A Closer Look At N95 Respirators And PPE Protocols During The COVID-19 Pandemic

In light of the COVID-19 pandemic, the authors of a new in-press article for the Journal of the American Podiatric Medical Association aim to demystify information regarding N95 respirators and review key facts regarding proper mask use and reuse, sterilization techniques and definitions of the various types of personal protective equipment (PPE). 

During the initial weeks of the COVID-19 pandemic in the United States, Nicole DeLauro, DPM, FFPM RCPS (Glasg), the lead author of the article, shares that PPE was scarce and timely replenishment was not always available in both private practice and hospital settings. 

Dong Yu, DPM, a co-author of the JAPMA article, shares that due to PPE shortages, she and her team preserved supplies by modifying usage. She shares an example of using five N95 masks, one per day, covered with a surgical mask. At the end of each day, Dr. Yu placed the mask in a labelled paper bag for five days before using it again. She also relates disinfecting goggles daily and wearing one gown to see all patients with COVID-19 during this PPE shortage. 

Nader Ghobrial, DPM, another co-author of the article, recalls using single-use masks multiple times during the PPE shortage. 

At the beginning of the COVID-19 pandemic in the U.S., Patrick McEneaney, DPM, FACFAS relates that even simple surgical masks were hard to obtain at his private clinic. He adds that some ORs only allowed surgeons N95 masks for patients with confirmed COVID-19. He feels that as the supply chain caught up, masks became easier to find in the hospital and to purchase for private clinics. 

Dr. DeLauro feels adaptability and staying informed are important focuses for clinicians during the COVID-19 pandemic. 

“Staying informed … enabled me to continue to practice in a safe environment,” says Dr. DeLauro, Secretary of the American Board of Podiatric Medicine. “This not only provided peace of mind to me as a practitioner but also to my patients.” 

Drs. Ghobrial and Yu, who are both residents at Hoboken University Medical Center in Hoboken, N.J., stress the importance of following universal precautions as closely as possible and heeding the advice of the Centers for Disease Control and Prevention (CDC), and the National Institutes of Health (NIH). 

Dr. McEneaney feels it is important for providers to seek information on the various types of PPE available, such as KN95 masks versus N95 masks, which the authors discuss in this paper. 

“I had to look up what (KN95 masks) were and research the changing regulations surrounding them,” says Dr. McEneaney, the President of the Illinois Podiatric Medical Association. 

Until there is a vaccination or herd immunity, Dr. DeLauro and her co-authors stress that podiatrists must remain vigilant and informed about PPE use. She urges the use of face masks in public areas but comments that if the person wearing the mask is not washing his or her mask or hands properly, the virus can continue to spread. 

“For those in health care exposed at a higher level, N95 masks are still … the best at filtering contaminant aerosols. It is important to understand how you can reuse your N95 (masks) and the alternatives to remaining protected while practicing,” says Dr. DeLauro. 

Podiatric Sports Medicine Organization Celebrates 50-Year Anniversary 

As a young podiatrist interested in sports medicine in the early 1990s, Alex Kor, DPM, says the American Academy of Podiatric Sports Medicine (AAPSM) played an important role in shaping his career and adds that the organization continues to do so for interested podiatrists. 2020 marks the 50th anniversary of the AAPSM, the only organization that comprehensively focuses on all issues of foot and ankle sports medicine, according to Richard Bouche, DPM. 

Dr. Bouche says the AAPSM helped facilitate the development of multiple one-year podiatric sports medicine fellowships, including one he helped to establish in 1998 at the Virginia Mason Medical Center in Seattle. 

Drs. Bouche and Kor both cite recognition of the AAPSM by the Joint Commission on Sports Medicine and Science (JCSMS) as a vital accomplishment since the academy’s inception. Dr. Bouche points out that in 1993, there were over 100 sports medicine organizations and the JCSMS only chose to recognize 32 of these organizations, including AAPSM. 

Another major accomplishment of AAPSM that promotes the practice of podiatric sports medicine is the organizations’s involvement nationally and internationally with the Fit Feet program for Special Olympics, points out Dr. Bouche, a Fellow and Past President of AAPSM. 

“My vision for the future of the AAPSM and sports podiatry is for our organization to be even more recognized as an essential partner in all aspects of sports medicine and ultimately treat athletes at all international sporting events, such as the Olympics,” says Dr. Kor, a Fellow and Past President of the AAPSM. 

“The AAPSM must continue to maintain relevance in the field and continue to follow our mission statement, vision and strategic goals,” says Dr. Bouche. “We have to make sure we stay up to date with the times, continually being flexible, adapting and updating these strategic goals to remain the ‘go-to’ source for all issues pertaining to the lower extremity in sports.” 

Prior to the COVID-19 pandemic, AAPSM planned to celebrate its 50th anniversary in Seattle at its Stand Alone Meeting in October 2020. However, AAPSM has postponed this meeting to October 2021 and says it will include a three-day educational program, workshops and highlights of AAPSM history along with social events. 

Could An Emerging Imaging Technique Predict The Onset Of DFUs? 

A recent study in the Journal of Diabetes Complications found that unique biomarkers could provide a way to stratify risk for diabetic foot ulcers (DFUs) or even possibly predict DFU onset. 

Employing Spectral Frequency Domain Imaging (SFDI) (Clarifi^®, Modulim), a non-invasive optical imaging technique, researchers assessed 252 patients with diabetes. The study data showed that those patients at highest risk (a history of DFU) had significantly lower hemoglobin in the papillary dermis (HbT₁), higher tissue oxygenation (StO₂) due to poor extraction, higher values of hemoglobin in the reticular dermis (HbT₂) and more tissue scattering related to skin structure. 

The study authors found that HbT₁ levels and tissue scattering values predicted new ulcerations with a sensitivity/ specificity of 68.8 percent/64.8 percent and 75.0 percent/69.1 percent respectively. 

Suzette Lee, DPM, MS, FACFAS, the lead author of the study, shares that SFDI technology uses visible and near-infrared light images that provide a visual perfusion and oxygenation map of tissue in a portable unit. 

“SFDI can be used as a non-invasive measurement tool to detect microcirculation changes in the tissue before one is able to physically see the changes, which is extremely important when dealing with patients who have compromised circulation,” says Dr. Lee, a Regional Coordinating Physician in Charge of Podiatry for the Southern California Permanente Medical Group. 

She explains that the imaging apparatus measures the percentage of oxygen attached to the hemoglobin in the tissue (StO₂), the amount of hemoglobin with oxygen in the tissue (HbO₂) and the amount of hemoglobin without oxygen in the tissue (HbR). Dr. Lee says one may also use this imaging to evaluate the perfusion of hemoglobin distribution in the superficial (papillary) dermis (HbT₁) and the amount of hemoglobin in the deeper (reticular) dermis (HbT₂). She adds that these biomarkers then visually appear as color-coded maps with quantifiable numbers. 

“If clinicians use (SFDI data) to predict who will get DFUs, they may be able to focus on preventing these ulcers from occurring,” says Dr. Lee. “The potential impact is significant with the possibility of earlier intervention for at-risk patients, preventing lower extremity amputation.” 

Disclosure: Dr. Spector is a member of the medical advisory board for Modulim.