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Portela FSO, Louzada ACS, da Silva MFA, Teivelis MP, Kuzniec S, Wolosker N. Editor's Choice - Analysis of Lower Limb Amputations in Brazil's Public Health System over 13 Years. Eur J Vasc Endovasc Surg 2024; 68:91-98. [PMID: 38395382 DOI: 10.1016/j.ejvs.2024.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 01/30/2024] [Accepted: 02/20/2024] [Indexed: 02/25/2024]
Abstract
OBJECTIVE Understanding the causes of amputation is crucial for defining health policies that seek to avoid such an outcome, but only a few studies have investigated the epidemiology of patients submitted to amputations in developing countries. The objective of this study was to analyse all lower limb amputations performed in the public health system in Brazil over a 13 year period, evaluating trends in the number of cases, patient demographics, associated aetiologies, hospital length of stay, and in hospital mortality rate. METHODS This was a retrospective, population based analysis of all lower limb amputations performed in the Brazilian public health system between 1 January 2008 and 31 December 2020. Using a public database, all types of amputations were selected, defining the number of procedures, their main aetiologies, anatomical level of limb loss, demographic data, regional distribution, and other variables of interest. RESULTS A total of 633 455 amputations were performed between 2008 and 2020, mostly (55.6%) minor amputations, predominantly in males (67%). There was an upward trend in the number of amputations, determined mainly by the increase in major amputations (50.4% increase in the period). Elderly individuals have the highest rates of amputation. Diabetes mellitus (DM) is becoming the main primary diagnosis associated with amputations over the years. The highest in hospital mortality rate occurred after major amputations and was associated with peripheral arterial disease (PAD). CONCLUSION Amputation rates in Brazil show an upward trend. DM is becoming the most frequent associated primary diagnosis, although PAD is the diagnosis most associated with major amputations and in hospital death.
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Affiliation(s)
| | | | | | | | | | - Nelson Wolosker
- Hospital Israelita Albert Einstein, São Paulo, Brazil; Faculdade Israelita de Ciências da Saúde Albert Einstein, São Paulo, Brazil
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Tchankoni MK, Togan RM, Abalo GA, Adoli LK, Walla A, Dosseh DE, Tchangaï B, Preux PM, Aboyans V, Ekouevi DK. Epidemiology of Non-Traumatic Lower Extremities Amputations in West Africa: Nationwide Data from Togo. Eur J Vasc Endovasc Surg 2024; 67:959-968. [PMID: 38320645 DOI: 10.1016/j.ejvs.2024.01.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 12/22/2023] [Accepted: 01/30/2024] [Indexed: 02/08/2024]
Abstract
OBJECTIVE Non-traumatic lower limb amputation (NT-LLA) has consequences at individual and public health levels. Population based studies in sub-Saharan Africa are scarce and often related to single centre series. This study aimed to estimate the incidence of NT-LLA (minor and major) and to describe epidemiological, clinical, and prognostic aspects in Togo. METHODS This was a population based observational study conducted among all patients who underwent NT-LLA. Traumatic amputations were excluded. Sociodemographic, clinical, and work up data were collected from clinical files in any Togolese health centre from 1 January 2016 to 31 December 2021. Incidence rates were adjusted for age. RESULTS Over the six year period, 352 patients (59% males) underwent NT-LLA (mean ± standard deviation age 60 ± 15.7 years). The average age adjusted incidence rate of NT-LLA was 8.5 per million/year (95% confidence interval [CI] 7.6 - 9.4). Men were 1.7 times more likely to undergo a NT-LLA than women. The relative risk of NT-LLA was 48 times higher in patients with diabetes than in patients without diabetes. Around 61.0% of the NT-LLAs occurred within the 50 - 74 age group and 54.3% had diabetes mellitus. Among amputees, 54.5% had a diagnosis of peripheral artery disease (PAD) and 52.8% had diabetic ulcers, with co-existence of several factors. Less than 5% of participants had a history of smoking tobacco. Average length of hospital stay was 12 days. The in hospital mortality rate was 8.8% (9.0% for major, 6.7% for minor amputations). Only 18.2% had duplex ultrasound performed and 1.7% angiography prior to amputation. No patient underwent vascular intervention prior to amputation. CONCLUSION This is the first study to report nationwide and contemporary epidemiological data on NT-LLAs in West Africa, highlighting several specificities. Large scale interventions are needed to ameliorate the care of diabetes and PAD and improve facilities for optimal management of patients at risk of amputation in Africa.
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Affiliation(s)
- Martin K Tchankoni
- Inserm U1094, IRD U270, Univ. Limoges, CHU Limoges, EpiMaCT - Epidemiology of Chronic Diseases In Tropical Zone, Institute of Epidemiology and Tropical Neurology, Omega Health, Limoges, France; Public Health Department, Faculty of Health Sciences, University of Lomé, Togo; African Research Centre in Epidemiology and Public Health (CARESP), Lomé, Togo
| | - Roméo M Togan
- Public Health Department, Faculty of Health Sciences, University of Lomé, Togo
| | - Grégoire A Abalo
- Traumatology-Orthopedics Department of the Sylvanus Olympio University Hospital (CHU) of Lomé, Faculty of Health Sciences of the University of Lomé, Lomé, Togo
| | - Latame K Adoli
- Public Health Department, Faculty of Health Sciences, University of Lomé, Togo
| | - Atchi Walla
- Department of Orthopaedics, Campus Medical Teaching Hospital, Lomé, Togo
| | - David E Dosseh
- Department of General Surgery, Faculty of Health Sciences, University of Lomé, Lomé, Togo
| | - Boyodi Tchangaï
- Department of Visceral Surgery, University Teaching Hospital, Lomé, Togo
| | - Pierre-Marie Preux
- Inserm U1094, IRD U270, Univ. Limoges, CHU Limoges, EpiMaCT - Epidemiology of Chronic Diseases In Tropical Zone, Institute of Epidemiology and Tropical Neurology, Omega Health, Limoges, France
| | - Victor Aboyans
- Inserm U1094, IRD U270, Univ. Limoges, CHU Limoges, EpiMaCT - Epidemiology of Chronic Diseases In Tropical Zone, Institute of Epidemiology and Tropical Neurology, Omega Health, Limoges, France; Department of Cardiology, Dupuytren-2 University Hospital, Limoges, France.
| | - Didier K Ekouevi
- Public Health Department, Faculty of Health Sciences, University of Lomé, Togo; African Research Centre in Epidemiology and Public Health (CARESP), Lomé, Togo
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Limakatso K, Tucker J, Banda L, Robertson C, Parker R. The profile of people undergoing lower limb amputations at Groote Schuur Hospital. Afr J Disabil 2024; 13:1152. [PMID: 38445074 PMCID: PMC10912944 DOI: 10.4102/ajod.v13i0.1152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 10/23/2023] [Indexed: 03/07/2024] Open
Abstract
Background The annual incidence of lower limb amputations (LLA) at Groote Schuur Hospital is rising gradually. However, little is known about the sociodemographic and clinical profiles of people undergoing these limb amputations. Objectives To collect and analyse data to describe the sociodemographic, health and amputation profiles of people who have undergone LLA at Groote Schuur Hospital. Method A descriptive retrospective chart review was conducted using a sample of 107 participants who had undergone LLA at Groote Schuur Hospital between January 2019 and July 2020. A customised assessment tool was used to extract data on the sociodemographic, health and amputation profiles of patients who had LLA. Data were analysed descriptively. Results Sixty per cent of the patients who had undergone LLA at Groote Schuur Hospital were women. Most of the patients were over the age of 60 years and had not completed school and were pensioners or unemployed, with very low income and multiple co-morbidities including poorly controlled diabetes. Conclusions Complications because of uncontrolled diabetes were the primary indication for LLAs at Groote Schuur Hospital. Therefore, health literacy projects are indicated to address chronic diseases of lifestyle, which, in turn, may reduce the overall burden of LLA, particularly on the South African under-resourced healthcare system. Contribution The results of this study may help us identify key factors that predispose patients to LLAs. Consequently, this may help us identify key areas for prevention and better management of diseases that can result in complications that indicate the need for amputation.
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Affiliation(s)
- Katleho Limakatso
- Department of Anaesthesia and Perioperative Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Jenna Tucker
- Department of Health and Rehabilitation Sciences, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Lennie Banda
- Department of Health and Rehabilitation Sciences, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Cheyne Robertson
- Department of Health and Rehabilitation Sciences, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Romy Parker
- Department of Anaesthesia and Perioperative Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Njokweni M. Adjunctive topical oxygen therapy in the management of complex diabetes-related wounds: A South African case study series. Foot (Edinb) 2023; 57:101961. [PMID: 37866284 DOI: 10.1016/j.foot.2023.101961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 01/14/2023] [Indexed: 01/20/2023]
Abstract
Diabetic foot ulcers (DFUs) are a prevalent complication of diabetes mellitus and are associated with significant morbidity and mortality. The essential role of oxygen in the treatment of DFUs is documented. Indicated for use on a variety of wound types, topical haemoglobin therapy (Granulox®) is a novel therapeutic technology that binds atmospheric oxygen and improves the availability of oxygen at the wound site. When used as part of the wound management strategy, this therapy helps to reduce inflammation, exudate and slough, and promotes wound healing. In South Africa, health resources, coordinated foot care and podiatry, and data on diabetic foot complications are limited. Twelve patient case studies assessing the impact of adding topical haemoglobin therapy to the management regimes for DFUs and surgical (post-amputation) wounds were undertaken in South Africa. Patients were aged 50-71 years, and all had diabetes mellitus. At baseline, the area of the wounds ranged from 10.2 to 149.6 cm2 with depths ranging from 0.2 to 0.9 cm. Clinical signs of wound infection and high levels of viscous exudate were recorded in all cases. Wound dressings were changed twice weekly and sharp debridement of the wound performed as necessary. The wounds were cleansed and then completely coated with a thin film of Granulox® and dressings applied. Treatment was monitored over periods ranging from 57 to 276 days, during which dressings were changed and Granulox® administered to the wounds, ranging from 16 to 79 times. During the period of evaluation, wound size steadily reduced (by 87.1-100%), the condition of the wound bed tissue and peri-wound skin improved, and clinical signs of wound infection steadily resolved. Wounds significantly improved in two patients, almost healed in six patients, and healed in four patients. All patients reported a reduction in malodour and pain; seven patients were pain-free at the final followup assessment. The overall impression of Granulox® was rated as 'very good' by the clinicians, who considered that Granulox® facilitated an increase in tissue viability, with the promotion of granulation tissue, and stimulated epithelialisation.
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Affiliation(s)
- Mazizi Njokweni
- Leratong Regional Hospital, Chamdor Krugersdorp, South Africa.
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Ntuli S, Letswalo DM. Diabetic foot and lower limb amputations at central, provincial and tertiary hospitals-underscores the need for organised foot health services at primary healthcare level. Foot (Edinb) 2023; 56:102039. [PMID: 37244198 DOI: 10.1016/j.foot.2023.102039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 04/13/2023] [Accepted: 05/06/2023] [Indexed: 05/29/2023]
Abstract
BACKGROUND Diabetic foot amputations are a devastating outcome for any diabetic patient. They are associated with various risk factors, including failure to risk stratify the diabetic foot. Early risk stratification could lower foot complications risk at the primary healthcare level (PHC). In the Republic of South Africa (RSA), PHC clinics are the first entry point to the public healthcare system. Failure to correctly identify, risk categorise, and refer diabetic foot complications at this level may lead to poor clinical outcomes for diabetic patients. This study looks at the incidence of diabetic-related amputations at central and tertiary hospitals in Gauteng to highlight the case of the needed foot health services at the PHC level. METHODS A cross-sectional retrospective study that reviewed prospectively collected theatre records database of all patients who underwent a diabetic-related foot and lower limb amputation between January 2017 and June 2019. Inferential and descriptive statistics were performed, and patient demographics, risk factors and type of amputation were reviewed. RESULTS There were 1862 diabetic-related amputations in the period under review. Most patients (98 %) came from a poor socioeconomic background earning ZAR 0.00-70 000.00 (USD 0.00-4754.41) per annum. Most amputations, 62 % were in males, and the majority, 71 % of amputations, were in patients younger than 65. The first amputation was major in 73 % of the cases, and an infected foot ulcer was a primary amputation cause in 75 % of patients. CONCLUSION Amputations are a sign of poor clinical outcomes for diabetic patients. Due to the hierarchal nature of healthcare delivery in RSA, diabetic-related foot amputations could imply inadequate care of or access to diabetic foot complications at the PHC level in RSA. A lack of access to structured foot health services at PHC levels impedes early identification of foot complication identification and appropriate referral resulting in amputation in some of the patients.
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Affiliation(s)
- Simiso Ntuli
- Department of Podiatry, Faculty of Health Sciences, University of Johannesburg, P O Box 524 Auckland Park 2006, Gauteng, South Africa.
| | - Dimakatso Maria Letswalo
- Gauteng Department of Health, Dr George Mukhari Academic Hospital, 3111 Setlogelo Drive, Ga-Rankuwa Unit 2, Ga-Rankuwa, 0208, Pretoria, South Africa
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Owolabi EO, Chu KM. Knowledge, attitude and perception towards lower limb amputation amongst persons living with diabetes in rural South Africa: A qualitative study. Afr J Prim Health Care Fam Med 2022; 14:e1-e10. [PMID: 36226936 PMCID: PMC9623825 DOI: 10.4102/phcfm.v14i1.3398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 04/28/2022] [Accepted: 05/22/2022] [Indexed: 11/16/2022] Open
Abstract
Background South Africa has a high prevalence of diabetes mellitus (DM), a leading risk factor for lower limb amputation (LLA). Lower limb amputation is associated with significant morbidity and mortality. Lower limb amputation incidence can be mitigated through prompt identification and treatment of individuals at risk and engagement in self-management practices. Also, when LLA is inevitable, outcomes or prognosis can be improved with timely surgery. Aim This study explored the knowledge, attitude and perception of persons living with diabetes towards LLA and its prevention. Setting Nqamakwe, a rural community in the Eastern Cape province of South Africa. Method This was a descriptive, qualitative study involving persons living with DM, with and without LLA, and community leaders. Fifteen participants were recruited purposively and conveniently from a rural community in the Eastern Cape, South Africa. Data collection took place through semistructured interviews, in English and a local language, Xhosa. Interviews were transcribed and translated, and an inductive approach was used for thematic analysis. Results A total of 15 individual interviews were conducted. Of those, 13 were persons with DM, five with LLA, including one with bilateral LLA. There was a gap in knowledge on foot self-examination as a measure of preventing LLA amongst persons with DM. The attitude of persons without LLA was mostly fearful and their fears centred around perioperative death, risk for contralateral amputation, loss of limb and independence. Consent to LLA procedure was a last resort and only when pain levels were unbearable. Family support and information on rehabilitation services and assistive devices also fostered consent to LLA surgery. Conclusion There is a need for awareness creation and adequate health education for persons living with DM on LLA and its prevention measures, especially foot care practices. Also, health education programmes for persons living with DM in rural areas should address the various misperceptions of LLA to reduce delays. Contribution The article revealed gaps in knowledge on LLA and its prevention among individuals living with diabetes as well as areas of concerns that may potentially delay acceptance when LLA is inevitable. Findings from our study may assist primary health care providers to determine important issues to be addressed during routine and pre-operative patient education.
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Affiliation(s)
- Eyitayo O Owolabi
- Centre for Global Surgery, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town.
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Smith MTD, Bruce JL, Clarke DL. Health-Related Behaviours, HIV and Active Tuberculosis are Associated with Perioperative Adverse Events Following Emergency Laparotomy at a Tertiary Surgical Service in KwaZulu-Natal, South Africa. World J Surg 2021; 45:1672-1677. [PMID: 33641002 DOI: 10.1007/s00268-021-05986-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION This project aims to define the common comorbidities associated with patients undergoing emergency laparotomy in South Africa, to review the impact of these comorbidities on outcome and to attempt to model these various factors. METHOD A retrospective review of all patients undergoing emergency laparotomy for an emergency general surgical condition was performed from the prospectively entered Hybrid Electronic Medical Registry (HEMR). Univariate and multiple logistic regression analysis was performed to establish associations and independent risk factors for developing an adverse event. RESULTS Over a six-year time period, a total of 1464 patients underwent emergency laparotomy. The median age was 34 years. Males constituted 58.8% (861) of the patients and 754 patients (51.5%) experienced at least one adverse event. The mortality rate was 12 percent. Comorbidities and social factors were documented in 912 patients (62.3%). The rate of adverse events among patients with comorbidities was 59% (538). Patients without comorbidities or significant social factors had an adverse event rate of 39.1% (216). This difference was statistically significant (p < 0.001). The most frequent comorbidity in our sample was HIV, followed by hypertension, underlying malignancy, diabetes mellitus, active TB and cardiovascular disease. CONCLUSION Emergency laparotomy in South Africa is associated with significant morbidity and mortality. The patients are younger than in high-income countries. Diabetes mellitus, hypertension, HIV and active TB are associated with the development of an AE.
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Affiliation(s)
- Michelle T D Smith
- Department of General Surgery & Trauma, Greys Hospital, Pietermaritzburg, South Africa. .,Department of Surgery, University of KwaZulu Natal, Durban, South Africa. .,Department of General Surgery, Pietermaritzburg Metropolitan Complex, Trauma & Burns, Pietermaritzburg, South Africa.
| | - John L Bruce
- Department of General Surgery & Trauma, Greys Hospital, Pietermaritzburg, South Africa.,Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - Damian L Clarke
- Department of General Surgery & Trauma, Greys Hospital, Pietermaritzburg, South Africa.,Department of Surgery, University of KwaZulu Natal, Durban, South Africa.,Department of Surgery, University of Witwatersrand, Johannesburg, South Africa
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Soft Tissue Sepsis Places a Massive Burden on Regional and Tertiary Surgical Services in KZN Province South Africa. World J Surg 2020; 44:2526-2532. [DOI: 10.1007/s00268-020-05510-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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