BackgroundThe aim of the study is to assess the knowledge, attitudes and practices among healthcare professionals in Barbados in relation to healthcare ethics and law in an attempt to assist in guiding their professional conduct and aid in curriculum development.MethodsA self-administered structured questionnaire about knowledge of healthcare ethics, law and the role of an Ethics Committee in the healthcare system was devised, tested and distributed to all levels of staff at the Queen Elizabeth Hospital in Barbados (a tertiary care teaching hospital) during April and May 2003.ResultsThe paper analyses 159 responses from doctors and nurses comprising junior doctors, consultants, staff nurses and sisters-in-charge. The frequency with which the respondents encountered ethical or legal problems varied widely from 'daily' to 'yearly'. 52% of senior medical staff and 20% of senior nursing staff knew little of the law pertinent to their work. 11% of the doctors did not know the contents of the Hippocratic Oath whilst a quarter of nurses did not know the Nurses Code. Nuremberg Code and Helsinki Code were known only to a few individuals. 29% of doctors and 37% of nurses had no knowledge of an existing hospital ethics committee. Physicians had a stronger opinion than nurses regarding practice of ethics such as adherence to patients' wishes, confidentiality, paternalism, consent for procedures and treating violent/non-compliant patients (p = 0.01)ConclusionThe study highlights the need to identify professionals in the workforce who appear to be indifferent to ethical and legal issues, to devise means to sensitize them to these issues and appropriately training them.

SummaryBackgroundSurgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world.MethodsThis international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231.FindingsBetween Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p<0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p<0·001).InterpretationCountries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication.FundingDFID-MRC-Wellcome Trust Joint Global Health Trial Development Grant,...

NISH CHATURVEDI, MRCP, MD 4OBJECTIVE -Diabetes-related lower-extremity amputation (LEA) rates are elevated in blacks compared with whites in the U.S., but are lower in African Caribbeans in the U.K., whereas anecdotal reports suggest high rates in the Caribbean. We aimed to establish the incidence and risk factors for diabetes-related LEA in a Caribbean population.RESEARCH DESIGN AND METHODS -We conducted an incident and prospective case-control study of case patients (individuals with diabetes having a LEA) and communitybased control subjects (individuals with diabetes without a LEA) in Barbados, West Indies. Participants completed an interview and examination of risk factors for amputation, including footwear use. CONCLUSIONS -Diabetes LEA rates in Barbados are among the highest in the world. Inadequate footwear independently tripled amputation risk. Education of professionals and patients, particularly about footwear and foot care, coupled with improved diabetes clinical care, is key to reducing amputation risk in this population. RESULTS Diabetes Care 27:2636 -2641, 2004T ype 2 diabetes is a global public health concern, with middleincome developing countries such as those in the Caribbean having a disproportionate disease burden (1). Populations of black African descent in the U.S., U.K., and Caribbean share a common genetic ancestry and experience high prevalences of type 2 diabetes (2).Data on the risk of diabetes-related lower-extremity amputation (LEA) in populations of African descent are conflicting. A twofold excess risk observed in blacks in the U.S. can largely be accounted for by poor access to health care (3-6). Paradoxically, in the U.K., where access to health care is thought to be more equitable, the risk of diabetes-related LEA is one-third lower in African Caribbeans compared with Europeans living in London (relative risk 0.67) (7). Although anecdotal evidence from the Caribbean based on hospital bed occupancy suggests high rates of diabetes-related amputations (8), definitive data are still lacking. This study was therefore conducted to determine the incidence of amputation and relevant risk factors to plan efforts to reduce the burden of amputation in this and similar populations. RESEARCH DESIGN ANDMETHODS -There were two parts to this study: an incidence study to document diabetes-related amputation rates and to compare findings with those of other population-based studies and a case-control study to determine reasons for the anticipated especially high rates of amputation in the Caribbean. Each individual undergoing an amputation during the study period contributed data once at the time of the first observed procedure. Amputation incidence studyAll persons having a LEA during the 12-month period commencing in November 1999 were identified prospectively. An amputation was defined as the complete loss in a transverse plane of any part of a lower limb (9), including wedge and ray amputations. Minor amputations involved the toes and foot, and major amputations were those through the tibia a...

OBJECTIVE -To determine the mortality rate after diabetes-related lower-extremity amputation (LEA) in an African-descent Caribbean population.RESEARCH DESIGN AND METHODS -We conducted a prospective case-control study. We recruited case subjects (with diabetes and LEA) and age-matched control subjects (with diabetes and no LEA) between 1999 and 2001. We followed these groups for 5 years to assess mortality risk and causes.RESULTS -There were 205 amputations (123 minor and 82 major). The 1-year and 5-year survival rates were 69 and 44% among case subjects and 97 and 82% among control subjects (case-control difference, P Ͻ 0.001). The mortality rates (per 1,000 person-years) were 273.9 (95% CI 207.1-362.3) after a major amputation, 113.4 (85.2-150.9) after a minor amputation, and 36.4 (25.6 -51.8) among control subjects. Sepsis and cardiac disease were the most common causes of death.CONCLUSIONS -These mortality rates are the highest reported worldwide. Interventions to limit sepsis and complications from cardiac disease offer a huge potential for improving post-LEA survival in this vulnerable group.