Saving the Diabetic Foot During the COVID-19 Pandemic: A Tale of Two Cities

The experience of an adult diabetic foot unit continuing face-to-face consults during the COVID-19 pandemic

BACKGROUND AND AIMS

The COVID-19 pandemic significantly disrupted lower limb diabetes care. We aimed to map trends in diabetes-related lower limb amputation and hospitalisation rates through the COVID-19 pandemic.

METHODS

We performed a retrospective cohort study of all individuals who underwent a lower limb amputation for a diabetes-related foot complication from 2018 to 2021 at the Royal Melbourne Hospital, a quaternary hospital in Australia. Hospitalisation rates with a diabetes-related foot complication were collected for comparison. The start of the COVID-19 epoch was defined as 16 March 2020, when a state of emergency was declared in Melbourne.

RESULTS

During the study period, 360 lower limb amputations for diabetes-related foot complications were performed in 247 individuals. The median monthly number of amputations remained stable prior to and during the COVID-19 epoch; there was a median of 8.0 amputations per month (interquartile range (IQR) = 6.5-11) before COVID-19, compared to 6.5 amputations (IQR = 5.0-8.3) during the COVID-19 epoch (P = 0.23). Hospitalisation with a diabetes-related foot complication significantly increased from a median monthly rate of 11 individuals (IQR = 9.0-14) before COVID-19 to 19 individuals (IQR = 14-22) during the COVID-19 epoch (p < 0.001).

CONCLUSIONS

Despite increased hospitalisations for diabetes-related foot complications during COVID-19, there was not a corresponding increase in amputation rates. Face-to-face care of diabetes-related foot complications was prioritised at this centre and may have contributed to stable amputation rates during the pandemic.

Research hotspots and trends in nursing for diabetic foot ulcers: A bibliometric analysis from 2013 to 2023

Background

Nursing can effectively prevent and ameliorate diabetic foot ulcers (DFU). However, there is a lack of literature on the bibliometric analysis of DFU nursing. This study aimed to analyze the research hotspots and development trends in DFU nursing over the past 10 years to provide references for future related research.

Methods

The Web of Science Core Collection was used to retrieve literature related to DFU nursing from 2013 to 2023. Analyses included the annual publication trends; author, institution, and country collaborations; journal and literature co-citation; and keyword co-occurrence, clustering, and bursting, performed using CiteSpace 5.8 R3.

Results

A total of 229 papers were included, showing an upward trend in annual publications. American scholar David G Armstrong (n = 3) and King's College Hospital London (n = 4) were the most productive authors and institutions, respectively. The United States ranked first (n = 45) in national contributions, followed by China and Brazil. The overall research strength between authors and institutions was relatively scattered, and intensive cooperation has not yet been formed. National collaborations resulted in a core team dominated by Europe and North America with concentrated research strengths. The most frequently co-cited journal and co-cited reference were Diabetes Care (111 citations) and Armstrong DG (2017) (131 citations), separately. Research hotspots mainly focused on risk assessment, classification systems, protective measures, and clinical management of DFU. "Primary care" and "intervention efficacy" were identified as the research trends in the coming years.

Conclusion

The field of DFU nursing requires more attention. Academic exchange and cooperation between authors, institutions, and countries should be strengthened. Our future research will focus on the latest hotspots and trends, conducting more in-depth and comprehensive studies on DFU management.

Diabetic peripheral arterial disease in COVID-19 pandemic

Both diabetes and peripheral arterial disease (PAD) have complex interactions with COVID-19. PAD is one of the most important underlying factors in the development of diabetic foot. The COVID-19 pandemic has also caused an increase in cardiovascular complications in those with chronic diseases, including diabetics, due to both the thrombophilic course of the viral disease and the lockdown measures applied for prevention. Since both COVID-19 and diabetes mellitus predispose to thrombosis, PAD is likely to have a more severe course in diabetic patients with COVID-19. The aim of our study is to discuss the complications, prophylaxis, and treatment of PAD, which is a serious complication of diabetes, during the pandemic period.

The impact of COVID-19 on the care of diabetic foot ulcers: A scoping review

AIM

The aims and objectives of this scoping review were to conduct a systematic search of the literature to identify the nature and extent of the research evidence to which the COVID-19 pandemic impacted and disrupted the care of Diabetic Foot Ulcers (DFU) and the subsequent impact on patient outcomes. Secondly, to identify transformation in models of care and service delivery, adoption of innovative technologies and new models of service innovations, including modalities such as telehealth that were adopted during the pandemic.

METHODS

This systematic scoping review was conducted in accordance with the Joanna Briggs Institute methodology for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping reviews (PRISMA-ScR).

RESULTS

Nineteen papers were included. These studies explored aspects of care for DFUs during the COVID-19 pandemic. The focus of these studies ranged from exploring new modalities of care such as telehealth, reporting of clinical outcomes, development of triage systems and patient behaviors during COVID-19.

CONCLUSION

Ten of twelve studies reported on DFU outcomes and reported a worsening of outcomes compared to pre-pandemic times. Reduced DFU presentations, alongside an increase in urgent hospitalisations and amputation, were key themes that emerged from this review. More high-quality evidence is needed to establish any longer-lasting effects of the Covid-19 pandemic on people living with DFU. Further, there is a lack of evidence relating to the feasibility and success of telemedicine and limited data on changes to service delivery, including triage systems in this patient cohort.

Confronting a New Challenge in Plastic Surgery: MDR Infections in Patients with Chronic Wounds

BACKGROUND

The presence of a wound can be anywhere from non-problematic to life-threatening on a severity spectrum, with bacterial infection and resistance playing a major role in the development of chronicity, delaying wound healing. Wound colonization with multiple organisms and the limited number of effective antibiotics place a heavy burden on the healthcare system, with patients going through multiple surgeries during a prolonged hospitalization time. By analyzing the resistance patterns of pluri-bacterial populations and the approach used in managing complex cases, we aim to improve the protocols applied in caring for chronic wounds in our practice and share our experiences and observations.

METHODS

We designed a retrospective study on 212 diabetic and non-diabetic patients, aiming to evaluate the course of chronic wound treatment in our practice. We focused on the impact that MDR bacteria and diabetes have on surgical outcomes and their role in the healing process.

RESULTS

Patients who received empiric antibiotic therapy before being admitted eventually presented with multiple MDR bacteria compared to those who did not receive antibiotics (p = 0.014). The presence of at least one MDR bacteria in the wound bed was associated with ulcers reaching bone (p = 0.02) and was positively correlated with the number of surgeries performed (p < 0.001). Diabetes played a significant role in surgery-related complications (p = 0.02) and hospitalization time (p < 0.001).

CONCLUSIONS

Proper management of chronic wounds requires a comprehensive, multidisciplinary approach and a thorough understanding of antibiotic usage. To address this need, we have developed and implemented a chronic wound treatment protocol in our clinic, with the goal of discharging patients once their ulcers have been treated and closed. A key summary of the protocol presented is to reduce the incidence of MDR bacteria and improve the patient's quality of life.

The Advent of Artificial Intelligence in Diabetic Foot Medicine: A New Horizon, a New Order, or a False Dawn?

In a world where automation is becoming increasingly common, easier collection of mass of data and powerful computer processing has meant a transformation in the field of artificial intelligence (AI). The diabetic foot is a multifactorial problem; its issues render it suitable for analysis, interrogation, and development of AI. The latter has the potential to deliver many solutions to issues of delayed diagnosis, compliance, and defining preventative treatments. We describe the use of AI and the development of artificial neural networks that may supplement the failed networks in the diabetic foot. The potential of this technology, current developing applications, and their limitations for diabetic foot care are suggested.

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.

Patients' Buying Behavior for Non-Reimbursed Off-Loading Devices Used in Diabetic Foot Ulcer Treatment-An Observational Study during COVID-19 Pandemic from a Romanian Physical Therapy Unit

Diabetic foot ulcer non-reimbursed treatment depends on multiple factors, including the patient's buying behaviors. Factors affecting buying behaviors for the removable off-loading devices are not completely understood. The aim of this study was to investigate the patients' buying behaviors of the removable off-loading devices and their influence on the DFU treatment outcomes remotely monitored during the COVID-19 pandemic. In this prospective observational study, 45 patients affected by diabetic peripheral neuropathy, with/without peripheral arterial disease, with foot ulcers treated with removable devices were remotely monitored. Prefabricated removable cast walkers, insoles, and therapeutic footwear were the proposed off-loading methods. Patients affected by high blood pressure (p = 0.018), peripheral arterial disease (p = 0.029), past amputations (p = 0.018), and ulcer on the left foot (p = 0.007) bought removable cast walkers. Rural provenience (p = 0.011) and male (p = 0.034) did not buy a removable walker. The healing rate was 69.4%, while the median healing time was 20 weeks. High blood pressure negatively influenced healing time (p = 0.020). Patients who bought the most efficient treatment method for DFUs were females from urban provenience, with amputation in the past, with peripheral arterial disease, and with high blood pressure.

Revascularization prevents amputation among patients with diabetic foot during the COVID-19 era

OBJECTIVE

The COVID-19 pandemic has led to significant changes in healthcare systems that impact the management of chronic diseases such as diabetic foot (DF). We hypothesized that lack of access to healthcare would increase the severity of disease and lead to worse outcomes.

METHODS

The medical records of patients with DF were reviewed to determine demographic data and outcomes including wound healing, major amputation (MA), and death. Groups were divided into the pre-COVID-19 era (15 March 2019-15 March 2020) and the COVID-19 era (16 March 2020-16 March 2021); multivariable logistic analysis was performed to identify risk factors for MA.

RESULTS

261 patients with DF were included, 163 in the pre-COVID-19 era and 98 during the COVID-19 era. Patients in the COVID-19 presented with increased cardiovascular disease (19 vs 7%, p = 0.01), increased mean HbA1C (9.1 ± 2.1 vs 8.2 ± 2.1, p = 0.008) and higher WIFI-IV stage (78 vs 53%, p ≤ 0.0001). Patients with DF in the COVID-19 era were more likely to require MA (41 vs 21%, p ≤ 0.0001). Revascularization (OR = 0.12; 95% CI, 0.038-0.38) was a protective factor to reduce MA.

CONCLUSIONS

MA among DF patients increased two-fold during the COVID-19 era. Revascularization avoids MA in diabetic patients even during the COVID-19 pandemic, suggesting that revascularization should be performed when possible.

Wearable non-invasive glucose sensors based on metallic nanomaterials

The development of wearable non-invasive glucose sensors provides a convenient technical means to monitor the glucose concentration of diabetes patients without discomfortability and risk of infection. Apart from enzymes as typical catalytic materials, the active catalytic materials of the glucose sensor are mainly composed of polymers, metals, alloys, metal compounds, and various metals that can undergo catalytic oxidation with glucose. Among them, metallic nanomaterials are the optimal materials applied in the field of wearable non-invasive glucose sensing due to good biocompatibility, large specific surface area, high catalytic activity, and strong adsorption capacity. This review summarizes the metallic nanomaterials used in wearable non-invasive glucose sensors including zero-dimensional (0D), one-dimensional (1D), and two-dimensional (2D) monometallic nanomaterials, bimetallic nanomaterials, metal oxide nanomaterials, etc. Besides, the applications of wearable non-invasive biosensors based on these metallic nanomaterials towards glucose detection are summarized in detail and the development trend of the wearable non-invasive glucose sensors based on metallic nanomaterials is also outlook.

Pie diabético y pandemia de la COVID-19: adaptación al uso de la Telemedicina por los especialistas de pie y tobillo de los Servicios de Traumatología de la Argentina

Introducción: La telemedicina fue la recomendación internacional durante la pandemia de COVID-19 para las consultas médicas de los pacientes con pie diabético. El objetivo de este estudio fue analizar el empleo de la telemedicina como herramienta en pacientes con pie diabético, por parte de especialistas en pie y tobillo de la Argentina. Como objetivos secundarios se planteó valorar la satisfacción percibida por los profesionales con el uso de esta herramienta, evaluar qué estrategias se usaron para realizar la consulta médica remota y determinar la permanencia al retornar a la actividad asistencial habitual. Materiales y Métodos: Se enviaron tres encuestas a los socios de la Sociedad Argentina de Medicina y Cirugía de la Pierna y Pie, entre mayo 2020 y abril de 2022. Resultados: La función más valiosa de la consulta remota fue la prevención (75% de los encuestados), el seguimiento clínico (54,1%), el seguimiento posoperatorio (41,6%) y el diagnóstico (29,1%). El recurso más utilizado fue la conversación telefónica, seguida del envío de imágenes por mensajería instantánea. Solo el 37,5% utilizó las plataformas de historia clínica virtual. Conclusiones: Los recursos más utilizados para la consulta remota fueron la conversación telefónica, seguida del envío de imágenes por mensajería instantánea. El 33,4% estaba conforme con la consulta por telemedicina en mayo de 2020, mientras que, en julio, la conformidad ascendió al 46,7%. En abril de 2022, solo el 13% continuaba con las consultas remotas.

Prediction of Foot Ulcers Using Artificial Intelligence for Diabetic Patients at Cairo University Hospital, Egypt

Introduction

In Egypt, diabetic foot ulcers markedly contribute to the morbidity and mortality of diabetic patients. Accurately predicting the risk of diabetic foot ulcers could dramatically reduce the enormous burden of amputation.

Objective

The aim of this study is to design an artificial intelligence-based artificial neural network and decision tree algorithms for the prediction of diabetic foot ulcers.

Methods

A case-control study design was utilized to fulfill the aim of this study. The study was conducted at the National Institute of Diabetes and Endocrine Glands, Cairo University Hospital, Egypt. A purposive sample of 200 patients was included. The tool developed and used by the researchers was a structured interview questionnaire including three parts: Part I: demographic characteristics; Part II: medical data; and Part III: in vivo measurements. Artificial intelligence methods were used to achieve the aim of this study.

Results

The researchers used 19 significant attributes based on medical history and foot images that affect diabetic foot ulcers and then proposed two classifiers to predict the foot ulcer: a feedforward neural network and a decision tree. Finally, the researchers compared the results between the two classifiers, and the experimental results showed that the proposed artificial neural network outperformed a decision tree, achieving an accuracy of 97% in the automated prediction of diabetic foot ulcers.

Conclusion

Artificial intelligence methods can be used to predict diabetic foot ulcers with high accuracy. The proposed technique utilizes two methods to predict the foot ulcer; after evaluating the two methods, the artificial neural network showed a higher improvement in performance than the decision tree algorithm. It is recommended that diabetic outpatient clinics develop health education and follow-up programs to prevent complications from diabetes.

A Novel Classification for Diabetic Foot Ulcers of the First Ray

OBJECTIVE

Diabetic foot ulcers of the first ray result from several distinct biomechanical mechanisms related to anatomical deformities, which must be addressed if surgical offloading is contemplated. The objective of this study was to create a classification of the anatomical deformities of first-ray ulcers that could lead to better standardization of treatment and reporting.

METHODS

The authors performed a file review of patients with diabetic neuropathy diagnosed with first-ray ulcers over a period of 3 years in an outpatient setting. Anatomical deformities were diagnosed clinically and reported with ulcer location. The primary classification was the metatarsophalangeal joint, the interphalangeal joint, and the distal phalanx.

RESULTS

Records for 59 patients (mean age, 62 years) with University of Texas A1 and A2 ulcers were reviewed. Mean ulcer duration was 2 months. The more common deformities were hallux valgus (41%), hallux valgus interphalangeus (14%), and hallux malleus (20%), and these were primarily associated with metatarsophalangeal, interphalangeal joint, and tip-of-toe ulcers, respectively (P < .0001).

CONCLUSIONS

By classifying ulcer locations, the relevant corrective surgery may be chosen. Although some prophylactic procedures may be safe and effective, prophylactic hallux valgus correction in the diabetic foot requires further study.

Tackling diabetic foot: limb salvage during the COVID-19 pandemic

PURPOSE

Lower extremity amputation resulting from diabetic foot ulcer, with neuropathic and/or ischemic etiologies, remains a devastating and costly complication of diabetes mellitus. This study evaluated changes in care delivery of diabetic foot ulcer patients during the COVID-19 pandemic. A longitudinal assessment evaluating the ratio of major lower extremity amputation to minor lower extremity amputations after implementation of novel strategies to combat access restrictions was compared to the pre-COVID-19 era.

METHODS

The ratio of major to minor lower extremity amputation (i.e. the high-to-low ratio) was assessed at two academic institutions, the University of Michigan, and University of Southern California, in a population of patients with diabetes who had direct access to multidisciplinary foot care clinics in the 2 years prior to the pandemic and the first 2 years of the COVID-19 pandemic.

RESULTS

Patient characteristics and volumes including patients with diabetes and those with a diabetic foot ulcer were similar between eras. In addition, inpatient diabetic foot-related admissions were similar, but were suppressed by government shelter in placed mandates and subsequent COVID-19 variants surges (e.g. delta, omicron). In the control group, the Hi-Lo ratio increased every 6 months by an average of 11.8%. Meanwhile, following STRIDE implementation during the pandemic, the Hi-Lo ratio reduced by (-)11% (p < 0.001) and doubled limb salvage efforts as compared to the baseline era. The reduction of the Hi-Lo ratio was not influenced significant by patient volumes or inpatient admissions for foot infections.

CONCLUSION

These findings signify the importance of podiatric care in the at-risk diabetic foot population. Through strategic planning and rapid implementation of at-risk diabetic foot ulcer triage, multidisciplinary teams were able to maintain accessible care during the pandemic which resulted in a reduction of amputations. Furthermore, this manuscript highlights the value of the Hi-Lo ratio as an indicator of institutional limb salvage efforts.

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.

The amputation and mortality of inpatients with diabetic foot ulceration in the COVID-19 pandemic and postpandemic era: A machine learning study

This study aimed to explore the clinical characteristic and outcomes of inpatients with diabetic foot ulceration (DFU) in 2019 (prelockdown) and 2020 (postlockdown) due to the COVID-19 pandemic, at an emergency medical service unit. Prediction models for mortality and amputation were developed to describe the risk factors using a machine learning-based approach. Hospitalized DFU patients (N = 23) were recruited after the lockdown in 2020 and matched with corresponding inpatients (N = 23) before lockdown in 2019. Six widely used machine learning models were built and internally validated using 3-fold cross-validation to predict the risk of amputation and death in DFU inpatients under the COVID-19 pandemic. Previous DF ulcers, prehospital delay, and mortality were significantly higher in 2020 compared to 2019. Diabetic foot patients in 2020 had higher hs-CRP levels (P = .037) but lower hemoglobin levels (P = .017). The extreme gradient boosting (XGBoost) performed best in all models for predicting amputation and mortality with the highest area under the curve (0.86 and 0.94), accuracy (0.80 and 0.90), sensitivity (0.67 and 1.00), and negative predictive value (0.86 and 1.00). A long delay in admission and a higher risk of mortality was observed in patients with DFU who attended the emergency center during the COVID-19 post lockdown. The XGBoost model can provide evidence-based risk information for patients with DFU regarding their amputation and mortality. The prediction models would benefit DFU patients during the COVID-19 pandemic.

Impaired wound healing is associated with poorer mood and reduced perceived immune fitness during the COVID-19 pandemic: A retrospective survey

Background and Aims

The coronavirus disease-2019 (COVID-19) pandemic disrupted medical care of patients with chronic wounds, and in combination with other negative effects of lockdown measures, this may have a negative effect on mood and quality of life. Until now, the consequences of the COVID-19 pandemic and associated lockdowns for individuals with impaired wound healing have not been investigated.

Methods

An online survey was conducted to evaluate perceived immune fitness, mood, and health, both before and during the COVID-19 pandemic.

Results

Of the 331 Dutch pharmacy students that completed the survey, N = 42 participants reported slow healing wounds and/or wound infection and were allocated to the impaired wound healing group; the other N = 289 participants served as control group. The survey assessed mood, perceived immune fitness, and health correlates for (a) the year 2019 (the period before the lockdown), (b) the first lockdown period (March 15-May 11, 2020), (c) summer 2020 (no lockdown), and (d) the second lockdown (November 2020-April 2021). The analysis revealed that negative mood effects, reductions in quality of life, and perceived immune fitness during the two lockdowns were significantly more pronounced among individuals that reported impaired wound healing compared to the control group. The effects on mood, perceived immune fitness, and health correlates were most pronounced for the second lockdown period.

Conclusion

The COVID-19 pandemic is associated with significantly poorer mood, quality of life, and reduced perceived immune fitness. These effects are significantly more pronounced among individuals with self-reported impaired wound healing.

Impact of COVID-19 pandemic on foot care services in Ontario, Canada

BACKGROUND

The COVID-19 pandemic has directly affected the delivery of health care services in Canada, including foot care. The goal of this descriptive study was to understand the impact of the early COVID-19 pandemic (March 2020 to April 2021) on chiropodists' and podiatrists' clinical practices and foot care service delivery in Ontario, Canada.

METHODS

A web-survey was completed by participating chiropodists and podiatrists registered with the College of Chiropodists of Ontario. The survey consisted of 31 multiple choice and open-ended items on clinical practice characteristics, foot care service delivery changes, perceived barriers during the pandemic, and its impact on clinicians. Descriptive statistics were used to characterize the sample and examine clinicians' responses, and qualitative content analysis was used to explore opened-ended items.

RESULTS

Of the 773 eligible clinicians, 279 participated for a response rate of 36.1%. Most respondents reported a decline in patient volume, an increase in urgent foot health problems, a financial impact on their clinical practices, an emotional impact, and substantial changes to how they provided foot care services, such as incorporating telehealth/virtual care into patient care. Factors that impact clinicians' perception of future pandemic preparedness are identified.

CONCLUSION

This study describes foot care service delivery in Ontario, Canada during the COVID-19 pandemic. The COVID-19 pandemic saw an increase in urgent foot health problems, decline in patient volume, and impacted clinicians' mental health and emotional well-being. Future studies should examine patients' experiences of foot care service delivery and maintaining their foot health during the pandemic, and further examination of factors that impact clinicians' perception of pandemic preparedness.

Post-COVID-19 related osteonecrosis of the jaw (PC-RONJ): an alarming morbidity in COVID-19 surviving patients

Purpose

The recent coronavirus disease (COVID-19) pandemic mainly affects the respiratory system; however, several oral and maxillofacial post-COVID-19 complications have also been observed. This series reports the growing number of osteonecrosis cases associated with post-COVID-19 patients.

Materials and methods

This is a retrospective, multi-center case series that reports cases with maxillary osteonecrosis after various periods of SARS-CoV-2 infection in the period between January and August 2021 based on the PROCESS guidelines.

Results

Twelve cases were reported with post-COVID-19 manifestation of spontaneous osteonecrosis of the maxillary jaw. Five patients were hospitalized during COVID-19 management and all of the twelve cases had at least one systematic Co-morbidity, and undertake corticosteroids prescription based on the COVID-19 disease treatment protocol. The mean onset of osteonecrosis symptoms appearance was 5.5 ± 2.43 weeks calculated from the day of the negative PCR test. The management was successfully done through surgical debridement and pre and post-operative antibiotics. No anti-fungal medications were prescribed as the fungal culture and the histopathological report were negative.

Conclusion

Post-COVID-related osteonecrosis of the jaw (PC-RONJ) could be now considered as one of the potential post-COVID-19 oral and maxillofacial complications that occurs unprovokedly and mainly in the maxilla.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07518-9.

Effects of the COVID-19 pandemic on the outcome and mortality of patients with diabetic foot ulcer

The outbreak of the coronavirus disease 2019 (COVID-19) led to events that significantly impaired the treatment and management of patients with chronic diabetes. Therefore, elective treatments at hospitals were cancelled and patients with chronic ailments were instructed to stay at home and minimise the time spent in public areas. The second was due to COVID-19-induced anxiety that deterred many patients from seeking care and adhering to periodic out-patient visits. In this study, we examined the short-term effects of the COVID-19 pandemic on patients with chronic diabetes who suffered from contaminated diabetic ulcers. We conducted a retrospective study with patients who had undergone amputations following diabetic ulcers during 2019-2020. The research group included diabetic amputees during the COVID-19 outbreak period ranging from March 2020 to December 2020. The control group included diabetic amputees from the corresponding period in 2019. Using the Wagner Scale, we measured the difference in the severity of ulcers upon the patient's initial admission. Additionally, we examined patient survival rates based on the size of amputations, by specifically focusing on the period between 1- and 6-months post-surgery. The results failed to suggest a clear and statistically significant worsening trend in the condition of patients in the research and control groups. Due to public lockdowns, transportation restrictions, scarcity of healthcare staff, and reduced adherence to exposure anxiety, patients with diabetic foot ulcers received inferior medical care during the COVID-19 pandemic. However, this study could not find a statistically significant difference in the mortality and major amputation rates in patients with diabetic ulcer before and during the pandemic. The health system should incorporate the existing institutional and technological recommendations to facilitate care and follow-up of patients with diabetic foot ulcers during the current and future pandemics.

Covid-19 lockdown showed a likely beneficial effect on diabetic foot ulcers

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.

Screening, diagnosis and management of diabetic sensorimotor polyneuropathy in clinical practice: International expert consensus recommendations

Diabetic sensorimotor polyneuropathy (DSPN) affects around one third of people with diabetes and accounts for considerable morbidity, increased risk of mortality, reduced quality of life, and increased health care costs resulting particularly from neuropathic pain and foot ulcers. Painful DSPN is encountered in 13-26% of diabetes patients, while up to 50% of patients with DSPN may be asymptomatic. Unfortunately, DSPN still remains inadequately diagnosed and treated. Herein we provide international expert consensus recommendations and algorithms for screening, diagnosis, and treatment of DSPN in clinical practice derived from a Delphi process. Typical neuropathic symptoms include pain, paresthesias, and numbness particularly in the feet and calves. Clinical diagnosis of DSPN is based on neuropathic symptoms and signs (deficits). Management of DSPN includes three cornerstones: (1) lifestyle modification, optimal diabetes treatment aimed at near-normoglycemia, and multifactorial cardiovascular risk intervention, (2) pathogenetically oriented pharmacotherapy (e.g. α-lipoic acid and benfotiamine), and (3) symptomatic treatment of neuropathic pain including analgesic pharmacotherapy (antidepressants, anticonvulsants, opioids, capsaicin 8% patch and combinations, if required) and non-pharmacological options. Considering the individual risk profile, pain management should not only aim at pain relief, but also allow for improvement in quality of sleep, functionality, and general quality of life.

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.

Diabetic Foot Syndrome in the COVID-19 era: How to Move from Classical to new Approaches

Diabetic foot syndrome (DFS) is a major complication of diabetes mellitus. Coronavirus infectious disease 2019 (COVID-19) has created new necessities and priorities in DFS management. These include telemedicine and patient triage to minimise hospitalisation and visits to the clinic. Moreover, new studies will be needed to evaluate whether the lockdown in patients with DFS or in those with high risk of DFS have increased the risk of deteriorating outcomes, including limb loss. Our future challenge will lie in re-organising our world during the pandemic and after its resolution. We need more awareness of the widespread ways of the changes in taking care of patients and to improve education, skills, and behaviour of high-risk patients.

The UK foot and ankle COVID-19 national (FAlCoN) audit - Regional variations in COVID-19 infection and national foot and ankle surgical activity

AIMS

This paper details the impact of COVID-19 on foot and ankle activity in the UK. It describes regional variations and COVID-19 infection rate in patients undergoing foot and ankle surgery before, during and after the first national lock-down.

PATIENTS & METHODS

This was a multicentre, retrospective, UK-based, national audit on foot and ankle patients who underwent surgery between 13th January and 31st July 2020. Data was examined pre- UK national lockdown, during lockdown (23rd March to 11th May 2020) and post-lockdown. All adult patients undergoing foot and ankle surgery in an operating theatre during the study period included from 43 participating centres in England, Scotland, Wales and Northern Ireland. Regional, demographic and COVID-19 related data were captured.

RESULTS

6644 patients were included. In total 0.53% of operated patients contracted COVID-19 (n = 35). The rate of COVID-19 infection was highest during lockdown (2.11%, n = 16) and lowest after lockdown (0.16%, n = 3). Overall mean activity during lockdown was 24.44% of pre-lockdown activity with decreases in trauma, diabetic and elective foot and ankle surgery; the change in elective surgery was most marked with only 1.73% activity during lock down and 10.72% activity post lockdown as compared to pre-lockdown. There was marked regional variation in numbers of cases performed, but the proportion of decrease in cases during and after lockdown was comparable between all regions. There was also a significant difference between rates of COVID-19 and timing of peak, cumulative COVID-19 infections between regions with the highest rate noted in South East England (3.21%). The overall national peak infection rate was 1.37%, occurring during the final week of lockdown. General anaesthetic remained the most common method of anaesthesia for foot and ankle surgery, although a significant increase in regional anaesthesia was witnessed in the lock-down and post-lockdown periods.

CONCLUSIONS

National surgical activity reduced significantly for all cases across the country during lockdown with only a slow subsequent increase in elective activity. The COVID-19 infection rate and peaks differed significantly across the country.

The Role of New Technological Opportunities and the Need to Evaluate the Activities Performed in the Prevention of Diabetic Foot with Exercise Therapy

The diabetic foot (DF) is one of the most feared conditions among chronic complications of diabetes, which affects a growing number of patients. Although exercise therapy (ET) has always been considered a pillar in the treatment of patients at risk of DF it is not usually used. Several causes can contribute to hindering both the organization of ET protocols for Diabetes Units and the participation in ET programs for patients at different levels of risk of foot ulceration. The risk of favoring the occurrence of ulcers and the absence of clear evidence on the role played by ET in the prevention of ulcers could be considered among the most important causes leading to the low application of ET. The increased availability of new technologies and in particular of systems and devices equipped with sensors can enable the remote monitoring and management of physical activity performed by patients. Consequently, they can become an opportunity for introducing the systematic use of ET for the treatment of patients at risk. Considering the complexity of the clinical conditions that patients at risk or with diabetic foot ulcer can show, the evaluation of how patients perform the ET proposed can consequently be very important. All this can contribute to improving the treatment of patients and avoiding possible adverse effects. The aim of this brief review was to describe that the use of new technologies and the assessment of the execution of the ET proposed allows an important step forward in the management of patients at risk.

Digital technologies in the care of people with diabetes during the COVID-19 pandemic: a scoping review

OBJECTIVE

To map evidence on the use of digital technologies in the care of people with diabetes during the COVID-19 pandemic.

METHOD

This is a scoping review, based on the JBI manual, which included scientific articles and gray literature from nine primary and seven secondary databases. Articles were independently assessed by two reviewers. Rayyan® was used to select the studies. The description of study characterization is presented in a table and tables, ending in a narrative synthesis.

RESULTS

A total of 1,964 studies were identified and, after selection, 23 publications remained for analysis. It turned out that telemedicine was used in all studies and remote consultation support technologies included continuous glucose monitoring devices, glucose data analysis software, insulin delivery systems, applications, audio and/or voice communication devices, which facilitated remote diabetes mellitus monitoring and management.

CONCLUSION

Telehealth, monitoring technologies, insulin delivery systems and communication devices were tools used to monitor patients with diabetes during the pandemic.

The impact of the COVID-19 pandemic on the workload, case mix and hospital resources at a tertiary vascular unit

Background

: The aim of this study was to examine the COVID-19 pandemic and its associated impact on the provision of vascular services, and the pattern of presentation and practice in a tertiary referral vascular unit.

Methods

: This is a retrospective observational study from a prospectively maintained data-base comparing two time frames, Period 1(15th March-30th May 2019-P1) and Period 2(15th March-30th May 2020-P2)All the patients who presented for a vascular review in the 2 timeframes were included. Metrics of service and patient care episodes were collected and compared including, the number of emergency referrals, patient encounters, consultations, emergency admissions and interventions. Impact on key hospital resources such as critical care and imaging facilities during the two time periods were also examined.

Results

: There was an absolute reduction of 44% in the number of patients who required urgent or emergency treatment from P1 to P2 (141 vs 79). We noted a non-significant trend towards an increase in the proportion of patients presenting with Chronic Limb Threatening Ischaemia (CLTI) Rutherford 5&6 (P=0.09) as well as a reduction in the proportion of admissions related to Aortic Aneurysm (P=0.21). There was a significant absolute reduction of 77% in all vascular interventions from P1 to P2 with the greatest reductions noted in Carotid (P=0.02), Deep Venous (P=0.003) and Aortic interventions (P=0.016). The number of lower limb interventions also decreased though there was a significant increase as a relative proportion of all vascular interventions in P2 (P=0.001). There was an absolute reduction in the number of scans performed for vascular pathology; Duplex scans reduced by 86%(P<0.002), CT scans by 68%(P<0.003) and MRIs by 74%(P<0.009).

Conclusion

: We report a decrease in urgent and emergency vascular presentations, admissions and interventions. The reduction in patients presenting with lower limb pathology was not as significant as other vascular conditions, resulting in a significant rise in interventions for CLTI and DFI as a proportion of all vascular interventions. These observations will help guide the provision of vascular services during future pandemics.

Behavioral Sciences in the Optimization of Pharmacological and Non-Pharmacological Therapy for Type 2 Diabetes

Type 2 diabetes mellitus is one of the main chronic diseases worldwide, with a significant impact on public health. Behavioral changes are an important step in disease prevention and management, so the way in which individuals adapt their lifestyle to new circumstances will undoubtedly be a predictor of the success of the treatments instituted, contributing to a reduction in the morbidity and mortality that may be associated with them. It is essential to prepare and educate all diabetic patients on the importance of changing behavioral patterns in relation to the disease, with health professionals assuming an extremely important role in this area, both from a pharmacological and non-pharmacological point of view, and also ensuring the monitoring of the progress of these measures. Diabetes is a chronic disease that requires a high self-management capacity on the part of patients in order to achieve success in treating the disease, and non-adherence to therapy or non-compliance with the previously defined plan, together with an erratic lifestyle, will contribute to failure in controlling the disease. The lower adherence to pharmacological and non-pharmacological treatment in diabetes is mainly correlated to socio-economic aspects, lower health literacy, the side effects associated with the use of antidiabetic therapy or even the concomitant use of several drugs. This article consists of a narrative review that aims to synthesize the findings published in the literature, retrieved by searching databases, manuals, previously published scientific articles and official texts, following the methodology of the Scale for Assessment of Narrative Review Articles (SANRA). We aim to address the importance of behavioral sciences in the treatment of diabetes, in order to assess behavior factors and barriers for behavior changes that have an impact on the therapeutic and non-therapeutic optimization in patients with type 2 diabetes mellitus control.

The impact of the SARS-CoV-2 pandemic on the management of chronic limb-threatening ischemia and wound care

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.

Impact of COVID-19 restrictions on diabetes health checks and prescribing for people with type 2 diabetes: a UK-wide cohort study involving 618 161 people in primary care

Objective

To compare rates of performing National Institute for Health and Care Excellence-recommended health checks and prescribing in people with type 2 diabetes (T2D), before and after the first COVID-19 peak in March 2020, and to assess whether trends varied by age, sex, ethnicity and deprivation.

Methods

We studied 618 161 people with T2D followed between March and December 2020 from 1744 UK general practices registered with the Clinical Practice Research Datalink. We focused on six health checks: haemoglobin A1c, serum creatinine, cholesterol, urinary albumin excretion, blood pressure and body mass index assessment. Regression models compared observed rates in April 2020 and between March and December 2020 with trend-adjusted expected rates derived from 10-year historical data.

Results

In April 2020, in English practices, rates of performing health checks were reduced by 76%–88% when compared with 10-year historical trends, with older people from deprived areas experiencing the greatest reductions. Between May and December 2020, the reduced rates recovered gradually but overall remained 28%–47% lower, with similar findings in other UK nations. Extrapolated to the UK population, there were ~7.4 million fewer care processes undertaken March–December 2020. In England, rates for new medication fell during April with reductions varying from 10% (95% CI: 4% to 16%) for antiplatelet agents to 60% (95% CI: 58% to 62%) for antidiabetic medications. Overall, between March and December 2020, the rate of prescribing new diabetes medications fell by 19% (95% CI: 15% to 22%) and new antihypertensive medication prescribing fell by 22% (95% CI: 18% to 26%), but prescribing of new lipid-lowering or antiplatelet therapy was unchanged. Similar trends were observed across the UK, except for a reduction in new lipid-lowering therapy prescribing in the other UK nations (reduction: 16% (95% CI: 10% to 21%)). Extrapolated to the UK population, between March and December 2020, there were ~31 800 fewer people with T2D prescribed a new type of diabetes medication and ~14 600 fewer prescribed a new type of antihypertensive medication.

Conclusions

Over the coming months, healthcare services will need to manage this backlog of testing and prescribing. We recommend effective communications to ensure patient engagement with diabetes services, monitoring and opportunities for prescribing, and when appropriate use of home monitoring, remote consultations and other innovations in care.

Impact of COVID-19 disease and its treatment on the development of maxillofacial complications

The novel coronavirus spread worldwide in 2020, causing millions of deaths and disabilities. Even though the virus was considered a respiratory virus, its adverse effects can be detected in several body systems. The article describes COVID-19 disease and its complications in the maxillofacial area. Several complications develop either in response to therapeutic modalities used to treat the underlying disease, or due to overuse of particular medications namely glucocorticoids, antirheumatic agents, interleukin 6-inhibitors, and antibiotics. This article will describe a number of complications ranging from mild complications to severe ones such as osteonecrosis of the upper jaw and facial bones, ophthalmologic and neurological complications. It will also summarize recommendations that will help prevent or minimize these complications.

Monitoring and Prevention the Risk of Diabetic Foot Ulcer Infection during Coronavirus Disease-19 Pandemic: A Narrative Review and Perspective Algorithm

BACKGROUND: The coronavirus disease (COVID)-19 pandemic leads to significant changes in the healthcare system and undermining best practices for maintaining a diabetic limb. A large number of patients with diabetic foot are left without timely medical care and are at increased risk of complications, hospitalization, lower limb amputation, and death. A new paradigm must be adopted for the transition from inpatient care to community-based care. The introduction of a pandemic remote management for patients with diabetic foot ulcer includes an assessment of the risk of complications through telemedicine and further stratification of patients according to the developed algorithm. METHODS: A literature review was performed for articles related to telemedicine. We used PubMed, Google Scholar, Cochrane Library, and Ovid MEDLINE to search published articles. We used the following keywords: “Telemedicine,” “diabetes mellitus,” “COVID-19,” “diabetic foot ulcer,” and “remote monitoring.” RESULTS: Implementation of the proposed pandemic care includes telemedicine for remote monitoring and treatment of patients with diabetic foot ulcers, as well as an algorithm for determining the risk of diabetic ulcer infection and patient management tactics according to the identified risk. CONCLUSION: The management of patients with diabetic foot ulcers during a pandemic includes the following goals – to reduce the burden on the health-care system, maintain the safety and functionality of diabetic foot at home, and reduce the risk of COVID-19 in patients with diabetic foot ulcers.

Management of diabetes-related foot disease in the outpatient setting during the COVID-19 pandemic

The use of telephone and/or video consultation in routine management of acute diabetes‐related foot disease (DFD) before the coronavirus disease 2019 (COVID‐19) pandemic at a tertiary hospital is unprecedented. In March 2020, the Diabetes Feet Australia (DFA) released a national guideline to inform DFD management during the COVID‐19 pandemic. The present study aimed to describe the adherence to the DFA guideline of managing acute DFD using telephone and/or video consultation at a Western Australian tertiary hospital during this period. We found >80% adherence rate to the DFA guideline and the management of active DFD using telephone and/or video consultations was feasible and acceptable in carefully selected patients.

Impact of the COVID-19 Epidemic on hospitalization for diabetic foot ulcers during lockdown: A French nationwide population-based study

AIMS/HYPOTHESIS

The aim of this study was to examine the impact of the COVID-19 epidemic on the hospitalization rates for diabetic foot ulcer (DFU), osteomyelitis and lower limb revascularization procedure in people with DFU.

METHODS

This nationwide retrospective cohort study included hospital data on all people hospitalized in France for diabetes in weeks 2-43 in 2020, including the COVID-19 lockdown period, compared to same period in 2019.

RESULTS

The number of hospitalizations for DFU decreased significantly in weeks 12-19 (during the lockdown) (p < 10^-4 ). Hospitalization for foot osteomyelitis also decreased significantly in weeks 12-19 (p < 10^-4 ). The trend was the same for lower limb amputations and revascularizations associated with DFU or amputation.

CONCLUSIONS/INTERPRETATION

The marked drop in hospitalization rates for DFU, osteomyelitis and lower limb revascularization procedures in people with DFU observed in France during the lockdown period suggests that COVID-19 was a barrier to DFU care, and may illustrate the combined deleterious effects of hospital overload and changes in health-related behaviour.

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.

A, Jude EB. Virtual triage and outcomes of diabetic foot complications during Covid-19 pandemic: A retro-prospective, observational cohort study

AIMS

Limb and patient outcomes in people with diabetic foot complications including diabetic foot ulcer (DFU) provided virtual triage and personalized video consultations during COVID-19 pandemic are not known.

METHODS

Patients with foot complications attending the diabetic foot clinic prior to lockdown who sought teleconsultations during COVID-19 lockdown underwent virtual triage to include clinical history, visual inspection of feet, domiciliary wound care (community nurse assisted dressings) and offloading instructions. The subsequent ulcer, limb and mortality outcomes during the following 24 weeks of COVID-19 lockdown (April-September 2020, group 1) were assessed and compared with those who attended foot clinic during the same period in 2019 (April-September, group 2).

RESULTS

Group 1 included 561 participants with foot complications provided with teleconsultations, median age 57 (51 to 63) years and diabetes duration of 10 (5 to 16) years. Twelve patients with severe DFU were excluded and 549 patients [357 (65%) neuropathic foot, 104 (18.9%) ischemic foot and 88 (16%) chronic Charcot foot with deformities] were evaluated. There were 227 (41.3%) participants with active DFU at start of lockdown, 32 (5.8%) with new onset ulcer during lockdown (47.1%) and 290 patients without ulcers. Group 2 included 650 participants; active foot ulcer was present in 366 patients. Wound closed or reduced in area in 78.4% of participants of group 1 compared to 76.0% (p = 0.318) in group 2. Fourteen (5.4%) patients required amputations [3 major and 11 minor] in group 1 during the study period compared to 6.8% in group 2 (p = 0.191). Twenty-one (3.8%) and 28 (4.3%) patients died (p = 0.532) during 24 weeks of follow up in group 1 and 2, respectively.

CONCLUSIONS

Targeted foot-care service through virtual triage and teleconsultations during COVID-19 pandemic for people with foot complications have similar ulcer and limb outcomes compared to face-to-face foot care delivery.

The impact of the COVID-19 pandemic on people with diabetes and diabetes services: A pan-European survey of diabetes specialist nurses undertaken by the Foundation of European Nurses in Diabetes survey consortium

AIM

To describe diabetes nurses' perspectives on the impact of the COVID-19 pandemic on people with diabetes and diabetes services across Europe.

METHODS

An online survey developed using a rapid Delphi method. The survey was translated into 17 different languages and disseminated electronically in 27 countries via national diabetes nurse networks.

RESULTS

Survey responses from 1829 diabetes nurses were included in the analysis. The responses indicated that 28% (n = 504) and 48% (n = 873) of diabetes nurses felt the COVID-19 pandemic had impacted 'a lot' on the physical and psychological risks of people with diabetes, respectively. The following clinical problems were identified as having increased 'a lot': anxiety 82% (n = 1486); diabetes distress 65% (n = 1189); depression 49% (n = 893); acute hyperglycaemia 39% (n = 710) and foot complications 18% (n = 323). Forty-seven percent (n = 771) of respondents identified that the level of care provided to people with diabetes had declined either extremely or quite severely. Self-management support, diabetes education and psychological support were rated by diabetes nurse respondents as having declined extremely or quite severely during the COVID-19 pandemic by 31% (n = 499), 63% (n = 1,027) and 34% (n = 551), respectively.

CONCLUSION

The findings show that diabetes nurses across Europe have seen significant increases in both physical and psychological problems in their patient populations during COVID-19. The data also show that clinical diabetes services have been significantly disrupted. As the COVID-19 situation continues, we need to adapt care systems with some urgency to minimise the impact of the pandemic on the diabetes population.

I fear COVID but diabetic foot (DF) is worse: a survey on patients' perception of a telemedicine service for DF during lockdown

AIMS

To evaluate the patients' perceptions of telemedicine visits during COVID-19 lockdown and their level of anxiety about COVID and diabetic foot (DF).

METHODS

In May 2020, we contacted by phone all the patients who underwent in March and April to remote monitoring visits for DF during the lockdown for COVID-19, with a structured interview, focusing on their perceptions about telemedicine service for DF and on the anxiety toward COVID and DF.

RESULTS

We analyzed 257 remote monitoring visits in 211 patients. Two hundred and six patients answered the follow-up interview; 177 patients (85.9%) remembered the monitoring visit, 140 (67.9%) the health care professional and 181 patients (87.9%) the reason of contact; 169 patients were alone during the visit, 37 with a relative. Patients judged useful both the monitoring during pandemic (4.35 ± 0.28 on a maximum of five) and the possibility to continue after the lockdown (4.34 ± 0.23 on a maximum of five). Eventually, we observed that DF patients were more worried by DF than by COVID on a scale from 0 (not fear at all) to 5 (terrified) (4.79 ± 0.05 vs. 3.27 ± 1.03, p < 0.05). This difference was higher in previously ulcerated patients (4.84 ± 0.03 vs. 3.03 ± 1.13, p < 0.05) and even more in amputees (4.93 ± 0.03 vs. 2.73 ± 1.21, p < 0.05).

CONCLUSIONS

DF patients appreciated televisits during lockdown and the continuation of this service after its end. In this context DF prevails on COVID in the worries of patients, especially if they are recurrent ones.

Antibiotic resistance in diabetic foot infection: how it changed with COVID-19 pandemic in a tertiary care center

AIM

To investigate the rate of antibiotic resistance and its main risk factors in a population of patients with diabetic foot infection (DFI) during the COVID-19 pandemic, in comparison with the population of 2019.

METHODS

Two hundred and twenty-five patients with DFI were admitted in a tertiary care center from January 2019 to December 2020. Antibiotic resistance was evaluated by microbiological examination of soft tissues' or bone's biopsy.

RESULTS

Compared with 2019 group (n = 105), 2020 group (n = 120) had a significantly higher prevalence of antibiotic resistance [2019 vs 2020, 36% vs 63%, P <0.001] and more often was admitted with recent or current antibiotic therapy (18% vs 52%, P <0.001), which was frequently self-administered (5% vs 30%, P = 0.032). The risk of antibiotic resistance was also higher in 2020 group [OR 95% CI, 2.90 (1.68 to 4.99)]. Prior hospitalization, antibiotic self-administration and antibiotic prescription by general practitioners resulted as independent predictors of antibiotic resistance.

CONCLUSIONS

In a population of people with DFI admitted in a tertiary care center during the COVID-19 pandemic the prevalence of antibiotic resistance was higher than 2019. Previous hospitalization, antibiotic self-administration /prescription by general practitioners were related to higher risk of antibiotic resistant infections.

Epidemiological Survey of the Impact of COVID-19 on Telemedicine in the Practice of Foot and Ankle Surgery in the United States

In response to loosened telehealth regulations and local restrictions on elective procedures during the coronavirus disease 2019 (COVID-19) pandemic, telemedicine use has dramatically increased. The goal of this study was to analyze patterns in telemedicine use among podiatric physicians during the COVID-19 crisis on a national level. Anonymous responses to a survey of practice metrics as well as subjective impressions of telemedicine efficacy were collected from 246 respondents, representing >1% of practicing podiatrists in the United States. Linear regression was performed to identify variables associated with COVID-19 prevalence and variables associated with higher self-reported likelihood of offering telemedicine visits post-COVID-19. Physicians in areas of lower COVID-19 prevalence were found to dispense durable medical equipment more frequently in-office and conduct more post-op telemedicine visits, with fewer visits for infections and trauma. Podiatrists in these regions also rated telemedicine more effective for medical and musculoskeletal pathologies. Additionally, fewer of their practices had modified office hours, and more of them advertised telemedicine services. Physicians more likely to offer telemedicine post-COVID-19 had significantly higher new patient volume and increased acuity of cases, with patient admission to the hospital after telemedicine visits. These physicians ranked the effectiveness of telemedicine more highly for every pathology surveyed. Of note, American College of Foot and Ankle Surgeons region and years in clinical practice were not statistically associated with likelihood of offering telemedicine visits post-COVID-19. This study represents the first systematic national assessment of telemedicine use in podiatry and highlights clinically relevant changes in practice and perception of telemedicine in response to the COVID-19 pandemic.

Diabetic Foot Amputation Prevention During COVID-19

ABSTRACT

In this case report, the treatment of a patient with a diabetic foot ulcer on his left foot was interrupted by the novel coronavirus 2019 pandemic lockdown in India. The author guided the patient via telephone and online services. Based on the history given by the patient, the lesion started as blistering from improperly fitted footwear that then evolved into multiple infected ulcerations on the dorsal surface of the great toe (osteomyelitis with septic arthritis of the joint). Based on a radiograph and other photographs of the foot lesions, the author prescribed amoxicillin/clavulanic acid in combination with linezolid for 2 weeks. Further, the author guided the patient to dress the wound at home using a medical-grade honey-based product. With no option for an outpatient visit, the author guided the patient to use a plastic ruler and place it below the toe during each dressing. Healing (complete epithelialization) was achieved within 4 weeks.

The UK Foot and Ankle COVID-19 National (FAlCoN) audit

Aims

The primary objective was to determine the incidence of COVID-19 infection and 30-day mortality in patients undergoing foot and ankle surgery during the global pandemic. Secondary objectives were to determine if there was a change in infection and complication profile with changes introduced in practice.

Methods

This UK-based multicentre retrospective national audit studied foot and ankle patients who underwent surgery between 13 January and 31 July 2020, examining time periods pre-UK national lockdown, during lockdown (23 March to 11 May 2020), and post-lockdown. All adult patients undergoing foot and ankle surgery in an operating theatre during the study period were included. A total of 43 centres in England, Scotland, Wales, and Northern Ireland participated. Variables recorded included demographic data, surgical data, comorbidity data, COVID-19 and mortality rates, complications, and infection rates.

Results

A total of 6,644 patients were included. Of the operated patients, 0.52% (n = 35) contracted COVID-19. The overall all-cause 30-day mortality rate was 0.41%, however in patients who contracted COVID-19, the mortality rate was 25.71% (n = 9); this was significantly higher for patients undergoing diabetic foot surgery (75%, n = 3 deaths). Matching for age, American Society of Anesthesiologists (ASA) grade, and comorbidities, the odds ratio of mortality with COVID-19 infection was 11.71 (95% confidence interval 1.55 to 88.74; p = 0.017). There were no differences in surgical complications or infection rates prior to or after lockdown, and among patients with and without COVID-19 infection. After lockdown the COVID-19 infection rate was 0.15% and no patient died of COVID-19.

Conclusion

COVID-19 infection was rare in foot and ankle patients even at the peak of lockdown. However, there was a significant mortality rate in those who contracted COVID-19. Overall surgical complications and postoperative infection rates remained unchanged during the period of this audit. Patients and treating medical personnel should be aware of the risks to enable informed decisions.

Cite this article: Bone Joint Open 2021;2(4):216–226.

The tip of the iceberg: an overview of diabetic foot disease

Diabetic foot disease is the leading cause of lower-extremity amputation globally and imposes a significant burden for healthcare services and patients alike. The main pathology is ulceration, due to neuropathy or peripheral arterial disease. The most frequent sign is ulceration on the foot. Ulceration needs to be referred to the multidisciplinary diabetic foot team promptly for a comprehensive management plan to be developed. Delay in referral is associated with poor outcomes. Management of diabetic foot ulceration is multifaceted, including offloading, revascularisation, infection control, debridement, glycaemic control and wound care. Management plans need to be patient focused and developed collaboratively across primary and secondary care settings.

Impact of the COVID-19 pandemic on the management of chronic limb-threatening ischemia in Northern Jordan: Case series and literature review

INTRODUCTION

The novel COVID-19 pandemic has imposed unprecedented restrictions on healthcare services worldwide. In developing nations such as Jordan, appreciable impacts on healthcare delivery ensued owing to limited resources. As a result, managing chronic limb-threatening ischemia (CLTI) has been modified to accommodate altercations in the system. This study assessed the impact of the COVID-19 pandemic on managing patients with critical limb-threatening ischemia (CLTI) during the lockdown.

METHODS

Objectives were accomplished by retrieving records of clinical data and perioperative results for patients diagnosed with CLTI at King Abdullah University Hospital between March 17 and June 1, 2020. Patients' demographics, Rutherford classification, type of intervention, and intervention variables during the outbreak were retrospectively analyzed (pandemic Group A) and compared with patients from the same period last year (control Group B).

RESULTS

A total of 96 patients with CLTI were included in the study; Groups A and B consisted of 28 and 68 patients, respectively. The mean ages for Groups A and B were 62.8 and 60.2 years, respectively. Conservative management was applied to 53.6% (P < 0.01) of Group A patients, whereas endovascular revascularization was the primary approach in Group B (39.7%, P < 0.01). After the intervention, the majority of patients in Group A were classified as category six on the Rutherford classification system (46.4%, P < 0.01), whereas the majority in group B were classified as category five (55.9%, P < 0.01).

CONCLUSIONS

The more unsatisfactory outcome of CLTI during the pandemic entails substantial measures to ensure conscientious virtual encounters and ambulatory community-based services during current and future pandemics. The endovascular-first policy should be endorsed in future pandemics as it is better at reducing aerosol transmission than standard surgical intervention. Moreover, endovascular procedures are minimally invasive and associated with favorable outcomes when medical optimization and hospital beds are limited.