At the time of writing there have been >85 million COVID-19 cases across the world with more than 1.8 million fatalities. One of the more.It was in late 2019 that a pneumonia of unknown cause was first reported from Wuhan, China: this was later named “coronavirus disease 2019” (COVID-19) by the World Health Organisation. Most foot problems that people with diabetes face arise from two serious complications of the disease: nerve damage and poor circulation. Complicated foot infections may require treatment by amputationas many as 610 of all patients with diabetes will undergo amputation for treatment of infection ( 1 , 2 , 3 ), accounting for 57 of nontraumatic lower extremity amputations. Foot infections are among the most common causes of hospitalization in the diabetic population, accounting for 20 of all diabetes-related admissions.It soon became apparent that older patients with other comorbidities, including diabetes, were at greater risk of poor outcomes and death. This can lead to injuries such as wounds or scrapes. The two major conditions that can ultimately cause foot problems in diabetes are: Neuropathy occurs because of nerve damage, causing diminished sensation in the feet.The global pandemic has presented many challenges in the management of people with diabetes particularly with late complications such as risk factors for foot ulceration. It is therefore vital throughout this pandemic that the most vulnerable populations, including those with diabetes and obesity, will require support and the necessary resources to restrict a day-to-day exposure to infection. Thus, for many reasons, the COVID-19 pandemic has raised major challenges to the entire diabetes community. At the height of the pandemic, this resulted in lesser attention being payed to non-communicable diseases such as heart disease, cancer, and diabetes, which remain the major cause of mortality across the world. During the last 12 months there has understandably been a swing back of research and media interest into communicable diseases such as COVID-19. In diabetic patients, foot ulcers or wounds that do not heal occur due to the two major complications of diabetes: nerve damage (.Recognising the frequency of diabetes in patients with COVID-19, the International Diabetes Federation has been at the forefront of increasing the importance of good diabetes care to those people living with diabetes across the world.
Diabetic Foot Problems Images Full Physical ExaminationAs can be seen, during the strictest of lockdowns in many countries, most routine investigations which are normally required for the assessment of the diabetic foot, even including a plain X-ray, were not possible.Legend: CRP = c-reactive protein. Other threats to those with neuropathy and peripheral arterial disease are listed in Table 3. Realising the risk to people with neuropathy and vascular disease, the American Podiatric Medical Association put out a special communication in 2020 emphasising the importance of appropriate management of DFUs and other complications during these difficult times. The proper and careful clinical examination and assessment of risk of diabetic foot disease still requires a full physical examination of the lower limbs. This development has therefore posed a threat to those with diabetic foot problems including active DFUs, ischaemia, and Charcot neuroarthropathy. Thus, the outpatient management of people with diabetes and its complications has faced a huge challenge during the last twelve months and in many countries, the classical “face-to-face” clinics have been cancelled and replaced by telephone consultations as noted above.Thus, many people with diabetes have been truly frightened to attend hospital clinics as they quite rightly perceive that the hospital is likely to be occupied by many patients with active COVID-19 disease. Widespread publicity of the COVID-19 pandemic has alerted those with diabetes to realise that should they be admitted to the hospital, the risk of a poor outcome is higher than in those without diabetes. CAD = coronary artery disease.A further problem amongst people with diabetes has been an understandable and real element of fear. PAD = peripheral arterial disease. MRI = magnetic resonance imaging. These authors also raised the likelihood that patients feared attending the hospital for similar reasons to those outlined earlier in this review.European Union—it was Italy that suffered amongst the worst of the consequences of the first wave of the COVID-19 pandemic in Europe leading to an almost complete lockdown of the country in the first quarter of 2020. Overall, the study that also looked at admissions later during 2020, suggested that the COVID-19 outbreak had a serious and disruptive effect on the delivery of hospital care for those with DFUs. One early communication from Hangzhou reported significant reductions in hospitalisations for diabetic foot problems during the first three months of 2020. Diabetic Foot Problems during the COVID-19 Pandemic: Global ReportsChina—it was in China that the coronavirus COVID-19 was first identified and there have been reports of difficulties with managing DFUs from China. Thus, in summary, the current pandemic of COVID-19 raises the possibility of the world experiencing a tsunami of late complications of diabetes in subsequent years when the pandemic is over.The next section of this article will review specific reports on diabetic foot care from countries around the world during the last twelve months.3. A further report from Rome described the development of a new triage pathway to manage patients with DFUs such that those with severely complicated lesions were urgently seen at the hospital outpatient service and admitted if necessary, whereas those with less complicated DFUs were managed by telemedicine after a brief outpatient evaluation. This group from Naples reported that patients with diabetes admitted to a Tertiary Care Centre for DFU management had a 3-fold increased risk of amputation compared with figures from 2019. Its widespread lockdown significantly affected patients with chronic diseases including diabetes and particularly those with DFUs. It was possible partially to compensate for this non-attendance by using telephone and email consultations.Turkey—a group of authors from Istanbul reported on their development of an algorithm to manage diabetic foot problems during the COVID-19 pandemic. Severe logistical problems were encountered in caring for patients with DFUs such as lack of public transport and, again, fear of infection with COVID-19, keeping patients away from the outpatient services. In Eastern Europe, Urbancic-Rovan reported on the experience of diabetic foot ulcers during the pandemic in the small country of Slovenia. The authors concluded that this triage pathway provided adequate management of DFUs during the pandemic and there were no cases of hospital-acquired COVID-19 infections. The inability to perform X-rays made clinical signs such as the “sausage toe” and the positive “probe-to-bone test” very important as clinical markers for the presence of underlying osteomyelitis. It was during this first six-week lockdown that virtually all routine tests for outpatient services were suspended, emphasising the importance of good clinical medicine with careful history taking and, especially, examination of the feet. The threats to the management of DFUs during this difficult time are summarised in Table 3. Visual photometric softwareAs this patient was first seen in the week prior to lockdown, an X-ray was possible confirming the presence of osteomyelitis as shown in Figure 1b. Figure 1 shows in this first case a large neuropathic wound on the medial side of the hallux which did probe-to-bone, suggesting osteomyelitis. Two cases from Manchester illustrate the importance of these signs. Cliffs of dover blitz manual(Reproduced from , with permission from ADA, 2020.)In the cases reported from Los Angeles, the use of telemedicine was highlighted in. ( c) Plantar view of the right foot 6 weeks later, after continuous treatment with oral antibiotics showing near healing of the wound, reduced erythema, and reduced swelling of the toe. ( b) Frontal view of same toes showing purulent discharge from metatarsal head wound at presentation. ( a) Dorsal view of the right foot showing sausage-shaped swelling of the second toe with tracking cellulitis (note previous amputation of third toe) when the patient first presented. This showed healing and a subsequent X-ray confirmed radiologic healing.Images from case 2. Similarly, local amputation of toes was performed in an outpatient facility in a patient who was terrified to come to the hospital because of fear of contracting COVID-19: this patient had already had a renal transplant for end-stage renal disease and was therefore immuno-suppressed.
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