Explanations for the High Risk of Diabetes-Related Amputation in a Caribbean Population of Black African Descent and Potential for Prevention
Article Figures & Tables
Tables
- Table 1—
Factors associated with diabetes-related LEA
Case patients Control subjects Univariate OR (95% CI) P n 205 104 Sex (male/female) 44.9 (92/205) 34.5 (67/194) 1.54 (1.03–2.31) 0.035 Age (years) 70.3 ± 0.90 (205/205) 69.6 (0.87) (194/194) 1.01 (0.99–1.02) 0.57 Marital status (single/spouse) 71.2 (146/205) 50.0 (97/194) 2.47 (1.64–3.74) <0.0001 Occupation (professional/nonprofessional) 7.4 (15/204) 11.3 (22/194) 0.62 (0.31–1.23) 0.17 Monthly household income (<$500 U.S.) 45.7 (58/127) 31.4 (48/153) 1.84 (1.13–3.00) 0.0145 Vehicle ownership (yes/no) 45.6 (93/204) 55.2 (107/194) 0.68 (0.46–1.01) 0.057 Hypertension history (yes/no) 64.9 (133/205) 63.4 (123/194) 1.07 (0.70–1.64) 0.75 Stroke history (yes/no) 17.1 (35/205) 7.2 (14/194) 2.65 (1.38–5.09) 0.0036 Diabetes duration (years) 17.8 ± 0.84 (173/205) 11.9 ± 0.74 (177/194) 1.06 (1.03–1.08) <0.0001 Usual treatment with insulin use (yes/no) 26.5 (54/204) 10.3 (20/194) 3.13 (1.79–5.47) 0.0001 Smoker (yes/no) 18.0 (37/205) 17.5 (34/194) 1.04 (0.62–1.73) 0.89 Foot inspection advice (yes/no) 78.3 (159/203) 82.0 (159/194) 0.80 (0.48–1.31) 0.37 Foot exam by a medic (yes/no) 96.1 (197/205) 98.4 (190/193) 0.39 (0.10–1.49) 0.17 Daily foot self-exam (yes/no) 71.9 (146/203) 86.5 (167/193) 0.40 (0.24–0.67) 0.0005 Blood glucose monitoring (yes/no) 17.9 (36/201) 25.0 (48/192) 0.65 (0.40–1.06) 0.088 BMI (kg/m2) 25.6 ± 0.61 (117/205) 26.8 ± 0.36 (194/194) 0.96 (0.92–1.004) 0.075 Pulse rate (per min) 88.1 ± 1.2 (195/205) 77.2 ± 0.83 (194/194) 1.06 (1.04–1.08) <0.001 Sitting SBP (mmHg) 131.6 ± 1.45 (191/205) 145.4 ± 1.43 (194/194) 0.97 (0.96–0.98) <0.001 Claudication (yes/no) 30.6 (52/170) 16.2 (23/142) 2.28 (1.31–3.96) 0.0035 Absent foot pulses (yes/no) 84.1 (138/164) 21.6 (42/194) 19.2 (11.2–33.0) <0.0001 ABI (low/normal) 42.8 (71/166) 16.1 (31/192) 3.88 (2.37–6.35) <0.0001 Composite PVD index positive 94.1 (160/170) 60.0 (75/159) 17.9 (8.80–29.48) <0.0001 Ever foot ulcer (yes/no) 61.0 (125/205) 1.0 (2/194) 149.4 (36.2–617.1) <0.0001 Current limb infection (yes/no) 26.6 (54/203) 1.0 (2/194) 34.5 (8.32–143.22) <0.001 Callus (yes/no) 33.2 (67/202) 17.5 (34/194) 2.34 (1.46–3.74) 0.0004 Absent lower-limb reflexes (yes/no) 65.8 (104/158) 41.3 (78/189) 2.74 (1.77–4.25) <0.0001 VPT right malleolus (volts) 2.0 ± 1.46 (113/205) 23.0 ± 0.76 (192/194) 1.07 (1.05–1.10) <0.001 Monofilament insensitivity (yes/no) 94.1 (111/118) 33.2 (64/193) 31.9 (14.06–72.48) <0.0001 GHb 11.1 (0.27) 9.1 (0.19) 1.24 (1.15–1.34) <0.001 -
Data are means ± SE or % (n), unless otherwise indicated. ABI, ankle brachial index; VPT, vibration perception threshold.
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- Table 2—
Types of footwear associated with increased amputation risk
Case patients Control subjects OR (95% CI) P Barefoot in the garden Men (yes/no) 38.5 (35/91) 17.9 (12/67) 2.86 (1.35–6.09) 0.005 Women (yes/no) 31.2 (34/109) 25.2 (32/127) 1.35 (0.76–2.38) 0.31 All (yes/no) 34.5 (69/200) 22.7 (44/194) 1.80 (1.15–2.80) 0.01 Sneakers at work Men (yes/no) 31.9 (29/91) 22.4 (15/67) 1.62 (0.80–3.34) 0.19 Women (yes/no) 45.0 (49/109) 27.6 (35/127) 2.15 (1.25–3.69) 0.005 All (yes/no) 39.0 (78/200) 25.8 (50/194) 1.84 (1.20–2.83) 0.005 Sneakers to town Men (yes/no) 40.0 (36/90) 39.4 (26/66) 1.03 (0.54–1.96) 0.94 Women (yes/no) 39.4 (43/109) 12.6 (16/127) 4.52 (2.36–8.66) <0.001 All (yes/no) 39.7 (79/199) 21.8 (42/193) 2.37 (1.52–3.69) <0.001 Rubber thong sandals worn daily Men (yes/no) 40.7 (37/91) 23.9 (16/67) 2.18 (1.08–4.40) 0.027 Women (yes/no) 47.7 (52/109) 29.1 (37/127) 2.22 (1.30–3.79) 0.003 All (yes/no) 44.5 (89/200) 27.3 (53/194) 2.13 (1.40–3.25) <0.001 Fashion footwear once weekly Men (yes/no) 7.7 (7/91) 1.5 (1/67) 5.49 (0.66–45.71) 0.08 Women (yes/no) 23.9 (26/109) 6.3 (8/127) 4.66 (2.01–10.80) <0.001 All (yes/no) 16.5 (33/200) 4.6 (9/194) 4.06 (1.89–8.74) <0.001 High-risk footwear* 86.5 (173/200) 64.9 (126/194) 3.46 (2.09–5.71) <0.001 - *
↵* Composite variable comprising going barefoot in the garden, wearing sneakers to work or town, daily wearing of rubber thong sandals, or fashion footwear once weekly.
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- Table 3—
Types, causes, and care related to current amputation
Level of current amputation Toe only 118 (57.6) Above toe, below ankle 5 (2.4) Below knee, above ankle 47 (22.9) Above knee 35 (17.1) Reported antecedents of amputation* PVD 114 (55.6) Acute infection 91 (44.4) Chronic ulcer 68 (33.2) Nonpenetrating injury 24 (11.7) Source of medical help after event Private primary care physician 82 (40.0) Polyclinic 75 (36.6) Outpatient department 16 (7.8) AED 12 (5.9) Specialist 11 (5.4) Treatment Treated and reviewed 90 (43.9) Referred to AED 48 (23.4) Admitted to hospital 32 (15.6) Referred to outpatient department 20 (9.8) Treated and discharged 6 (2.9) Initial treatment received Antibiotics 53 (25.9) Wound care 34 (16.6) Source of usual care Polyclinic 102 (56.0) Private doctor 67 (36.8) Hospital 13 (7.1) Hospitalized in previous year 55 (26.8) Reason for hospitalization (n = 55) Foot problem 40 (72.2) Coronary heart disease 6 (10.9) Hypoglycemia 3 (5.5) Hyperglycemia 2 (3.6) -
Data are n (%).
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↵* More than one cause possible. AED, accident and emergency department.
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- Table 4—
Multivariate ORs for key risk factors associated with amputation in diabetes
OR (95% CI) P Minor amputation High-risk footwear 2.52 (1.07–5.92) 0.03 Daily foot self-examination 0.28 (0.12–0.63) 0.002 GHb level (per % increase) 1.35 (1.20–1.52) <0.001 ABI (per unit increase) 0.27 (0.10–0.74) 0.01 VPT (per unit volt increase) 1.06 (1.03–1.09) <0.001 Major amputation High-risk footwear 3.85 (0.93–15.95) 0.06 Daily foot self-examination 0.09 (0.03–0.31) <0.001 GHb level (per % increase) 1.51 (1.28–1.79) <0.001 ABI (per unit increase) 0.15 (0.03–0.71) 0.02 VPT (per unit volt increase) 1.04 (0.99–1.08) 0.08 All amputations High-risk footwear 2.71 (1.23–5.97) 0.03 Daily foot self-examination 0.20 (0.10–0.42) 0.002 GHb level (per % increase) 1.40 (1.26–1.57) <0.001 ABI (per unit increase) 0.25 (0.10–0.66) 0.01 VPT (per unit volt increase) 1.05 (1.03–1.08) <0.001 -
ABI, ankle brachial index; VPT, vibration perception threshold.
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In this Issue
November 2004, 27(11)
Explanations for the High Risk of Diabetes-Related Amputation in a Caribbean Population of Black African Descent and Potential for Prevention
