcer (DFU) evolution of outpatients between the lockdown period and 1 month after its end. MATERIALS AND METHODS We conducted a prospective, observational, single-centre study without modification of care. All patients who followed up for a DFU in the study centre between 15 April 2020 and 11 May 2020 were included. The baseline assessment occurred 4 weeks after the beginning of lockdown and the follow-up visit 4-6 weeks after easing of lockdown. The primary analysis was based on the Site, Ischaemia, Neuropathy, Bacterial infection, Area, Depth (SINBAD) classification. RESULTS Twenty-seven patients were included, median 69.4 years, and 25 were followed-up at easing of lockdown. The median SINBAD score was 2 (interquartile range 1; 3) at inclusion and 1 (1; 2) at easing of lockdown, with a mean change of -0.32 (95% confidence interval -0.93; 0.29). Seventy-two percent of the population had a stable or improved score between the two visits. The proportion of patients using off-loading footwear was higher among those whose SINBAD score improved compared to those whose score worsened or remained stable (72%, 44% and 28%, respectively). Diabetes type was linked to DFU prognosis. Five patients (20%) were hospitalized during the follow-up period. CONCLUSION Lockdown appears to have had a positive effect on DFU if patients remain under the care of their expert wound centre. We believe this effect is related to better compliance with offloading. The wide use of tele-medicine seems relevant for the follow-up of DFU.
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Affiliation(s)
- Jean‐Baptiste Bonnet
- Endocrinology Diabetes DepartmentCHU MontpellierUniversité MontpellierMontpellierFrance
- Desbrest Institute of Epidemiology and Public HealthIDESP UMR UA11 INSERMUniversité MontpellierMontpellierFrance
| | - Valérie Macioce
- Clinical Research and Epidemiology UnitCHU MontpellierUniversité MontpellierMontpellierFrance
| | - Abdulkader Jalek
- Endocrinology Diabetes DepartmentCHU MontpellierUniversité MontpellierMontpellierFrance
- Desbrest Institute of Epidemiology and Public HealthIDESP UMR UA11 INSERMUniversité MontpellierMontpellierFrance
| | - Karim Bouchdoug
- Clinical Research and Epidemiology UnitCHU MontpellierUniversité MontpellierMontpellierFrance
| | - Cécile Elleau
- Endocrinology Diabetes DepartmentCHU MontpellierUniversité MontpellierMontpellierFrance
| | | | - Julie Pochic
- Endocrinology Diabetes DepartmentCHU MontpellierUniversité MontpellierMontpellierFrance
| | - Antoine Avignon
- Endocrinology Diabetes DepartmentCHU MontpellierUniversité MontpellierMontpellierFrance
- Desbrest Institute of Epidemiology and Public HealthIDESP UMR UA11 INSERMUniversité MontpellierMontpellierFrance
| | - Ariane Sultan
- Endocrinology Diabetes DepartmentCHU MontpellierUniversité MontpellierMontpellierFrance
- PhymedexpUniversité de MontpellierInsermCNRSCHRU de MontpellierMontpellierFrance
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de Mestral C, Gomez D, Wilton AS, Lee DS, Albalawi Z, Austin PC, Jacob-Brassard J, Urbach DR, Al-Omran M, Baxter NN. A Population-Based Analysis of Diabetes-Related Care Measures, Foot Complications, and Amputation During the COVID-19 Pandemic in Ontario, Canada. JAMA Netw Open 2022; 5:e2142354. [PMID: 34985514 PMCID: PMC8733837 DOI: 10.1001/jamanetworkopen.2021.42354] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
IMPORTANCE Deferred diabetic foot screening and delays in timely care of acute foot complications during the COVID-19 pandemic may have contributed to an increase in limb loss. OBJECTIVE To evaluate the association of the COVID-19 pandemic with diabetes-related care measures, foot complications, and amputation. DESIGN, SETTING, AND PARTICIPANTS This population-based cohort study included all adult residents of Ontario, Canada, with diabetes and compared the rates of selected outcomes from January 1, 2020, to February 23, 2021, vs January 1, 2019, to February 23, 2020. MAIN OUTCOMES AND MEASURES Comprehensive in-person diabetes care assessment, including foot examination; hemoglobin A1c (HbA1c) measurement; emergency department visit or hospitalization for diabetic foot ulceration, osteomyelitis, or gangrene; lower extremity open or endovascular revascularization; minor (toe or partial-foot) amputation; and major (above-ankle) leg amputation. Rates and rate ratios (RRs) comparing 2020-2021 vs 2019-2020 for each measure were calculated for 10-week periods, anchored relative to onset of the pandemic on March 11, 2020 (11th week of 2020). RESULTS On March 11, 2020, the study included 1 488 605 adults with diabetes (median [IQR] age, 65 [55-74] years; 776 665 [52.2%] men), and on March 11, 2019, the study included 1 441 029 adults with diabetes (median [IQR] age, 65 [55-74] years; 751 459 [52.1%] men). After the onset of the pandemic, rates of major amputation in 2020-2021 decreased compared with 2019-2020 levels. The RR for the prepandemic period from January 1 to March 10 was 1.05 (95% CI, 0.88-1.25), with RRs in the pandemic periods ranging from 0.86 (95% CI, 0.72-1.03) in May 20 to July 28 to 0.95 (95% CI, 0.80-1.13) in October 7 to December 15. There were no consistent differences in demographic characteristics or comorbidities of patients undergoing amputation in the 2020-2021 vs 2019-2020 periods. Rates of comprehensive in-person diabetes care assessment and HbA1c measurement declined sharply and remained below 2019-2020 levels (eg, in-person assessment, March 11 to May 19: RR, 0.28; 95% CI, 0.28-0.28). The rates of emergency department visits (eg, March 11 to May 19: RR, 0.67; 95% CI, 0.61-0.75), hospitalization (eg, March 11 to May 19: RR, 0.77; 95% CI, 0.68-0.87), open revascularization (eg, March 11 to May 19: RR, 0.66; 95% CI, 0.56-0.79), endovascular revascularization (March 11 to May 19: RR, 0.70; 95% CI, 0.61-0.81), and minor amputation (March 11 to May 19: RR, 0.70; 95% CI, 0.60-0.83) initially dropped but recovered to 2019-2020 levels over the study period. CONCLUSIONS AND RELEVANCE In this population-based cohort study, disruptions in care related to the COVID-19 pandemic were not associated with excess leg amputations among people living with diabetes. As the pandemic ends, improved prevention and treatment of diabetic foot complications will be necessary to maintain these positive results.
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Affiliation(s)
- Charles de Mestral
- Li Ka Shing Knowledge Institute of St Michael’s Hospital, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Ontario, Canada
- Diabetes Action Canada, Toronto, Ontario, Canada
| | - David Gomez
- Li Ka Shing Knowledge Institute of St Michael’s Hospital, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Ontario, Canada
| | | | - Douglas S. Lee
- ICES, Toronto, Ontario, Canada
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Ontario, Canada
| | - Zaina Albalawi
- Division of Endocrinology and Metabolism, Faculty of Medicine, Memorial University, St John’s, Newfoundland and Labrador, Canada
| | | | - Jean Jacob-Brassard
- ICES, Toronto, Ontario, Canada
- Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Ontario, Canada
| | - David R. Urbach
- ICES, Toronto, Ontario, Canada
- Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Ontario, Canada
| | - Mohammed Al-Omran
- Li Ka Shing Knowledge Institute of St Michael’s Hospital, Toronto, Ontario, Canada
- Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Ontario, Canada
- Diabetes Action Canada, Toronto, Ontario, Canada
| | - Nancy N. Baxter
- Li Ka Shing Knowledge Institute of St Michael’s Hospital, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Ontario, Canada
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
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7
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Driver VR, Couch KS, Eckert KA, Gibbons G, Henderson L, Lantis J, Lullove E, Michael P, Neville RF, Ruotsi LC, Snyder RJ, Saab F, Carter MJ. The impact of the SARS-CoV-2 pandemic on the management of chronic limb-threatening ischemia and wound care. Wound Repair Regen 2021; 30:7-23. [PMID: 34713947 PMCID: PMC8661621 DOI: 10.1111/wrr.12975] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/13/2021] [Accepted: 10/05/2021] [Indexed: 01/02/2023]
Abstract
In the wake of the coronavirus pandemic, the critical limb ischemia (CLI) Global Society aims to develop improved clinical guidance that will inform better care standards to reduce tissue loss and amputations during and following the new SARS‐CoV‐2 era. This will include developing standards of practice, improve gaps in care, and design improved research protocols to study new chronic limb‐threatening ischemia treatment and diagnostic options. Following a round table discussion that identified hypotheses and suppositions the wound care community had during the SARS‐CoV‐2 pandemic, the CLI Global Society undertook a critical review of literature using PubMed to confirm or rebut these hypotheses, identify knowledge gaps, and analyse the findings in terms of what in wound care has changed due to the pandemic and what wound care providers need to do differently as a result of these changes. Evidence was graded using the Oxford Centre for Evidence‐Based Medicine scheme. The majority of hypotheses and related suppositions were confirmed, but there is noticeable heterogeneity, so the experiences reported herein are not universal for wound care providers and centres. Moreover, the effects of the dynamic pandemic vary over time in geographic areas. Wound care will unlikely return to prepandemic practices. Importantly, Levels 2–5 evidence reveals a paradigm shift in wound care towards a hybrid telemedicine and home healthcare model to keep patients at home to minimize the number of in‐person visits at clinics and hospitalizations, with the exception of severe cases such as chronic limb‐threatening ischemia. The use of telemedicine and home care will likely continue and improve in the postpandemic era.
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Affiliation(s)
- Vickie R Driver
- Wound Healing, Limb Preservation and Hyperbaric Centers, Inova Heart and Vascular Institute Inova Health System, Falls Church, Virginia, USA
| | - Kara S Couch
- Wound Care Services, George Washington University Hospital, Washington, District of Columbia, USA
| | | | - Gary Gibbons
- Center for Wound Healing, South Shore Health, Weymouth, Massachusetts, USA.,Boston University School of Medicine, Boston, Massachusetts, USA
| | - Lorena Henderson
- PULSE Amputation Prevention Centers, Affiliates, El Paso Cardiology Associates, P.A., El Paso, Texas, USA
| | - John Lantis
- Mount Sinai West Hospital, Icahn School of Medicine, New York, New York, USA
| | - Eric Lullove
- West Boca Center for Wound Healing, Coconut Creek, Florida, USA
| | - Paul Michael
- Palm Beach Heart & Vascular, JFK Wound Management & Limb Preservation Center, Lake Worth, Florida, USA
| | - Richard F Neville
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA.,Department of Surgery, Inova Health System, Falls Church, Virginia, USA
| | - Lee C Ruotsi
- Saratoga Hospital Center for Wound Healing and Hyperbaric Medicine, Saratoga Springs, New York, USA
| | - Robert J Snyder
- Barry University School of Podiatric Medicine, Miami Shores, Florida, USA
| | - Fadi Saab
- Advanced Cardiac & Vascular Centers for Amputation Prevention, Grand Rapids, Michigan, USA
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