A Prospective Observational Study on Diabetic Induced Complications and their Prone towards Surgery

Background: This study was mainly aimed to find out the diabetic complications that had been lead to surgey. The Diabetes mellitus describes a metabolic disorder of multiple aetiology characterized by chronic hyperglycaemia with disturbances of carbohydrate,fat and protein metabolism resulting from defects in insulin secretion,insulin action, or both.The effects of diabetes mellitus include long-term damage,dysfunction and failure of various organs. Materials and Methods: A prospective observational study was conducted in the Santhiram college & general hospital for 6 months (December 2020 – May 2021)to assess the macro vascular and micro vascular complications of diabetes mellitus and prone to surgery of diabetic complications by using case sheets, prescriptions in tertiary care teaching hospital. Results: A total of 150 patients are included in this study.In patients with diabetic complications we have observed: Diabetic ulcer with cellulitis in 19, gangrene in 19, peripheral vascular disease in 6, Original Research Article Chetty et al.; JPRI, 33(53A): 343-353, 2021; Article no.JPRI.76607 344 gangrene with cellulitis in 11,Non healing diabetes foot ulcer in 35, Coronary artery disease 24, diabetic retinopathy 25, MI in 11 patients.Among all complications, non healing diabetic foot was observed to be more when compared to other diabetic complications.In the study performed in diabetic induced complications of patients, debridement was performed in 30% patients, Amputation were performed in 13%, skin grating was performed in 13% patients, Angioplasty were performed in 23% patients and lasix surgery performed in 13% patients. Conclusion: In our study we conclude that out of 150 cases, male patients are more prone to diabetic complications than females.The patient counselling should involve in minimizing the incidence and prevalence of diabetes by conducting the continuing health education and other health programms.


INTRODUCTION
Diabetes is a chronic disease with a group of metabolic disorders characterized by high sugar levels in blood (hyperglycemia). It is caused due to deficiency of insulin or resistance to insulin or both. Insulin is secreted by pancreatic β-cells to regulate blood sugar levels [1]. According to recent diabetes atlas, the global prevalence of diabetes is estimated at 415 million (8.8%), which is predicted to rise to 642 million in next 25 years. In India, there are about 69.2 million people with diabetes and are expected to cross 123.5 million by 2040 [2]. Moreover, worldwide approximately 193 million diabetics remain undiagnosed predisposing them to the development of several long-term complications of untreated chronic hyperglycemia [3] etiology of Type2DM is constitutional insulin resistance with relative insulin deficiency. The main factors that contribute to the development of insulin resistance (T2DM) include Age, Obesity, Physical inactivity, Smoking and alcohol, dyslipidemia, hypertension, and cardiovascular disease, Mutations in the insulin gene and Insulin receptors. The symptoms diabetic includes Excessive thirst, frequently urination, extreme hunger, weight loss, Fatigue, polyuria, Dry mouth and skin [4].The diagnosis of patients with diabetes or pre diabetes some test are needed to performed ,like oral glucose tolerance testing, fasting blood sugar, Random blood sugar, HbA1c testing etc. HbA1c test is much better than the FGP test for determination risk of cardiovascular disease and death from any cause [4].
The micro complications mainly include: Diabetic neuropathy, nephropathy, and retinopathy. Macro vascular complications include: Coronary heart disease, cerebrovascular disease, peripheral vascular disease [5]. When compared to people without diabetes, diabetics have a 30-fold higher risk of lower-extremity amputation owing to infection. Diabetic foot infections that aren't treated well result in lower-extremity amputation in about 10% of patients [4]. Diabetic retinopathy(DR) is a condition in which the retina of the eye is damaged as a result of long-term diabetes. In most nations, diabetic retinopathy is the leading cause of blindness. It's frequent in both type 1 (40%) and type 2 diabetes (20%). The most common cause of visual impairment in people with T2DM is fovea involvement due to edema and hard exudates or ischemia [6]. The main risk factors for DR include hyperglycemia and diabetes for a longer period of time. Hypertension, hyperlipidemia, pregnancy, and microalbuminuria are all risk factors. Symptoms of diabetic retinopathy manifest only after damage to the eyes has occurred, and include blurred vision and gradual vision loss, floaters, shadows or missing portions of vision, and difficulty seeing at night. The most significant and prevalent complication of diabetes is related to blood vessels [7]. Because of the lack of protective feeling and coordination of the foot muscles caused by neuropathy, mechanical stresses during ambulation are increased. Ischemia is caused by a lack of oxygen in the lower leg, and it can also result in a wound. DFU is caused by a combination of ischemia and neuropathy, which deteriorates the skin integrity of the patient.DFU is a type of DM complication that can be treated. Diet, activity, and therapy adjustments can all have an impact on DFU recovery. DFU will heal 60-80% of the time. However, 10-15 percent will stay germinate, and 5-24 percent will require amputation within 6-18 months more than half of DFU were able to manage the sign of healing with adequate care [8].

Cellulitis
Cellulitis is a most common bacterial infection of the skin and subcutaneous tissue which is characterised by an inflammatory condition like erythema,swelling,fever,redness of the skin,blisters warmth,pian,tenderness and dimpling of the skin [9,10]. Cellulitis is mainly occurs when the wounded areas like breaks,cuts,cracks,ulceration,bite wounds are exposed to the streptococci and staphylococcus aureus bacteria. The severity of Non diabetic foot ulcer graded according to the CREST guidelines for cellulitis .Cellulitis usually disappears with appropriate antibiotic treatment if the practitioner correctly diagnoses and treats it quickly [11].

Aim
To study diabetic induced complications and prone towards surgery.

Objectives
 To analyse micro and macro vascular complications.  To find out the causes of diabetic induced surgery based on severity of patients.  To analyse the parameters to overcome the complications and as well as surgery.

Parameters Analysed
Main parameters in the study includes -

Study Design
It is a Prospective observational study.

Sample procedure
The study sample consists of patient with diabetic complications which includes patients with, cellulitis, gangrene,non healing diabetic foot ulcers,myocardial infraction,coronary artery disease with angiogram procedure,retinopathy from general medicine cardiology, ophthalmology inpatient department of selected tertiary care hospital.

Study Site
Santhiram General Hospital, Nandyal, which is 1000 bedded Tertiary care teaching Hospital with multi specialisations.

Method of Data Collection
This prospective observational study was carried out after obtaining the permission of institutional ethical committee Santhiram medical college and general hospital, Nandyala A.P, India, with proposal number 150.All patients according to the study criteria, admitted in the Cardiology, General surgery, ophthalmology, between December to May were included in the study.
Proforma was used for collecting data which includes patient demographics, past medical history, family and surgical history, comorbidities, diagnosis and present medications prescribed for each patient. The data was obtained by direct patient interview and from patient case profiles. Total 150 cases were collected from wards, according to study criteria. All the prescriptions which contain different laboratory values concerning blood sugar and drugs were collected during the study period to analyze the information. And the satisfaction of the patient after surgery was measured by 5point likert scale which contains excellent, very good, good, average and poor.

statistical Analysis
The data was subjected to descriptive and inference statistics using Graphpad Prism 5. Data subjected to mean, standard deviation, standard error and percentages. According to the ordinal data kruskal wallis test was used to obtain p-value and also Dunn's multiple comparison test was performed between groups. P-value < 0.05 considered as statistically significant.

RESULTS
Rural Population(77%) were more effected with diabetic complication when compared to urban Population(23%). Among the 150 patients of our study the alcoholics were 36 members, smokers were 48 members, and both (alcoholic and smokers) were 20 members and the females were excluded.
Among the 150 patients of our study the family history of diabetic was high compare to the hypertension and comorbid condition that was hypertension & diabetic Among the 150 patients of our study the widely used medications were metformin and H.Actropid of 25%.   After performing non-parametric Kruskal wallis test for ordinal data the obtained p-value was 0.0653. That means it was not statistically significant. Why because the value > 0.05 slightly. Eventhough it was not statistically significant, but it was significant clinically. The values were explain the data was clinically significant.

DISCUSSION
Among 150 patients of our study patients suffering from diabetic complication were observed more in the age group of 51-60 years (females-39% and males -43%) and less observed at age group of 31-40 years and 81-90 years (females 3% and males-0) and .Males were more affected when compare to females.
Among the 150 patients of our study the diet maintenance was followed only by 36 members and not followed by 114 members, and the physical activity was followed only by 30 members and not followed by 120 members. So due to lack of proper diet maintenance and physical activity most of the participants suffering from to diabetic complications that we observed in our study. Among the 150 patients of our study Zostum (cefoperazone + salbactum) was the most commonly prescribed antibiotic that we observed in our study when compared to other antibiotics. Diabetic patients prescribed antibiotics based on culture sensitivity test.
Among the 150 patients of our study we observed the 50% population outcome was excellent, 31% population outcome was very good, 24% population outcome was good and the remaing 20%population outcome was average.Due to the irregular followups and medication and lack of care the 13% population were at average outcome.
Outcome satisfaction of the patient were also estimated bt using 5point likert scale. All the patients who were undergone to various surgical procedures expressed their satisfaction. In total of 150 patients 75 patients were expressed their outcomme as excellent, 31 as very good, 24 as good, 20 as average and zero for the poor respectively. These indicates the data was clinically significant.

CONCLUSION
In our study we conclude that out of 150 cases Male patients are more prone to diabetic complications than females.The surgical data also explains the need of controlling of blood sugar levels. All the patients in our study undergone for different surgical procedures. Those were debriment, amputation, skin grafting, angioplasty and lasix surgery. These data also suggests to patients to control blood sugar levels.
All the health care professionals in this regard conducted counselling and explained about the diabetes disease, controlling of the blood sugar levels and its importance. Diabetes is a world wide health care problem, in view of this concern all the health care professionals like physicians, pharmacists and nurses should involved to minimize the incidence and prevalence of diabetes by conducting the continuing health education and other health programms. Ultimately this may help in minizing the number of cases in across the world.

CONSENT
Informed consent from was obtained from the participants.

ETHICAL APPROVAL
The ethical committee considered protocol revision and the IRB board complicated a review. Institutional Review board members approved for further research.The ethical Committee has reviewed and approved without any changes.