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Forrester JD, Teslovich NC, Nigo L, Brown JA, Wren SM. Undertreated Medical Conditions vs Trauma as Primary Indications for Amputation at a Referral Hospital in Cameroon. JAMA Surg. 2018;153(9):858–860. doi:10.1001/jamasurg.2018.1059
Historically, amputations in sub-Saharan Africa (SSA) were performed to address pathologic changes due to traumatic injury.1 However, SSA countries are currently experiencing the epidemiologic double burden of disease; as treatment for and education about infectious diseases improve, these countries are increasingly faced with a transition to noncommunicable chronic diseases (NCDs), including diabetes and peripheral vascular disease.2 This transition is attributed to longer life expectancy and greater exposure to risk factors that include smoking, poor diet, and sedentary lifestyle.2 We hypothesized that NCDs have overtaken trauma as the primary cause for amputation in SSA, with postoperative mortality driven by untreated or undertreated medical conditions.
We performed a retrospective cohort study of amputations at Mbingo Baptist Hospital, a rural referral hospital in Cameroon, from January 1, 2014, through August 30, 2016. Patients were identified through operative case logs, and perioperative variables were obtained through medical record review. Univariate analysis was performed with in-hospital mortality as the primary outcome. Any variable on univariate analysis with P ≤ .10 was included in logistic regression multivariate analysis. Statistical analysis used Stata software (version 14.1; StataCorp), and P < .05 indicated statistical significance. Institutional review board approval at Mbingo Baptist Hospital and Stanford University, Palo Alto, California, was obtained before study initiation; the institutional review board waived the need for informed consent for this retrospective study.
A total of 283 amputations were recorded in the operative log, of which 255 (90.1%) had corresponding medical record numbers allowing for cross-reference. One hundred seventy records (60.1%) included sufficient clinical information for analysis (Table), including 105 male (62.5%) and 63 female (37.5%) patients, with data missing in 2 (median age, 58 years; range, 1-95 years). Most amputations were of the lower extremity (155 [91.2%]), including 75 (44.1%) above-knee, 70 (41.2%) below-knee, and 8 (4.7%) transmetatarsal amputations and 1 (0.6%) hip disarticulation. Upper extremity amputations (15 [8.8%]) included 11 (6.5%) above-elbow, 3 (1.8%) below-elbow, and 1 (0.6%) partial-hand amputations and 1 (0.6%) shoulder disarticulation. One hundred fourteen of 170 amputations (67.1%) were performed for infection, 23 (13.5%) for peripheral vascular disease, and 17 (10.0%) for cancer. Of the 15 amputations performed as a direct result of trauma (8.8%), 7 were related to motor vehicle crashes.
Seventy-four of 114 patients undergoing amputation (64.9%) had known diabetes before admission, with only 39 of these (52.7%) actually receiving medical treatment before admission. One hundred twenty-eight patients had hemoglobin A1c levels measured at admission, of whom 119 (93.0%) met criteria for diabetes, with levels greater than 6.5% (median, 9.6%; range, 5.2%-17.1%; to convert to a proportion of total hemoglobin, multiply by 0.01). Twenty-nine of 170 patients (17.1%) died in the hospital (median time to death, 3 days after admission; range, 1-33 days). The only perioperative variables associated with mortality included intraoperative hypoxia (Po2<90%) (odds ratio [OR], 3.40; 95% CI, 1.19-9.50; P = .02), prolonged anesthesia time (OR, 0.58; 95% CI, 0.38-0.90; P = .01), and postoperative intensive care unit admission (OR, 10.00; 95% CI, 1.99-50.70; P = .005).
In Cameroon, infections and vascular disease stemming from inadequately treated diabetes and peripheral vascular disease, not trauma, are driving amputations. Other modern studies from SSA have shown similarly concerning trends3-5 and represent a change from historical norms.1 More than 90% of tested amputees had hemoglobin A1c values greater than 6.5%, underscoring the prevalence of diabetes among this population. Although the total percentage of amputations secondary to trauma varies among centers, the progression is clear: NCDs are increasingly responsible for amputations in SSA at present compared with in past decades. This trend will only continue because the frequency of persons living with diabetes in SSA is projected to double by 2030.6
Improving NCD management in these patient populations will be challenging. Without government-subsidized health care, families and patients can spend considerable portions of income on NCD management.6 In our population, only half of the patients with diabetes were receiving therapy before admission. Downstream consequences of NCDs, including amputation, further impair a family’s or individual’s ability to cover cost of medical care as income from potentially employable individuals is lost.6 Addressing the rapid increase of NCDs in SSA is critical now and represents an opportunity for collaboration among surgeons, physicians, and public health professionals. Study limitations include the retrospective design and incomplete capture of all amputations performed.
Accepted for Publication: March 10, 2018.
Corresponding Author: Joseph D. Forrester, MD, MSc, Department of Surgery, Stanford University, 300 Pasteur Dr, Ste H3591, Stanford, CA 94305 (firstname.lastname@example.org).
Published Online: June 6, 2018. doi:10.1001/jamasurg.2018.1059
Author Contributions: Drs Forrester and Wren had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Teslovich, Brown, Wren.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Forrester, Teslovich.
Critical revision of the manuscript for important intellectual content: Forrester, Nigo, Brown, Wren.
Statistical analysis: Forrester, Teslovich.
Administrative, technical, or material support: Nigo, Brown, Wren.
Study supervision: Brown, Wren.
Conflict of Interest Disclosures: None reported.
Disclaimer: The views expressed in this article are those of the authors and do not necessarily represent those of their affiliated institutions.
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