Podiatric Risk Assessment in Diabetic Patients at University Hospital Center of Point G ()
1. Introduction
WHO predicts that by 2025, the number of diabetics will increase by 170% in developing countries against 41% in developed countries [1] .
The diabetic foot is a real public health problem which is still dominated by a very high lower limb amputation rate even in countries with high socioeconomic status [2] .
In the department of internal medicine of University Hospital Center of Point G in Bamako (Mali), the foot problem represented 55% of hospitalized diabetics, including 41% of amputation and 5.8% of deaths [3] . The diabetic foot typically results from the combination of three entangled mechanisms that are neuropathy, arterial disease and infection.
However, regardless of the location of the attack also on the foot or hand, ignorance, bad practice and lack of resources make it the stage of osteitis or gangrene that the care is sought by patients or their families.
Given the magnitude of this problem, we began this study on the diabetic foot in the department of internal to assess the podological risk in diabetic patients, and to determine the frequency of arterial disease and diabetic neuropathy.
2. Methodology
This was a cross sectional study with a prospective survey of all diabetic patients received in consultation and hospitalization during the period of 1 July 2017 to 31 October 2017 in the Internal Medicine Department of the G-University Hospital Center.
Included in our study were all diabetic patients aged 15 years and older who had been admitted to the Department of Internal Medicine during the study period and who had accepted.
The sampling was exhaustive and the data were collected on a pre-established individual survey form addressed to patients who were admitted to a consultation or hospitalization by a trained investigator.
The questionnaire was pre-tested and validated before its uses in the study.
Each patient was inquired for the collection of epidemiological data, a clinical examination measuring anthropometric parameters; appreciating the state of staining of the integuments, the lesions and deformations of the foot, the palpation of the pedal and posterior tibial pulses, the tuning fork and the mono-filament tests.
Recent paraclinical assessments less than three months old were collected systematically, others according to the clinical symptomatology: complete lipid balance, creatinine, micro albuminuria, glycated hemoglobin (HbA1c), Doppler echography cardiac, electrocardiogram, Doppler ultrasound of the lower limbs, the funduscopy.
Operational definition:
Glycemic balance: HbA1c: <7% = Good balance
HbA1c: >7% = poor balance
Patients’ feet will be graded according to ALFEDIAM gradation.
Grade 0: No neuropathy No arterial disease, possibility of non-specific deformity;
Grade 1: Isolated insensitive foot;
Grade 2: Neuropathy + arterial disease and/or deformity of the foot;
Grade 3: History of amputation or ulceration of more than 3 months.
The data was entered and analyzed on the SPSS version 22.0 statistical software after their verification. The continuity correction and the Fisher exact test were used for the comparison of the proportions with a significance level at 5%.
3. Results
Our study included 50 patients (35 women for 15 men) out of 95 diabetic patients received a frequency of 52.6%.
The average age of our patients was 54.38 ± 13.98 years.
The sex ratio was 0.42 (Table 1).
In our study, 44% of patients were overweight or obese (Table 1).
Patients with diabetes less than 5 years of age accounted for 56% with an average duration of 5.39 ± 5.34 years.
The mode of discovery of diabetes polyuria syndrome represented 56% of the cases.
Type 2 diabetes accounted for 74% of patients. In our study, among the patients who had performed the HbA1c assay, 80.77% were not well balanced.
In our sample, patients who did not know foot hygiene recommendations accounted for 82%.
Diabetic neuropathy accounted for 73.8% of podiatry risk factors.
Arteriopathy was found in 32.3% of patients who developed macroangiopathy.
Grade 1 patients at risk of foot accounted for 52% (Table 1).
We found a significant link between the duration of diabetes progression and sensory neuropathy (p = 0.012) (Table 2).
A significant link was found between dyslipidemia and sensory neuropathy (p = 0.026) (Table 3).
In our study, we found a significant link between glycemic imbalance and diabetic neuropathy (p = 0.034) (Table 4).
There is no significant relationship between the duration of diabetes progression and lower extremity arterial disease in diabetic patients (p = 0.488).
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Table 1. Distribution according to demographic data, BMI and podiatry risk gradation according to ALFEDIAM.
Sex ratio = 0.42.
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Table 2. Distribution according to diabetic neuropathy and the duration of evolution of diabetes.
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Table 3. Distribution by diabetic neuropathy and cardiovascular risk factors.
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Table 4. Distribution according to diabetic neuropathy and HbA1c level.
Exact Fisher test = 2.404; p = 0.034. The minimum theoretical strength is 1731.
4. Discussion
Limitations of our study: during the study we encountered some difficulties among which:
* Economic reasons: not all paraclinical assessments have been performed by all patients;
* The weak sample of our study.
Our study included 50 patients (15 men for 35 women) with a sex ratio of 0.42. This result is comparable to those of Drago [4] who found a sex ratio of 0.36; however it is different from that of Rose [5] who found a sex ratio of 2.47.
The average age of our patients was 54.38 ± 13.98 years. This result is comparable to that of Drago [4] and Rose [5] who respectively found an average age of 53.03 ± 11.75 years and 66.90 years.
Forty-four percent (44%) of the patients were overweight/obese. This result is lower than that of Drago [4] who found 58.2%. The average BMI of our patients was 27.16 kg/m2. This result is lower than that of Rose [5] and Matthieu [6] who found respectively an average of 30.11 kg/m2 and 30.03 kg/m2. Our results are consistent with data from the literature that showed a link between diabetes (especially type 2 diabetes) and overweight/obesity [7] .
Patients whose diabetes had evolved for less than 5 years represented 56% with an average duration of 5.39 ± 5.34 years. Our result is comparable to that of Drago [4] who found 65.5%.However it is lower than that of Matthew [6] who found an average duration of 16 ± 10.2 years. This difference could be explained by the late treatment and management of diabetes in Bamako [7] .
In our study, among the patients who had performed the HbA1c assay, 80.77% were not well balanced. This result is higher than those obtained by Drago [4] and Rose [5] who found respectively 58.12% and 64%. This difference could be explained by the non-observance of certain patients, the financial reasons or the denial of the disease.
In our sample, patients who did not know foot hygiene recommendations were 82%. This result is different from that of Drago [4] , who found that 34.1% of patients did not have a good knowledge of foot hygiene recommendations. This difference could be explained by the fact that the diabetic education sessions in the internal medicine unit of the University Hospital Center of Point G mainly take into account only hospitalized patients.
Among podiatric risk factors, diabetic neuropathy accounted for 73.8%. This result is comparable to those obtained by Rose [5] and Drago [4] who found respectively 63% and 67.7%.
Amongthe patients who have developed macroangiopathy, 32.3% presented with arteriopathy.
This result is comparable to that found by Hamdi et al. 21.4% [8] .
Grade 1 patients in our study accounted for 52%. This result differs from those found by Drago [4] and Matthieu [6] who regained a predominance of grade 0, i.e. 70.30% and 44% respectively of the sample. This difference could be explained by the fact that the diabetic education sessions set up by the service take into account practically only inpatients.
A significant link was found between dyslipidemia and sensory neuropathy (p = 0.026). Drago [4] in his study had found a comparable result (p = 0.03).
We found a significant link between the duration of diabetes progression and sensory neuropathy (p = 0.012). This result is comparable to that of Drago [4] (p = 0.005).
In our sample, we did not find a significant link between the age of diabetic patients and sensory neuropathy. This result is different from that of Drago [4] who found a significant link (p = 0001). This difference could be explained by the small size of our sample.
We found a significant link between glycemic imbalance and diabetic neuropathy (p = 0.0173). Our result is comparable to that of Drago [4] (p = 0.002).
We found a significant link between the duration of diabetes progression and arterial disease of the lower limbs in diabetic patients (p = 0.0219). Our result is comparable to that of Drago [4] (p = 0.002).
There is no significant relationship between the duration of diabetes progression and lower extremity arterial disease in diabetic patients (p = 0.488). Our result is different from that of Drago [4] (p = 0.002).
5. Conclusion
Diabetic neuropathy and arterial disease are the predominant podiatric risk factors in the Department of Internal Medicine at the University Hospital Center of Point G. The increasing incidence of diabetes worldwide continues to lead to a parallel rise in disabling and potentially fatal complications. Those that touch the foot are among the most feared and should be more monitor for better prevention of podiatry risk.
Annexes
Investigation sheet
No. of the survey sheet: .....................
I) Identification
Q1: Date of consultation: ...... / ......... / .........
Q2: Name and surname: .....................................................................
Q3: Sex: / ......... / 1 = Masculine; 2 = Female
Q4: Age (years): / ......... /
Q5: Ethnicity: /........../ 1 = Bambara; 2 = Sarakole, 3 = Soniké, 4 = Dogon, 5 = Peulh, 6 = Sonrai, 7 = Bozo, 8 = Others
If (8), specify .........................
Q6: Nationality: / ...... / 1 = Malian; 2 = Non-Malian
Q7: Profession / ......... /
1. Housewife; 2. Worker; 3. Official; 4. Studen; 5. High frame; 6. Unemployed; 7.Other
If other (7), Specify: .......................................
Q8: Residence: / .........../ 1 = Bamako, 2 = Outside Bamako, 3 = Outside Mali
Q9: Level of education: / ......... /
1: Primary; 2: Secondary; 3: Higher; 4: Illiterate; 5: Others
If Other (5) Specify: .......................................
II) The parameters
Q10: Anthropometric values measured on the day of the survey by the investigator
Weight: ............ Kg; Hip circumference: .................. cm
Size: ......... cm; Waist: ............ cm; RTH: ..................
IMC: / ......... /
Q11: Are you hypertensive? / ......... / 1. Yes; 2. No
If yes, last measurement done by TA investigator (mm hg): / ......... /
If yes treated by antihypertensive: / ......... /1. Yes; 2. No
If yes medicine (s) ..........................................
III) Data on the disease (diabetes)
Q12: Duration of diabetes discovery (in years): / ......... /
Q13: Discovery mode: / ......... / 1 = Fortuit; 2 = Polyuropolydyps in syndrome; 3 = Complications; 4 = Other
If other (4) Specify ..........................................................
Q14: Type of diabetes: / ......... /
1 = Type I 2 = Type II; 3 = Secondary; 4 = Gestational
Q15: Personal history: Macrosomia for women: / ......... /
1. Yes; 2. No; 3. Do not remember
Q16: Family history of diabetes: / ......... / 1. Yes; 2. No
Q17: How long have you been treated by a doctor? /………/years)
Q18: Drug treatment of diabetes / ......... / 1.Yes; 2. No
Q19: IF yes how long? /………/ years
Q20: What kind of treatment? / ......... /
1 = Insulin; 2 = Oral antidiabetic drugs; 3 = both; 4 = Single diet
Q21: Last HbA1c level: / ......... /%
Q22: As part of the care of the feet there are rules to follow meticulously:
- Quote 3 Things to do:
1 ...................................................
2 ...................................................
3 ...................................................
- Quote 3 Things to avoid:
1 .......................................................
2 .......................................................
3 .......................................................
- Name 3 Situations where you will need to see a doctor:
1 .......................................................
2 .......................................................
3 .........................................................
Q25: Do you practice the self examination of the feet? / ......... / 1. Yes; 2. No
If so, how often ? / ......... /
1. Every day; 2. 3 times/week; 3. 1 time/week
4. 1 time/month 5. Less than 1 time/month
Q26: Do you know the recommendations for foot hygiene?
/ ......... / 1. Yes; 2. No
If so why ?.............................................. ..............
Q27: Cardiovascular and other risk factors:
• Tobacco • Alcohol • Dyslipidemia
• History of amputation of a limb or part of the limb
• Antecedent ulcer lasting more than 3 months
Venous condition: / ......... / 1. Good; 2. Bad
If (2) specify ..................................
Q28: Summary of Complications
- Macro angiopathy
• Hypertension • Coronary artery disease • Stroke/Ait
• Arteritis • AOMI
- Microangiopathy
• Diabetic nephropathy • Diabetic retinopathy
• Cataract • Glaucoma
Peripheralneuropathy
Pain / ......... / 1. Yes; 2. No
Tube test Hot and cold / ......... / 1. Positive; 2. Negative
- Tuning test / ......... / 1. Positive; 2. Negative
- Monofilament test: / ......... / 1. Positive; 2. Negative
(On each orange zone of the foot note by a (−) if hypoesthesia or anesthesia of the zone and by a (+) if normal sensitivity)
- Sensorimotor
• Flat foot • Hammer toe
• Joint stiffness • Foot of Charcot
- Autonomic neuropathy
• Sweating Disorder • Dagger Disorder
• Hyperkeratosis • Skin atrophy • Local heat
- Lesions of the foot (the day of the survey)
• Ulceration • Gangrene • Athlete’s foot
• Wound • Crack • Crevice
• Durillon • Cracks
Q29: Gradation of the foot: / ......... /
1. Grade 0; 2. Grade 1; 3. Grade 2; 4. Grade 3