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Pran L, Baijoo S, Harnanan D, Slim H, Maharaj R, Naraynsingh V. Quality of Life Experienced by Major Lower Extremity Amputees. Cureus 2021; 13:e17440. [PMID: 34589346 PMCID: PMC8462540 DOI: 10.7759/cureus.17440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2021] [Indexed: 11/05/2022] Open
Abstract
Lower extremity amputations and diabetic foot-related complications in the Caribbean population have been previously reported. However, there is a lack of evidence that assess the quality of life experienced in such amputees. This study aimed to determine the health-related quality of life (HRQoL) in patients after a major lower limb amputation. Data collection was performed for all major lower limb amputations undertaken at a tertiary care institution in Trinidad and Tobago, between January 2012 to December 2016. The quality of life for patients who were accessible, alive, and willing to participate was assessed using the EuroQol 5D-5L tool. Statistical analysis was performed using the Mann-Whitney U and Kruskal-Wallis tests comparing medians across various subgroups. A total of 134 individuals were still alive and willing to participate in the study. The average EQ-5D-5L index value for the cohort was (0.598), which was significantly lower compared to EQ-5D-5L population norms for Trinidad and Tobago p < 0.05. Statistically significant differences were also seen in median EQ-5D-5L index value for patients who ambulated with a prosthesis (0.787) compared to those who used another device for mobilization (0.656), p < 0.05, and to those patients who did not ambulate (0.195), p < 0.05. A comparable Quality of life was seen between the level of amputation (transtibial versus transfemoral) and gender (males versus females), p-values were 0.21 and 1.0, respectively. Overall quality of life after major amputation, as well as independent mobilization with a prosthesis, continues to be problematic in the Caribbean population. Factors adversely related to the quality of life post major amputation include increasing age, problems related to mobility, and non-ambulatory patients.
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Affiliation(s)
- Lemuel Pran
- Surgery, Eric Williams Medical Sciences Complex, Mt. Hope, TTO
| | - Shanta Baijoo
- Surgery, Eric Williams Medical Sciences Complex, Mt. Hope, TTO
| | - Dave Harnanan
- Clinical Surgical Sciences, The University of the West Indies, St. Augustine, TTO
| | - Hani Slim
- Vascular Surgery, King's College Hospital, London, GBR
| | - Ravi Maharaj
- Clinical Surgical Sciences, The University of the West Indies, St. Augustine, TTO
| | - Vijay Naraynsingh
- Clinical Surgical Sciences, The University of the West Indies, St. Augustine, TTO.,Surgery, Medical Associates Hospital, St. Joseph, TTO
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Pran L, Harnanan D, Baijoo S, Short A, Cave C, Maharaj R, Cawich SO, Naraynsingh V. Major Lower Limb Amputations: Recognizing Pitfalls. Cureus 2021; 13:e16972. [PMID: 34540383 PMCID: PMC8423325 DOI: 10.7759/cureus.16972] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2021] [Indexed: 11/21/2022] Open
Abstract
Major lower extremity amputations have been an area of much concern in the Caribbean population. Hence, the purpose of this research was to investigate the current trends in major lower-extremity amputations. Data regarding all major lower-extremity amputations performed at a tertiary care institution in Trinidad and Tobago, from January 2010 to December 2016 were reviewed. The variation of yearly trends, gender, type of amputation and reason for amputation were analysed. The yearly amputation rate demonstrated a progressive increase from 2010 to 2016, the average for the seven years was 28 per 105/year. Males accounted for 59% of cases, and 60% of amputations were done above the level of the knee joint. The most common reason for amputation was control of sepsis in 71.5% of cases. A strong association between major amputations and prior intervention for a foot-related problem was observed, as 52% of the sample had a pre-existing wound or a prior minor amputation (32%). Overall, 14.5% of all amputees were able to acquire a prosthesis. Diabetes mellitus was the most consistently associated co-morbidity occurring in 91% of the study population. Major limb amputations continue to affect our population significantly, with a rise in the amputation rate despite the introduction of a Vascular Surgical Unit. Diabetes and its foot-related complications are one of the leading causes of major lower extremity amputations. Prosthetic limb acquisition for our amputee population continues to be lacking, reflected by the low prosthetic acquisition rate observed.
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Affiliation(s)
- Lemuel Pran
- Vascular Surgery, Eric Williams Medical Sciences Complex, Mount Hope, TTO
| | - Dave Harnanan
- Clinical Surgical Sciences, The University of the West Indies, St. Augustine, TTO
| | - Shanta Baijoo
- Surgery, Eric Williams Medical Sciences Complex, Mount Hope, TTO
| | - Andy Short
- Statistics, Eric Williams Medical Sciences Complex, Mount Hope, TTO
| | - Cristo Cave
- Surgery, Eric Williams Medical Sciences Complex, Mount Hope, TTO
| | - Ravi Maharaj
- Clinical Surgical Sciences, The University of the West Indies, St. Augustine, TTO
| | - Shamir O Cawich
- Clinical Surgical Sciences, The University of the West Indies, St. Augustine, TTO
| | - Vijay Naraynsingh
- Clinical Surgical Sciences, The University of the West Indies, St. Augustine, TTO
- Surgery, Medical Associates Hospital, St. Joseph, TTO
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Cawich SO, Naraynsingh V, Jonallagadda R, Wilkinson C. Caribbean “substitution culture” is a barrier to effective treatment of persons with diabetic foot infections. World J Surg Proced 2019; 9:12-18. [DOI: 10.5412/wjsp.v9.i2.12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 06/15/2019] [Accepted: 07/17/2019] [Indexed: 02/06/2023] Open
Abstract
Diabetes-related amputation rates are high in the Caribbean. Many authorities have identified independent risk factors for diabetes-related amputations, but cultural factors remain underappreciated. We coined the term “Caribbean substitution culture” to describe the attitude of patients with diabetic foot infections in which they refuse to access medical care, instead voluntarily choosing to substitute “bush medicines” or other alternative therapies in the place of conventional treatment. Recognizing that the Caribbean substitution culture is a barrier to effective treatment of diabetic foot infections is the first step in curbing these practices. In this paper, we discuss the issues related to the Caribbean substitution culture, including the demographics of the population at risk, the alternative therapeutic practices and potential public health strategies to combat this practice.
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Affiliation(s)
- Shamir O Cawich
- Department of Clinical Surgical Sciences, University of the West Indies, St. Augustine, Trinidad & Tobago, West Indies
| | - Vijay Naraynsingh
- Department of Clinical Surgical Sciences, University of the West Indies, St. Augustine, Trinidad & Tobago, West Indies
| | - Ramesh Jonallagadda
- Department of Surgery, University of the West Indies, Cave Hill, Barbados, West Indies
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Cawich SO, Naraynsingh V, Jonallagadda R, Wilkinson C. Caribbean “substitution culture” is a barrier to effective treatment of persons with diabetic foot infections. World J Surg Proced 2019. [DOI: 10.5412/wjsp.v9.i2.0000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Kurup R, Ansari AA, Singh J. A review on diabetic foot challenges in Guyanese perspective. Diabetes Metab Syndr 2019; 13:905-912. [PMID: 31336544 DOI: 10.1016/j.dsx.2018.12.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 12/19/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND Diabetes mellitus signifies a major public health threat worldwide. Type 2 diabetes has been reported as the fourth leading cause of death and has affected 15.5% of the adult population in Guyana, South America. Diabetes has also led to major lower extremity amputation at the only referral public hospital in Guyana. Diabetic foot and related complications are known to be multifactorial. CONCLUSION In this review, we highlight the information on the diabetic foot and related complications with an emphasis on Guyanese background.
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Affiliation(s)
- Rajini Kurup
- Faculty of Health Sciences, University of Guyana, Georgetown, South America, Guyana.
| | - Abdullah Adil Ansari
- Faculty of Health Sciences, University of Guyana, Georgetown, South America, Guyana.
| | - Jaipaul Singh
- School of Pharmacy and Forensic and Investigative Sciences, University of South Lancashire, Preston, Lancashire, United Kingdom.
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Cawich SO, Harnarayan P, Islam S, Budhooram S, Ramsewak S, Naraynsingh V. Adverse events in diabetic foot infections: a case control study comparing early versus delayed medical treatment after home remedies. Risk Manag Healthc Policy 2014; 7:239-43. [PMID: 25473322 PMCID: PMC4251569 DOI: 10.2147/rmhp.s72236] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background The aim of conventional medical therapy in diabetic foot infections is to control infection, thereby reducing amputation rates, infectious morbidity, and death. Any delay incurred during a trial of home remedies could allow an infection to progress unchecked, increasing the risk of these adverse outcomes. This study sought to determine the effects of delayed operative interventions and amputations in these patients. Methods A questionnaire study targeting all consecutive patients admitted with diabetic foot infection was carried out over 1 year. Two groups were defined, ie, a medical therapy group comprising patients who sought medical attention after detecting their infection and a home remedy group comprising those who voluntarily chose to delay medical therapy in favor of home remedies. The patients were followed throughout their hospital admissions. We recorded the duration of hospitalization and number of operative debridements and amputations performed. Results There were 695 patients with diabetic foot infections, comprising 382 in the medical therapy group and 313 in the home remedy group. Many were previously hospitalized for foot infections in the medical therapy (78%) and home remedy (74.8%) groups. The trial of home remedies lasted for a mean duration of 8.9 days. The home remedy group had a longer duration of hospitalization (16.3 versus 8.5 days; P<0.001), more operative debridements (99.7% versus 94.5%; P<0.001), and more debridements per patient (2.85 versus 2.45; P<0.001). Additionally, in the home remedy group, there was an estimated increase in expenditure of US $10,821.72 US per patient and a trend toward more major amputations (9.3% versus 5.2%; P=0.073). Conclusion There are negative outcomes when patients delay conventional medical therapy in favour of home remedies to treat diabetic foot infections. These treatments need not be mutually exclusive. We encourage persons with diabetes who wish to try home remedies to seek medical advice in addition as a part of holistic care.
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Affiliation(s)
- Shamir O Cawich
- Department of Clinical Surgical Sciences, University of the West Indies, St Augustine Campus, Trinidad and Tobago, West Indies
| | - Patrick Harnarayan
- Department of Clinical Surgical Sciences, University of the West Indies, St Augustine Campus, Trinidad and Tobago, West Indies
| | - Shariful Islam
- Department of Clinical Surgical Sciences, University of the West Indies, St Augustine Campus, Trinidad and Tobago, West Indies
| | - Steve Budhooram
- Department of Clinical Surgical Sciences, University of the West Indies, St Augustine Campus, Trinidad and Tobago, West Indies
| | - Shivaa Ramsewak
- Department of Clinical Surgical Sciences, University of the West Indies, St Augustine Campus, Trinidad and Tobago, West Indies
| | - Vijay Naraynsingh
- Department of Clinical Surgical Sciences, University of the West Indies, St Augustine Campus, Trinidad and Tobago, West Indies
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Cawich SO, Islam S, Hariharan S, Harnarayan P, Budhooram S, Ramsewak S, Naraynsingh V. The economic impact of hospitalization for diabetic foot infections in a Caribbean nation. Perm J 2014; 18:e101-4. [PMID: 24626079 DOI: 10.7812/tpp/13-096] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
CONTEXT Foot infection is the most common complication of diabetes mellitus in the Caribbean. Diabetic foot infections place a heavy burden on health care resources in the Caribbean. OBJECTIVE To evaluate the treatment-related costs for diabetic foot infections in a Caribbean nation. METHODS We identified all patients with diabetic foot infections in a 730-bed hospital serving a catchment population of approximately 400,000 persons from June 1, 2011 through July 31, 2012. The following data were collected: details of infection, antibiotic usage, investigations performed, number of physician consultations, details of operative treatment, and duration of hospitalization. Total charges were tallied to determine the final cost for inhospital treatment of diabetic foot infections. RESULTS There were 446 patients hospitalized with diabetic foot infections, yielding approximately 0.75% annual risk for patients with diabetes to develop foot infections. The mean duration of hospitalization was 22.5 days. Sixteen patients (3.6%) were treated conservatively without an operative procedure and 430 (96.4%) required some form of operative intervention. There were 885 debridements, 193 minor amputations and 60 major amputations, 7102 wound dressings, 2763 wound cultures, and 27,015 glucometer measurements. When the hospital charges were tallied, a total of US $13,922,178 (mean, US $31,216) were spent to treat diabetic foot infections in these 446 patients during 1 year at this hospital. CONCLUSIONS Each year, the government of Trinidad and Tobago spends US $85 million, or 0.4% of their gross domestic product, solely to treat patients hospitalized for diabetic foot infections. With this level of national expenditure and the anticipated increase in the prevalence of diabetes, it is necessary to revive the call for investment in preventive public health strategies.
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Affiliation(s)
- Shamir O Cawich
- Senior Lecturer in the Department of Clinical Surgical Sciences at the University of West Indies in Port of Spain, Trinidad and Tobago.
| | - Shariful Islam
- Senior Resident in the Department of Surgery at San Fernando General Hospital in San Fernando, Trinidad and Tobago.
| | - Seetharaman Hariharan
- Professor of Anesthesia in the Department of Clinical Surgical Sciences at the University of West Indies St Augustine Campus in Trinidad and Tobago.
| | - Patrick Harnarayan
- Lecturer in the Department of Surgery at the University of West Indies in San Fernando, Trinidad and Tobago.
| | - Steve Budhooram
- Lecturer in the Department of Surgery at the University of West Indies in San Fernando, Trinidad and Tobago.
| | - Shivaa Ramsewak
- House Officer in the Department of Clinical Surgical Sciences at the University of West Indies St Augustine Campus in Trinidad and Tobago.
| | - Vijay Naraynsingh
- Professor of Surgery in the Department of Surgery at the University of West Indies in Port of Spain, Trinidad and Tobago.
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Ramdass MJ, Harnarayan P, Mooteeram N, Nath A, Naraynsingh V, Budhooram S, Dookie T, Henry R. Patterns of arteriosclerotic lesions of the lower extremity in a West Indian population based on angiographic findings and ethnicity. Ann R Coll Surg Engl 2014; 96:121-6. [PMID: 24780669 DOI: 10.1308/003588414x13814021676756] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION This study aimed to determine whether ethnic differences show different patterns of arterial disease in the lower limb. METHODS A prospective analysis of 100 consecutive patients with 160 lower limb arteriograms was performed looking at the pattern of disease with relation to ethnicity in Trinidad and Tobago. RESULTS There were 53 male and 47 female patients with an age range of 43-90 years (mean: 66 years). Of the 100 patients, 45 were of East Indian descent, 36 of Afro-Caribbean descent, 14 of mixed descent and 5 had other backgrounds. There were 32 smokers and 69 diabetics. The most commonly affected artery in East Indians was the anterior tibial artery (ATA, 70%) followed by the peroneal artery (60%), superficial femoral artery (SFA, 60%), posterior tibial artery (PTA, 57%) and tibioperoneal trunk (TPT, 39%). In Afro-Caribbeans, the most commonly affected artery was the ATA (79%) followed by the PTA (74%), peroneal artery (66%) and TPT (55%). The mixed group showed the PTA (85%) to be most diseased followed by the peroneal artery (75%), ATA (70%), SFA (70%), dorsalis pedis artery (DPA, 60%) and TPT (50%). Overall, the most diseased vessel in all groups was the ATA (73%) followed by the PTA (66%), peroneal artery (64%), SFA (59%), TPT (46%), DPA (38%), popliteal artery (31%) and medial plantar artery (MPA, 29%), with the proximal vessels not being affected severely. CONCLUSIONS Ethnic divisions were only statistically significant (p<0.05) with East Indians showing worse disease in the profunda femoris artery and Afro-Caribbeans showing worse disease in the PTA, DPA and MPA. This suggests that environmental factors may play a significant role in the disease process including smoking and dietary factors rather than purely genetics.
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Affiliation(s)
- M J Ramdass
- Port-of-Spain General Hospital, Trinidad and Tobago
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Harnarayan P, Cawich SO, Islam S, Ramsewak S, Naraynsingh V. Self-directed treatment for lower limb wounds in persons with diabetes: a short report. Patient Prefer Adherence 2014; 8:1173-7. [PMID: 25214770 PMCID: PMC4159497 DOI: 10.2147/ppa.s68680] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
AIM There has been little focus on self-directed treatment for lower limb wounds, although it a common practice among persons with diabetes across the Caribbean. We sought to document this practice in a Caribbean nation. METHODS We prospectively interviewed all consecutive patients with diabetes who were admitted with lower limb wounds at the San Fernando General Hospital in Trinidad and Tobago over a period of 18 months. A questionnaire was used to collect data on patient demographics, use of self-directed treatment, and details of these treatments. RESULTS Of 839 persons with diabetes who were admitted with infected lower limb wounds, 344 (41%) admitted to self-directed treatment before seeking medical attention. These patients were predominantly male (59.9%) at a mean age of 56.4±12.4 years. The practice was most common in persons of Afro-Caribbean descent (45.9%) and those with type 2 diabetes (93.9%). In this group, 255 (74.4%) patients were previously admitted to hospital for lower limb infections. And of those, 32 (12.6%) had a prior amputation and 108 (42.4%) had at least one operative debridement specifically for foot infections. CONCLUSION Caribbean cultural practices may be an important contributor to negative outcomes when treating lower limb wounds in persons with diabetes. Despite being acutely aware of the potentially devastating consequences of inadequate treatment, 41% of our patients with diabetes still opted to use self-directed treatment for lower limb wounds. This deserves further study in order to give a more tailored approach in care delivery.
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Affiliation(s)
- Patrick Harnarayan
- Department of Clinical Surgical Sciences, University of the West Indies, St Augustine Campus, Trinidad and Tobago
| | - Shamir O Cawich
- Department of Clinical Surgical Sciences, University of the West Indies, St Augustine Campus, Trinidad and Tobago
- Correspondence: Shamir O Cawich, Department of Clinical Surgical Sciences, University of the West Indies, St Augustine Campus, Trinidad and Tobago, Tel +1 868 798 9627, Email
| | - Shariful Islam
- Department of Clinical Surgical Sciences, University of the West Indies, St Augustine Campus, Trinidad and Tobago
| | - Shivaa Ramsewak
- Department of Clinical Surgical Sciences, University of the West Indies, St Augustine Campus, Trinidad and Tobago
| | - Vijay Naraynsingh
- Department of Clinical Surgical Sciences, University of the West Indies, St Augustine Campus, Trinidad and Tobago
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Islam S, Harnarayan P, Cawich SO, Budhooram S, Bheem V, Mahabir V, Ramsewak S, Aziz I, Naraynsingh V. Epidemiology of diabetic foot infections in an eastern Caribbean population: a prospective study. Perm J 2013; 17:37-40. [PMID: 23704841 DOI: 10.7812/tpp/12-126] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION This study evaluates the epidemiology of diabetic foot infections in an Eastern Caribbean nation in order to direct public health preventive measures. METHODS We prospectively identified all patients with diabetic foot infections who were admitted to tertiary care hospitals across Trinidad and Tobago from July 2011 to June 2012. A questionnaire was used to collect data on demographics, patient knowledge, avoidance of risk factors for chronic diseases (a proxy to unhealthy lifestyles), and glycosylated hemoglobin measurements on admission as an index of blood glucose control. The data were analyzed with statistical software. RESULTS There were 446 patients with diabetic foot infections (mean age = 56.9 years, standard deviation = 12.4 years). Most patients had Type 2 diabetes (93.3%) and were of Indo-Trinidadian (49.1%) or Afro-Trinidadian (41.7%) descent. There were preexisting complications of diabetes in 82.9% of patients with Type 2 diabetes: foot infections requiring hospitalization (70.2%), ischemic heart disease (32.5%), renal impairment (13.7%), and retinopathy (22.1%). Despite most patients claiming compliance with treatment, 75% had glycosylated hemoglobin levels above 7.1% at presentation, and 49.3% continued unhealthy lifestyles. Despite the high prevalence of diabetic complications at admission, and despite 70% having had previous hospitalization for treatment of foot infections, only 57.4% of patients reported ever being counseled or taught about foot care by medical personnel. CONCLUSIONS There is room for improvement in public health strategies to prevent diabetic foot complications in this setting. Such strategies should focus on patient education with emphasis on lifestyle modification and compliance with medical therapy.
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Affiliation(s)
- Shariful Islam
- Department of Surgery at the University of West Indies in San Fernando, Trinidad and Tobago.
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Islam S, Harnarayan P, Cawich S, Mahabir V, Budhooram S, Bheem V, Ramsewak S, Naraynsingh V. Secondary prevention of diabetic foot infections in a Caribbean nation: a call for improved patient education. INT J LOW EXTR WOUND 2013; 12:234-8. [PMID: 23667105 DOI: 10.1177/1534734613486151] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Most countries have instituted measures to limit the complications of diabetes. We evaluate secondary prevention strategies for diabetic foot infections in a Caribbean country. We performed a prospective questionnaire study evaluating all patients admitted to tertiary care hospitals across Trinidad and Tobago from July 2011 to June 2012. Primary study end points were the number of patient-detected injuries and the time interval between injury and presentation. Secondary end points included the practice of regular foot inspection (≥2 foot examinations per week) for early detection and the use of self-directed nonmedical therapies to treat foot infections. There were 446 patients admitted with diabetic foot infections at an average age of 56.9 ± 12.4 years. Three hundred and fifty-six (80%) were previously hospitalized with foot infections and 226 (51%) had already sustained end organ injury from diabetes. There were 163 (36.6%) patients walking barefoot at the time of injury and 189 (42.4%) had footwear-related injuries. In 257 (57.6%) cases, patients identified their foot injury shortly after the event. Despite early detection, they presented to hospital after a mean interval of 6.2 ± 5.03 days, with 78 (30.4%) having tried some form of home therapy first. Overall, 190 (42.6%) patients did not practice regular foot examinations. There is room for improvement in secondary preventative measures for diabetic foot infections in this setting. Educational campaigns may be beneficial to educate diabetics on the dangers of walking barefoot, the importance of appropriate footwear, regular foot inspection, and the importance of seeking immediate medical attention instead of experimenting with home remedies.
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Affiliation(s)
- Shariful Islam
- 1San Fernando General Hospital, Trinidad and Tobago, West Indies
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