The slipping slipper sign: a marker of severe peripheral diabetic neuropathy and foot sepsis

Major Lower Limb Amputations: Recognizing Pitfalls

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.

The Slipping Slipper Sign: A Poor Man's Test for Severe Diabetic Peripheral Neuropathy

BACKGROUND

Neuropathic feet are at very high risk for infection and amputation. The slipping slipper sign (SSS) is elicited by a simple questionnaire test reported to detect the presence of severe diabetic peripheral neuropathy. This test can be administered by non-medical staff. In this study, subjects with and without the SSS were evaluated by nerve conduction studies (NCS) and ultrasound measurements of the right sural nerve diameters as well as with traditional scoring systems for peripheral and autonomic neuropathy.

OBJECTIVE

To demonstrate that the Slipping Slipper Sign can be used as an index of severe diabetic peripheral neuropathyMethod:This was a prospective cross sectional study in which 74 patients with diabetes (38 positive and 36 negative for SSS) underwent ultrasonography and NCS of the right sural nerve by an examiner blinded to SSS status. Findings were evaluated against demography, clinical history, anthropometry as well as traditional clinical and autonomic neuropathic scores.

RESULTS

Patients without the SSS [median (IQR) = 10.0 years (4.0-20.3)] had a significantly shorter duration of diabetes compared with those with the SSS [median (IQR) = 15.0 years (8.5-25.0)], p = 0.028. The frequencies of retinopathy (36.8% vs 2.8%, p <  0.05) and cerebrovascular accidents (18.4% vs 13.9 %, p <  0.05) were higher among those with SSS compared with those without. Differences in nerve conduction characteristics were markedly significant. The amplitude of the sural sensory nerve action potential (SNAP) was ([median (IQR)] 0 microvolts vs 4.0 microvolts (0.0-10.8) p <  0.002) between those with and without SSS, respectively whilst none of patients with SSS had a recordable SNAP vs 78% without a SSS. Similarly, maximal thickness of the right sural nerve at the ankle 3.0 mm (2.3-3.4) vs 3.5 mm (3.0-3.9), and leg 3.4 mm (2.7-3.8) vs 3.9 mm (3.3-4.2) was reduced, p <  0.01 in patients with the SSS compared with those with a negative SSS.

CONCLUSION

The SSS identifies feet with objective neurophysiological and imaging characteristics of severe neuropathy.

Caribbean “substitution culture” is a barrier to effective treatment of persons with diabetic foot infections

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.

Does the 'slipping slipper sign' in patients with diabetes predict the presence of retinopathy and nephropathy?

BACKGROUND

Previous research had noted that an affirmative response in patients with diabetes to the question 'Have you ever lost your slipper/flip-flop from your feet while walking and not realised that you have done so'? That is, the presence of the 'slipping slipper sign' (SSS) reflected the presence of severe diabetic peripheral neuropathy with a high degree of precision. The objective of the current study was to determine whether the SSS may also predict the presence of diabetic retinopathy and/or nephropathy since microvascular complications are known to cosegregate.

SUBJECTS AND METHODS

Among 100 patients with diabetes, including 33 cases with the SSS and 67 controls without the SSS, data on demography, dipstick proteinuria as well as the presence and staging of diabetic retinopathy were obtained.

RESULTS

The mean (SD) age of all patients was 54.6 (13.0) years, mean duration of diabetes was 12.7 (10.2) years and mean haemoglobin A1c (HbA1c) 8.42 (1.95) %; 43% were males. All 33 (100%) of the patients with SSS but only 12 (18%) of the patients without SSS were found to exhibit diabetic retinopathy, p<0.001. Among those patients with retinopathy, proliferative retinopathy was far more likely (39%) in the SSS group compared with non-SSS subjects (8%). Similarly, 15 (46%) with SSS and only 4 (6%) without SSS were found to have dipstick proteinuria. The sensitivity of the SSS for retinopathy was 73% and the specificity was 100% with a positive predictive value (PPV) of 100% and negative predictive value (NPV) of 82%. For proteinuria, both the sensitivity and specificity was 78%.

CONCLUSIONS

Both diabetic retinopathy and dipstick proteinuria are strongly associated with the presence of the SSS that therefore holds potential as a tool for easier identification of this high-risk group.

Adverse events in diabetic foot infections: a case control study comparing early versus delayed medical treatment after home remedies

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.

The economic impact of hospitalization for diabetic foot infections in a Caribbean nation

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.

Self-directed treatment for lower limb wounds in persons with diabetes: a short report

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.

Epidemiology of diabetic foot infections in an eastern Caribbean population: a prospective study

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.

Secondary prevention of diabetic foot infections in a Caribbean nation: a call for improved patient education

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.

The slipping slipper sign: a simple test with high specificity and positive predictive value for peripheral neuropathy among diabetic patients

This study evaluated the ability of the slipping slipper sign (defined as unknowingly losing a slipper while walking) to identify diabetic neuropathy in Jamaican patients. A single question was used to ascertain the presence of the slipping slipper sign (SSS) among 69 patients attending a diabetes clinic. Nurses assessed pain, vibration and pressure perception among the same patients in order to detect diabetic neuropathy. The sensitivity, specificity and positive predictive value for the SSS were calculated. Eight participants (men=5, women=3) reported positive SSS. The SSS had a sensitivity of 28.6%, specificity of 100% and positive predictive value (PPV) 100% for neuropathy on at least one of the three tests. These findings indicate that the SSS has high specificity and PPV for diabetic neuropathy but the sensitivity is low. The sign may be a useful adjuvant to conventional methods of screening for severe neuropathy.