An evaluation of the burden of diabetes in Grenada

OBJECTIVE: To assess the burden of diabetes in Grenada in terms of changes in quality of life and trends of incidence, amputation and gender. DESIGN AND METHODS: A mixed methods approach was used in which statistical retrospective analysis determined trends of diabetic related amputations based on secondary data for the period 2008-2012. A qualitative approach was also used to assess perceptions of quality of life of diabetic related amputees using interviews. RESULTS: There were no statistically significant differences or trends (relationships) found between number of amputations and incidences of diabetes with respect to time. The quality of life of diabetics decreased after receiving an amputation surgery as a result of multifactorial issues such as feelings of loneliness and financial instability. CONCLUSION: The decreasing trend of diabetes in Grenada was found to be statistically insignificant while quality of life of amputees was shown to be lowered. Decreasing the incidence of amputations should involve focus on the role of peripheral neuropathy. Policy development to increase benefits to disabled citizens is recommended to improve quality of life of Grenadians.

Taking the next step in 2005, the year of the diabetic foot.

OBJECTIVES: To determine the age-standardized rate of lower limb amputations among Type 2 diabetics admitted to the Port of Spain General Hospital (POSGH), San Fernando General Hospital (SFGH) and Sangre Grande County Hospital (SGCH) for the period 2000-2004. To determine in-hospital mortality following amputation, for the same period. To determine the risk factors that contributed to diabetic foot complications. DESIGN AND METHODS: All patients who had a lower limb amputation at the three major public health institutions in Trinidad during the study period were enrolled. In addition patients attending the surgical out-patient clinic and currently admitted to the ward with a diabetic septic foot was selected for the administration of a questionnaire to determine the major contributing factors. Data on the type of amputation, age, sex, ethnicity, from which an age-standardized mortality rate, was determined for the age group 30-60. RESULTS: Of 822 patient files examined, 515 (80 per cent) of these major amputations were performed on Type 2 diabetics, of which 352 (68 per cent) were AKA and 163 (32 per cent) were BKA. The AKA:BKA ratio for the period 2000-2004 was 2.2:1. There was a significant difference between the mean ages at which females had a major amputation to males (p=0.001). The overall ratio of Africans to South East Asians was 1.5:1 amongst the Type 2 diabetic amputees. For major amputations the average length of stay was found to be 22.5 (0-192) days. The age-standardized rate for the age group 30-60 was 13.85 per 100,000 for 2004. Of 66 deaths, 31 (47 per cent) were septicemia cases and 14 (21 per cent) cardio-respiratory failure cases. Finally, of 97 persons interviewed, the major causative agent for diabetic foot complications and amputations was foot trauma (51 per cent). CONCLUSION: Type 2 diabetic amputation status of Trinidad would seem to have improved as shown by this study.

Preventing amputations from Diabetes Mellitus: The Indian health service experience

With the heavy burden of diabetes mellitus among American Indians and Alaskan Natives, lower-extremity amputation (LEA) has become a common complication. Rates of diabetes-related LEA are 2-3 times those observed in other diabetic populations. During the past 12 years, the Indian Health Service (IHS) has made LEA prevention a public health priority. From 1988 to 1992 screening criteria based on simple examinations were developed and validated in primary care settings. Prevention efforts have focused on targeting high-risk individuals for self-care foot education, provision of protective footwear, and routine podiatry care. Follow-up studies in Alaska and northern Minnesota saw 25-50 percent reduction in LEA rates associated with these interventions. In settings where these efforts were augmented with system changes, such as team coordination, patient tracking systems, comprehensive footcare practice guidelines, flowsheets, and outreach programmes, LEA incidence was reduced by 50-75 percent. Efforts were currently underway to desseminate system-based approaches for comprehensive diabetic footcare and to expand the availability of foot care resources to tribal communities served by the IHS.(Au)

Diabetes, lower extermity amputations and podiatry

We are all worried and simultaneously frustrated by the increasing prevalence of diabetes mellitus (DM) throughout the world and the anticipated increase in diabetes-associated complications, including lower-extremity amputations (LEAs). At the same time, we realize that primary prevention programmes for both Types 1 and 2 diabetes, and/or a "cure" are both still a few years into the future; and secondary (controlling blood glucose, blood pressure, and blood lipids) and tertiary (detecting complications early and treated appropriately) prevention programmes have been scientifically and economically validated. However, even with this knowledge, we are frustrated by two things: the "gap" between what we all should be doing and what is actually happening in daily clinical and public health practice; and between information we need about important and practical health services research questions about LEAs, e.g. how often should we really be examining the feet of someone with diabetes and with what methodology. With this background, where do podiatric health care professional fit into efforts to address diabetes-related LEAs? While certainly the rigour and completeness of podiatric training programmes in many countries legitimize their more active role in preventive care practices for people with DM, my own experience is that the podiatry community has skills, interests, abilities relevant to LEAs, beyond care. Both within academic centres and from practice, podiatrists have added and can add to the understanding and knowledge base about diabetes-related lower extermity disorders. Further, based on experiences with the CDC-NIH supported National Diabetes Education Programme (NDEP), podiatrist have embraced and enhanced general secondary prevention and public awareness activities about diabetes. Podiatrists have demonstrated their thoughtfulness and "power" by addressing a very large United States of America governmental agency - the Health Care Financing Administration (HCFA) - to begin to seriously address prevention programmes for diabetes-related LEAs, i.e. changing policies. While there are and will always be tensions within and among various diabetes disciplines, "today's podiatry is not your father's podiatry".(Au)

Trends in diabetes-related amputations in Barbados: 1980-1998 - poster abstract

OBJECTIVE: To describe trends in diabetic amputations from 1980-1998. METHODS: Amputations were categorized by type: diabetes-related or non-diabetes-related, gender, site (toe, foot leg/ ankle, thigh/knee) and age. No amputations occurred among diabeticsaged less than 25 years and these age categories were therefore omitted from the analysis. RESULTS: The majority (61 percent) of amputations performed were in diabetics. Female diabetics had significantly more amputations than non-diabetics females. The proportion of diabetic amputation increased with age. The highest proportion of diabetic amputation were at the leg level. Diabetic toe amputations decreased with age but leg and thigh amputations increased with age. The mean number of amputations continues to increase over time. CONCLUSIONS: Education in appropriate foot care of patients and their care givers, especially in high risk groups, is critical. Strategies for the prevention of lower limb amputations must be preceded by the identification of the associated independent risk factors. (Au)

Surgical management of critical limb ischaemia in the French West Indies

This retrospective study analyses the clinical presentation, surgical management and early outcome of 174 patients (mean age ñ SEM:73 ñ 15 yrs) admitted for critical limb ischaemia. 145 (84 percent) had tissue loss at admission: toe gangrene or ischaemic ulcer in 77, and gangrene extending beyond the forefoot in 68. 87 primary limb amputations and 107 revascularisation were performed at iliofemoral (n = 20), suprapopliteal (n = 22) or infrapopliteal level. The postoperative mortality rate was 14 percent in the "Amputation" group and 9 percent in the "Revascularisation" group but the difference was not statistically significant. Infective complications were comparable in both groups, although 5 to 14 deaths after amputation were directly related to infection and all deaths after revascularisation resulted from cardiovascular complications. The early limb salvage rate after revascularisation was 82 percent. 19 secondary limb amputations were performed for bypass failure. Patients in whom primary amputations were required were older (p < 0.03) and had significantly higher rates of heart disease and nonambulatory status (respectively, 24 vs 17 percent, p < 0.05; and 37 vs 13 percent, p < 0.001) than patients in whom revascularisation was performed. Ischaemic rest pain and tissue loss confined to digit gangrene or ischaemic ulcer occurred more frequently than extensive gangrene in the "Revascularisation" group (p < 0.0001), while extensive gangrene extending beyond the forefoot occurred more frequently than ischaemic rest pain and tissue loss in the "Amputation" group (p < 0.0001). Late presentation of patients and enhanced tissue loss are probably the reasons for the higher primary amputation rate in our patients compared to that observed elsewhere. In patients amenable to revascularisation (56 percent), arterial reconstruction for critical limb ischaemia improves the chances of limb salvage.(AU)

A study of diabetic patients and their knowledge of the importance of foot care in the prevention of foot problems in St. Catherine, Jamaica

The biggest fear of every diabetic patient is amputation of the lower limb. The literature review revealed that much of the morbidity, disability and death among diabetic patients results from complications due to lack of proper foot care. This study analysed the data obtained from 105 patients who attended the St. Jago Park Health Clinic during March 6th to April 3rd 1998. Questionnaire and docket information were used to collect the data. The age distribution in the sample ranged from 28 - 82 years with a mean and standard deviation of age being 60.41 ñ 11.21 years. The data revealed that the patients with a minority of excerptions, had a good knowledge of foot care. The knowledge scores ranged from 6 - 12 with a mean score of 10.68. There were three patients with foot problems. One male with an ulcer who had a score of six, another with an amputation who also had a similar score and one female with an amputation but having a score of twelve. There was a particularly low knowledge score with regard to "use of lotion between the toes" and "exposing foot to very hot or cold". In this study sample, foot problems did not have a high prevalence (2.9 percent). However, the education process must become an integral part in the life of every diabetic patient so that they will understand the need to have healthy practices in order to experience optimum health.(AU)

Surgical management of critical limb ischaemia in Guadeloupe, French West Indies - abstract

This retrospective study analyses the clinical presentation, surgical management and early outcome of 174 patients (mean age, 71 ñ 15 years) admitted for critical limb ischemia. 145 (84 percent) had tissue loss at admission including toe gangrene or ischemic ulcer in 77 and gangrene extending beyond the forefoot in 68. 87 primary limb amputations and 107 revascularizations were performed at iliofemoral (n=20), suprapopliteal (n=22) or infrapopliteal level. Postoperative mortality rate was not significantly different in the "Amputation" group (14 percent) and "Revascularizations" groups 9 percent. Infective complications were comparable in both groups although 5/14 deaths after amputations were were directly related to infections while all deaths after revascularizations resulted from cardiovascular complications. The early limb salvage after revascularizations was 82 percent. 19 secondary limb amputations were performed for bypass failure. Patients in whom primary amputations were required were older (p<0.03) and with significantly higher rates of heart diseases and non-ambulatory status (respectively 24 vs 17 percent, p<0.05 and 37 vs 13 percent, p<0.001) than patients in whom revascularizations were performed. The major findings were that ischemic rest pain and tissue loss confined to digit gangrene or ischemic ulcer were significantly more frequent in the group "Revascularizations" (p<0.0001), while extensive gangrene extending beyond the forefoot (p<0.0001) was significantly more frequent in group "Amputations". Therefore, late presentation of patients and enhanced tissue loss are very likely to play a role in our primary amputation rate, higher than those observed elsewhere. In patients amenable to revascularizations (56 percent), arterial reconstructiions for critical limb icshemia performed in the West Indies provide for a fair likelihood of limb salvage. (AU)

Primary leiomyosarcoma of bone

Primary leiomyosarcoma of bone is rare. We present the clinicopathological features of a case, the first documented from the Caribbean, seen recently at our institution. (AU)

Counting the cost of diabetic hospital admissions from a multi-ethnic population in Trinidad

Many middle-income countries are experiencing an increase in diabetes mellitus but patterns of morbidity and resource use from diabetes in developing countries have not been well described. We evaluated hospital admission with diabetes among different ethnic groups in Trinidad. We compiled a register of all patients with diabetes admitted to adult medical, general surgical, and ophthalmology wards at Port of Spain Hospital, Trinidad. During 26 weeks, 1447 patients with diabetes had 1722 admissions. Annual admission rates, standardized to the world population, for the catchment population aged 30-64 years were 1031 (95 percent CI 928 to 1134) per 100,000 in men and 1354 (1240 to 1468) per 100,000 in women. Compared with the total population, admission rates were 33 percent higher in the Indian origin population and 47 percent lower in those of mixed ethnicity. The age-standardized rate of amputation with diabetes in the general population aged 30-60 years was 54 (37 to 71) per 100,000. The hospital admission fatality rate was 8.9 percent (95 percent CI 7.6 percent to 10.2 percent). Mortality was associated with increasing age, admission with hyperglycaemia, elevated serum creatinine, cardiac failure or stroke and with lower-limb amputation during admission. Diabetes accounted for 13.6 percent of hospital admissions and 23 percent of hospital bed occupancy. Admissions associated with disorders of blood glucose control or foot problems accounted for 52 percent of diabetic hospital bed occupancy. The annual cost of admissions with diabetes was conservatively estimated at TT10.66 million (UK 1.24 million pounds). In this community diabetes admission rates were high and varied according to the prevalence of diabetes. Admissions, fatalities and resource use were associated with acute and chronic complications of diabetes. Investing in better quality preventive clinical care for diabetes might provide an economically advantageous policy for countries like Trinidad and Tobago. (AU)

What happens to the diabetic amputee after leaving hospital? - abstract

Very little known of the background, long-term functioning and survival of the amputee, especially in a West Indian setting. A questionnaire was designed to assess the social, domestic and economic effects of amputation in the diabetic. Statistics from the Department of Surgery, General Hospital, Port-of-Spain revealed that 126 patients with above- or below-knee (AK/BK) amputations were discharged from hospital from 1985 to 1988. Eighteen patients were not diabetic and were excluded and 11 could not be located. Data on the remaining 97 amputees were obtained by interviews with patients or relatives of those who had died. Most (76 percent) patients were >60 years old, and the majority were Negroes (66 percent). Sixty-six patients had AK while 31 had BK amputations. At the time of the survey, 36 (37 percent) patients had died, more than two-thirds (69 percent) of deaths occurring within 6 months after discharge. Only 5 percent used prosthesis, and 20 percent remained permanently bed-ridden. Over 90 percent of those employed experienced a fall in income. Only 6 percent were visited by a social worker. About one-quarter (24 percent) felt quite despondent since amputation. Lower limb amputation results in great psychological, social and economic disability and is associated with a high mortality. Much effort is required to prevent limb loss in the diabetic. Aggressive rehabilitation with early prosthetic fitting should improve the outcome for amputees (AU)

Lower limb amputations in Trinidad: analysis of 576 cases - abstract

Major lower limb amputation remains one of the commonest operations done by the general surgeon and carries the highest mortality of all operations at the Port-of-Spain General Hospital. While vascular insufficiency is the main indication for amputation in Great Britain and the United States, we had a clinical impression that the diabetic septic foot was more important in our population. Of 658 consecutive major limb amputations done at the Port-of-Spain General Hospital from January 1979 to December 1984, 576 case notes were available for analysis. There were 299 males and 277 females with an equal mean age of 63 years. Ages ranged from 27 years; 81 percent of patients were over 60 years, 76 percent were diabetics, 34 percent hypertensive and 28 percent were both diabetic and hypertensive. Seventy-seven per cent had above-knee (A-K) and 23 percent below-knee (B-K) amputations (BK: AK = 0.29) A-K amputees being older (65 years) than B-K amputees (59 years). Of 43 bilateral amputees, 38 were A-K (B-K: A-K = 0.13); 84 percent of bilateral A-K amputees had peripheral vascular disease (PVD). Diabetes mellitus with limb sepsis (55 percent) was the commonest indication for amputation followed by PVD (36 percent). The overall mortality rate was 23 percent, with a higher mean age among fatalities (72.1 yrs). Over whelming sepsis and "multiorgan failure" (54 percent), ischaemic heart disease (76 percent), cerebro-vascular accident (11 percent) and pulmonary embolism (9 percent) were the major causes of death. Mortality among diabetics (23 percent) was not different from among non-diabetics (23 percent), but PVD associated with diabetes (37 percent) had a significantly higher (p < 0.001) rate than PVD without diabetes (14 percent). Consistent with published data, the AKA mortality rate (26 percent) was higher than that for BKA (10 percent) (p0.001). The average hospital stay was 51 days (range of 4 - 190). Diabetics (57 days) stayed longer than non-diabetics (35 days). The high amputation rate, mortality rate and prolonged hospitalisation suggest that urgent measures be taken to improve the outcome for patients with ischaemic or septic feet. We recommend an extensive education programme in foot care for doctors, nurses and diabetic patients, early and aggressive medical and surgical treatment of the infected diabetic foot, that attempts be made to increase ou B-K: A-K ratio more frequent arteriography and vascular reconstruction (AU)

The problem of limb amputations in Barbados - abstract

There were 2,506 admissions to the general surgical wards of the Queen Elizabeth Hospital during the period April, 1978 to March, 1979. There were 358 admissions (14 percent) for "foot" problems of whom 131 were known diabetics. 136 major amputations were done during this time. This paper reviews the circumstances surrounding this problem of limb wastage. Of 358 patients with "foot" problems, 212 (60 percent) had operative procedures for the treatment of gangrene, ulceration and infection. About a third of the patients operated on had more than one operative procedure, usually in an attempt to save the limb. 136 limbs were lost. The average length of stay was extended by efforts that were made to save limbs from major amputations and was 55 days compared to 8 days for the hospital as a whole. 75 percent of the patients were over 60 years of age and 82 of 212 patients operated on were known diabetics. In a sub-sample of 32 diabetics, three quarters of the patients had had avoidable injuries which precipitated their admission to hospital. These were mainly associated with minor injury to the feet, yet only two patients were aware of the potential seriousness of these minor injuries. Minor trauma and sepsis in a diabetic must be treated as an emergency with adequate debridement and full protection. Observation must be particularly close in patients with loss of pain sensation as a result of a neuropathy. There is need for a limb manufacture and fitting service locally. In 1979 of 25 requests made for artificial limbs, only 10 were fitted, all of which had to be imported (AU)

Foot ischaemia - a need for early rehabilitation

Ischaemia of the foot usually affects the elderly. The correlative study based on clinical data and pathological study has shown that maturity onset, diabetic foot ischaemia is usually due to severe arteriosclerosis. Because of the late presentation, most patients show end-stage obliterative vascular changes when first hospitalized which makes reconstructive surgery impossible. By early referral of all diabetic patients with infection, the number of below-knee or above-knee amputations can be reduced. Early prosthetic fitting is essential for the early rehabilitation of the patient. This paper was presented in part at the Commonwealth Caribbean Medical Research Council Meeting held at Bridgetown, Barbados in April, 1978. (AU)

Patients requiring lower limb prostheses in Jamaica

One hundred and twenty-one consecutive cases of lower limb amputations seen at the Mona Rehabilitation Centre were reviewed. Diabetes accounted for the highest proportion of amputations. The ratio of above-knee to below-knee amputations was 1:1. Factors influencing the use of prostheses are discussed (AU)