title: Chronic neuropathic ulcer is not the most common antecedent of lower limb infection or amputation among diabetics admitted to a regional hospital in Jamaica: results from a prospective cohort study.
abstract: BACKGROUND
  Guidelines of the International Consensus on the Diabetic Foot state that "Amputation of the lower extremity or part of it is usually preceded by a foot ulcer". The authors' impression has been that this statement might not be applicable among patients treated in our institution. A prospective cohort study was designed to determine the frequency distribution of antecedents of lower limb infection or gangrene and amputation among adult diabetics admitted to a Regional Hospital in western Jamaica.
  
  
  METHODS
  Adult diabetics admitted to Hospital with a primary diagnosis of lower limb infection and/or gangrene were eligible for recruitment for a target sample size of 126. Thirty five variables were assessed for each patient-episode of infection and/or gangrene, main outcome variable being amputation during admission or 6-months follow-up. Primary statistical output is the frequency distribution of antecedents/precipitants of lower limb infection and/or gangrene. The data is interrogated by univariate and multivariable logistic regression for variables statistically associated with the main antecedent/precipitant events.
  
  
  RESULTS
  Data for 128 patient-episodes were recorded. Most common antecedents/precipitants, in order of decreasing frequency, were idiopathic acute soft tissue infection/ulceration (30.5%, CI; 22.6-39.2%), chronic neuropathic ulcer (23.4%, CI; 16.4-31.7%), closed puncture wounds (19.5%, CI; 13.1-27.5%) and critical limb ischemia (7.8%, CI; 3.8-13.9%). Variables positively associated with non-traumatic antecedents/precipitants at the 5% level of significance were male gender and non-ulcerative foot deformity for idiopathic acute soft tissue infection/ulcer; diabetes >5 years, previous infection either limb, insulin dependence and peripheral sensory neuropathy for chronic neuropathic ulcer and older age, diabetes >5 years, hypertension, non-palpable distal pulses and ankle-brachial index ≤0.4 for critical limb ischemia.
  
  
  CONCLUSIONS
  Chronic neuropathic ulcer accounted for only 23.4 % of lower limb infections and 27.7% of amputations in this population of diabetics, making it the second most common antecedent of either after acute idiopathic soft tissue infection/ulcer at 30.5 and 34.7% respectively. Trauma as a group (defined as closed puncture wounds, lacerations, contusion/blunt trauma and burns) also accounted for a greater number of lower limb infections but fewer amputations than chronic neuropathic ulcer, at 32 and 19.5% respectively.
authors.affiliation: Department of Surgery, Cornwall Regional Hospital (CRH), Montego Bay, Jamaica. jeast@cwjamaica.com.|Department of Surgery, Radiology, Anaesthesia and Intensive Care, University of the West Indies, Mona, Kingston 6, Jamaica. jeast@cwjamaica.com.
authors.forename: Jeffrey M
authors.initials: JM
authors.lastname: East
authors.affiliation: Department of Surgery, Cornwall Regional Hospital (CRH), Montego Bay, Jamaica.|Department of Surgery, Radiology, Anaesthesia and Intensive Care, University of the West Indies, Mona, Kingston 6, Jamaica.
authors.forename: Delroy A
authors.initials: DA
authors.lastname: Fray
authors.affiliation: Department of Surgery, Cornwall Regional Hospital (CRH), Montego Bay, Jamaica.|Department of Surgery, Radiology, Anaesthesia and Intensive Care, University of the West Indies, Mona, Kingston 6, Jamaica.
authors.forename: Dwayne E
authors.initials: DE
authors.lastname: Hall
authors.affiliation: Department of Surgery, Cornwall Regional Hospital (CRH), Montego Bay, Jamaica.
authors.forename: Chapman A
authors.initials: CA
authors.lastname: Longmore
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical / Q000706:statistics & numerical data*; D005260:Female; D005500:Follow-Up Studies; D016523:Foot Ulcer / Q000150:complications / Q000453:epidemiology / Q000601:surgery*; D006801:Humans; D015994:Incidence; D007239:Infections / Q000150:complications / Q000453:epidemiology*; D007563:Jamaica / Q000453:epidemiology; D035002:Lower Extremity / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D013997:Time Factors