Diabetic amputations soared amid Italian pandemic lockdown

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Patients with diabetic foot ulceration (DFUs) in Italy had more amputations during the height of the coronavirus pandemic—March to May 2020—than over the same time period in 2019, according to a newly published study.

The study, led by Paola Caruso (University of Campania Luigi Vanvitelli, Naples, Italy) appeared in Diabetes Care.

Amid a mandatory national lockdown, the rates of amputations skyrocketed at a hospital far from the hardest-hit region as many patients developed gangrene.

The findings offer critical lessons for the USA, says wound care specialist William H Tettelbach (Western Peaks Specialty Hospital, Salt Lake City, USA). “It has become more obvious that outpatient wound care is a critical care need for the community because of the risk of ignoring these chronic wounds and letting them remain open. We cannot let these services be closed down like some were when the pandemic started.”

The researchers launched the study to understand how patients with diabetes and DFU fared during the height of the pandemic in Italy, where tens of thousands of people died, mainly in the northern region of the country. They focused on patients in the southern region who were admitted to the division of endocrinology and metabolic diseases at the Teaching Hospital at the University of Campania Luigi Vanvitelli.

The study compared 25 patients who were admitted from 9 March to 18 May 2020, with 38 patients who were admitted from a longer period between January and May 2019. The demographics of the groups are similar, with average ages in the early 60s and more men than women (21:4, respectively, in 2020, and 23:15, respectively, in 2019.)

The results reveal high numbers of emergent and serious cases in 2020. Compared with 2019, fewer were outpatients (16% vs. 45%, p=0.028) and more were emergency patients (76% vs. 26%, p<0.001).

Clinically, gangrene was much more common in the 2020 group, compared with the 2019 group (64% vs. 29%, p=0.009), as was amputation (60% vs. 18%, p=0.001).

The researchers determined that amputation was more than three times more likely in the 2020 versus the 2019 group (relative risk, 3.26; 95% confidence interval [CI], 1.55–6.84) even though the 2019 period was longer. After adjustment for gender, the heightened risk in 2020 was 2.50 (95% CI, 1.18–5.29).

There was no statistically significant increase in the risk of revascularisation.

“The COVID-19 lockdown may have had a detrimental impact on amputation risk because of the sudden interruption of DFU care and lower-limb preservation pathways, resulting in delayed diagnosis and treatment,” the researchers wrote. “DFU is often characterised by progressive clinical course, which can rapidly lead patients to critical worsening of their ulcers.”

They added that “the higher risk of amputation observed during COVID-19 lockdown confirms the need for proper and timely management of DFU patients to prevent dramatic outcomes responsible for a reduction of quality of life and increased morbidity and mortality.”

The study authors did not discuss why more patients seemed to have stayed home and not gotten proper care. It is not clear if they were scared to get treatment or could not obtain it because of the national shutdown.

Both have been factors affecting diabetic foot care in the USA during the pandemic, says Tettelbach. He calls the study “timely and pertinent”, and says it highlights how wound care is “a critical need” that must remain available even when other medical services—such as elective surgeries—are shut down.

Infection-control protocols such as allowing patients to wait for appointments in their cars instead of waiting rooms will alleviate the fears of certain patients about seeking in-person care during the pandemic, he comments. But some patients will be afraid to come in no matter what, he adds, and home health may be the best solution for their care.

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