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Diabetic Control, Proteinnuria and Diabetic Retinopathy in Diabetes Clinic at Petchabun Hospital

การควบคุมเบาหวาน การตรวจพบโปรตีนในปัสสาวะและเบาหนาวเข้าจอประสาทตาในคลินิกเบาหวานโรงพยาบาลเพชรบูรณ์

วิกรม สุธีเวสารัช 1




บทคัดย่อ

หลักการและเหตุผล

                การขาดออกซิเจนของทารกแรกเกิดเป็นสาเหตุสำคัญของการตายของทารกปริกำเนิด และสาเหตุของการเกิดภาวะขาดออกซิเจนในทารกแรกเกิด  ส่วนใหญ่เกิดจากการดูแลในระหว่างการคลอด ซึ่งเป็นสาเหตุที่สามารถป้องกันได้

วัตถุประสงค์

                เพื่อหาปัจจัยเสี่ยงของการเกิดภาวะขาดออกซิเจนในทารกแรกเกิด ในโรงพยาบาลกาฬสินธุ์เพื่อนำไปสู่การหาแนวทางป้องกันภาวะ ขาดออกซิเจนในทารกแรกเกิด

รูปแบบการศึกษา  

การศึกษาย้อนหลังแบบเปรียบเทียบ (case control study)

สถานที่ทำการศึกษา  

กลุ่มงานสูติ-นรีเวชกรรม โรงพยาบาลกาฬสินธุ์

กลุ่มตัวอย่าง

                ทารกที่คลอดที่โรงพยาบาลกาฬสินธุ์ระหว่างเดือนตุลาคม 2544  ถึง เดือนธันวาคม 2545   กลุ่มศึกษา คือ ทารกแรกเกิดคลอดที่มีคะแนน Apgar น้อยกว่า หรือเท่ากับ 7 จำนวน 159 ราย   กลุ่มควบคุม คือ ทารกที่คลอดก่อนและหลังทารกในกลุ่มศึกษา และมีคะแนน Apgar มากกว่า 7 จำนวน 318 ราย

วิธีการศึกษา

                ศึกษาปัจจัยทั่วไป(socio-economic factors)  ปัจจัยก่อนคลอด (antepartum  factors)  ปัจจัยขณะคลอด (intrapartum  factors)  ปัจจัยด้านทารก (fetal  factors) จากบันทึกเวชระเบียน วิเคราะห์ข้อมูลโดยวิธี univariate analysis และ multiple logistic regression analysis.

ผลการศึกษา

                พบอุบัติการณ์ของ birth asphyxia เท่ากับ 36.1 ต่อ 1000 การเกิดมีชีพ  ปัจจัยเสี่ยงต่อการเกิดภาวะขาดออกซิเจนในทารกแรกเกิดจากการวิเคราะห์โดยวิธี   multiple logistic regression analysis.  ได้แก่ มารดามีภาวะความดันโลหิตสูงขณะตั้งครรภ์ (OR 26.81, 95% CI  6.44, 111.61), ทารกอยู่ในท่าก้น (OR 23.19,  95% CI  2.64, 203.54),  การตรวจพบความผิดปกติของ electronic fetal monitor (OR 8.3,  95% CI  3.08, 22.34),  การมีภาวะ cephalopelvic disproportion (OR 8.10,  95% CI  2.97, 22.20),  อายุครรภ์ 28-32 สัปดาห์ (OR 5.30,  95% CI  1.32, 21.22),  การคลอดโดยวิธี cesarean section (OR 3.87,  95% CI  1.94, 7.68),  อายุครรภ์ 33-36 สัปดาห์ (OR 3.29,  95% CI  1.13, 9.52),  ทารกแรกเกิดน้ำหนักน้อยกว่า 2500 กรัม (OR 3.17,  95% CI  1.25, 8.06),  การศึกษาระดับประถม (OR 3.09,  95% CI  1.60, 5.95)

 

สรุป       

พบปัจจัยเสี่ยงของการเกิดภาวะขาดออกซิเจนในทารกแรกเกิด มีทั้งปัจจัยทั่วไป ปัจจัยก่อนคลอด ปัจจัยระหว่างการคลอด และปัจจัยด้านทารก การทราบปัจจัยเสี่ยงทำให้โรงพยาบาลกาฬสินธุ์สามารถนำข้อมูลไปใช้พัฒนาแนวทางป้องกัน และปรับปรุงวิธีการปฏิบัติงานต่อไป

คำสำคัญ    ปัจจัยเสี่ยง ภาวะขาดออกซิเจนในทารกแรกเกิด

 

Abstract

Background        

Birth  asphyxia is an important cause of perinatal death. The causes of birth asphyxia are mostly due to the  processes during labor that may be prevented to reduce birth asphyxia and mortality of  the infant

Objective             

To determine risk factors for birth asphyxia  

Study design       

Case control study

Setting 

                Obstetric and Gynecology department of Kalasin Hospital.

Subject 

Cases were 159 newborns with 1-minute Apgar score of  7 or less, Controls were 318 newborns with 1-minute  Apgar score of more than 7,deliveried before and after each case.  All babies were deliveried in Kalasin Hospital between October 2001 and December 2002.

Method

Socio-economic factors, antepartum factors, intrapartum factors, fetal factors, were analysed with univariate  analysis and multiple logistic regression analysis.

Results

The incidence of birth asphyxia  was 36.1 per 1000 live births.  Factors significantly  associated with birth asphyxia included pregnancy induced hypertension (OR 26.81,  95% CI  6.44, 111.61),   breech presentation(OR 23.19,  95% CI  2.64, 203.54),  abnormal of electronic fetal monitoring (OR 8.3,  95% CI  3.08, 22.34),  cephalopelvic disproportion(OR 8.10,  95% CI  2.97, 22.20),  gestational age 28-32 weeks(OR 5.30,  95% CI  1.32, 21.22),  Cesarean section (OR 3.87,  95% CI  1.94, 7.68),   gestational age 33-36 weeks (OR 3.29,  95% CI  1.13, 9.52) , birth weight  less than 2500 grams (OR 3.17,  95% CI  1.25,8.06),   education £ 6th grade(OR 3.09,  95% CI  1.60, 5.95).               

Conclussion

                Risk factors for birth asphyxia included socio-economic factors, antepartum factors, intrapartum factors, fetal factors. The hospital will use this information in developing interventions to reduce birth asphyxia

 

Introduction

                Management of diabetes comprises not only glucose control but also control of hypertension and dyslipidemia in order to minimize their common long-term complications, i.e., atherosclerosis and its consequences. Poorly controlled diabetic patients suffer from macrovascular as well as microvascular complications including retinopathy, nephropathy and neuropathy 1-3. While the ultimate goal is to decrease morbidity and mortality, doctor 's intermediate concern is whether diabetic control is within the target range.

The aim of the study was to evaluate the control of diabetes mellitus (DM) which include controlling blood glucose, blood pressure and dyslipidemia, and to determine the prevalence of retinopathy and overt proteinuria in diabetes clinic at Petchabun Hospital. The author hoped that the knowledge would give an insight toward care improvement for the clinic.

 

Materials and methods

                A cross-sectional study was carried out in all patients attending the diabetes clinic during one year period from July 1,2003 to June 30,2004. All types of DM except gestational type were included. Routine diabetic control parameters were collected and inputted into the clinic's database for every patient's visit during the period. The parameters were body weight (BW), fasting blood glucose (FBG) by portable capillary whole blood glucose meter, blood pressure (BP) by standard manual application of mercury sphygmomanometer, hemoglobin A1C (Hb A1C), urinalysis (U/A) where proteinuria was measured by reagent strip with discrete result ranging from negative, trace, 1+, 2+, 3+, 4+, serum creatinine (Cr), serum total cholesterol (TC), serum triglyceride (TG), serum high-density lipoprotein cholesterol(HDL-C), serum low-density lipoprotein cholesterol (LDL-C) and fundoscopic exam by ophthalmologist.

FBG, BW and BP were recorded in every visit, while Hb A1C, U/A, Cr, TC, TG, HDL-C, LDL-C were collected only after doctor's order but every results were recorded. In addition to direct measurement, LDL-C was also derived from calculation by Friedewald's formula 4: LDL-C= TC- (HDL-C+TG/5) whenever TG<400 mg/dL and three samples collected on the same day. Each patient may have no, one or more records of Hb A1C, U/A, Cr, TC, TG, HDL-C, LDL-C. Fundoscopic exam was recorded by only one of the four doctors taking part in the clinic thus each patient may have no, one or more records during the one year period and only a fraction of the fundoscopic exams were recorded.

Fundoscopic exams done before the study period were also included as possible but only to identify patient with retinopathy. These values were excluded in the statistic calculation elsewhere.

Body mass index (BMI) was calculated from each patient's latest BW and height and rounded to integer. BMI 25 kg/sqm identified patients with obesity.

One or more of these means identified patients with HT

1. Doctor's diagnosis

2. Three consecutive systolic BP reach 130 mmHg and/or three consecutive diastolic BP reach 80 mmHg

One or more of these means identified patients with dyslipidemia

1. Doctor's diagnosis

2. Prescribed medication against dyslipidemia

Patients with overt proteinuria were identified by latest two U/A revealed "grade 1+ or more" proteinuria or latest one U/A revealed "grade 2+" proteinuria. All U/A with sediments, i.e., red cell   3-5/HPF and/or white cell 5-10/HPF, were excluded.

Patients with diabetic retinopathy (DR) were identified by ophthalmologist's diagnosis of either non-proliferative DR (NPDR) or proliferative DR (PDR).

Prescription data were derived from prescription database of the hospital.

Statistical analyses were carried out using simple descriptive analysis such as frequency, percentage, means, standard deviation and range. Selection biases of investigation or examination done were shown using Z-test or Chi-square test.

 

Results

                As shown in Table 1, total number of DM patients was 1,960. Male to female ratio was 1:2.27.The patients ' age ranged from 23-104 years with mean 58.8 years. The majority of patients (93.7%) were between 40-79 years old.

Table 1 : Characteristics of diabetic patients

 

Total patients

Number

Per cent

 

Sex (male : female)

1,960

600 : 1,360

30.6 : 69.4

 

HT

1,960

1,218

62.1

 

Dyslipidemia

1,960

711

36.3

 

Obesity

1,666(85.0%)

927

55.6

 

 

Total patients

Mean *

S.D. *

Range *

Age (years)

1,960

58.8

11.3

23-104

BMI (kg/sqm)

1,666(85.0%)

25.59

4.70

14-76

Average systolic BP (mmHg)

1,960

126.6

7.66

90-178

Average diastolic BP (mmHg)

1,960

77.4

4.37

60-96

Average FBG (mg/dL)

1,960

145.6

42.3

64-541

Average Hb A1C (%)

534(27.2%)

6.67

1.60

3.20-12.10

Average TC (mg/dL)

735(37.5%)

197.5

46.6

53-612

Average TG (mg/dL)

883(45.1%)

187.1

126.0

29-1320

Average HDL-C (mg/dL)

801(40.9%)

48.3

10.6

23-113

Average LDL-C (mg/dL)

1,046(53.4%)

114.4

32.4

16-249

Average serum creatinine (mg/dL)

1,157(59.0%)

1.34

0.86

0.1-10.4

* mean, S.D. and range of available data

 

 

 

 

                According to the study's criteria, HT and dyslipidemia were found in 62.1% and 36.3%, respectively.

                All patients had at least one FBG, BP record in the database. The mean average FBG was 145.6 mg/dL. The mean average BP was 126.6/77.4 mmHg.

                Mean, S.D. and range of other parameters were based on only available data. There were differences between the tested or examined group and not-tested or not-examined group as shown in table 2. Patients with diagnosis of associated HT or dyslipidemia were likely to be tested or examined. Younger age was also a significant factor of doctor's order to many tests while older age promoted more creatinine test.

Table 2 : Significant difference between tested and not-tested group *

Test or examination

Odds ratio between tested and not-tested

mean value of tested group / mean value of not-tested group

Diagnosis of HT

Diagnosis of Dyslipidemia

Male sex

age

Average FBG

Average SBP

Average DBP

BMI

1.660

 

 

58.6/60.2

 

127.2/128.6

 

Hb A1C

1.324

 

1.247

57.7/59.3

 

 

 

LDL-C

2.166

14.786

 

 

 

127.8/126.8

77.8/77.3

TC

 

5.251

 

 

 

 

 

TG

1.603

6.572

 

58.2/59.4

 

 

 

HDL-C

1.891

5.881

 

58.2/59.3

 

 

 

Cr

1.392

1.790

 

59.7/57.7

 

128.1/126.4

77.8/77.2

Urine protein

3.371

2.135

 

58.0/59.3

 

 

 

fundoscopy

4.523

2.300

 

 

 

 

 

* show only data with statistically significant difference by Z-test(odds ratio) or Chi-square test(mean)

                85.0% of patients had both body weight and height record sufficient to calculate BMI. BMI ranged from 14-76 kg/sqm with mean 25.59 kg/sqm. The prevalence of obesity was 55.6%.

                Only 27.2% were sent for Hb A1C test. The mean average Hb A1C was 6.67% with range of 3.2-12.1%. Among these patients, the mean average FBG was 143.4 mg/dL (range 74-328 mg/dL), which was not significantly different from that of the not-tested group with mean average FBG = 146.4 mg/dL (p = 0.11). However, the tested group were younger with mean age 57.7 vs. 59.3 years (p = 0.004) and had a slightly more male to female ratio (p = 0.042).

Records of LDL-C were derived from 2 ways, direct measurement and calculation. 53.4% of patients had one or more record. Among these patients, the mean average LDL-C was 114.4 mg/dL.

The mean serum creatinine of 59.0% of patients was 1.34 mg/dL. Older patients were more likely to be tested for, as noted above.

According to the latest practice recommendation from American Diabetes Association12, target range of blood pressure is < 130/80 mmHg, target range of prepandrial plasma glucose is 90-130 mg/dL and target range of LDL-C is <100 mg/dL. Table 3 shows numbers of patients whose diabetic control was outside target range.

1. 61.6% of patients in the clinic had average FBG 130 mg/dL.

2. Among 1,218 patients with associated HT, 60.3% had average BP 130/80 mmHg.

3. As high as 43.3% of total 1,960 patients were never tested for any serum lipid in the one-year period.

4. Among 711 patients with associated dyslipidemia, 68.8% had average LDL-C 100 mg/dL.

642 patients had one or more record of U/A without sediment. Among these patients, 5.1% had proteinuria 1+ or more in the latest 2 consecutive U/A during this period. More 7.2% had proteinuria 2+ or more in the latest U/A, made overall prevalence of overt proteinuria under the study's criteria 12.3%. Another 11.1% had one record of 1+ proteinuria in the latest U/A and had to be tested more to rule out non-persistent proteinuria. There was no record of proteinuria within the same day with record of systolic BP 180 mmHg or diastolic BP 110 mmHg.

                Only 302 patients (15.4%) were both sent for fundoscopy and recorded into the database. The prevalence of DR was 13.9% (NPDR:PDR = 20:1).

 

Discussions

                This study included all types of DM except gestational type because gestational DM presents in short term and has different target range of control from other types. There was no discrimination between type 1 and 2 in the database. No data of duration of diabetes, foot evaluation, complications such as neuropahty or macrovascular complications were taken into analysis.

                 Per cent of patients whose diabetic control parameter was outside target range was used to assess diabetic care in this study. Although the target cannot be applied appropriately to all patients, e.g., optimum diabetic control may be unnecessary in short life expectancy, etc, data has shown that better glycemic, blood pressure or lipid control were needed in a large portion of the patients. Annual screening of Hb A1C, lipid profile, kidney function and U/A were also inadequate.

The prevalence of HT in this study (62.1%) was higher than many other studies in the past 5-9 owing to diagnostic criteria following the latest practice recommendation. Three consecutive high systolic BP's or diastolic BP's triggered automatic diagnosis of each patient by computer program. With this method of diagnosis, doctors sometimes did not realize their patients have associated HT. It may be the reason why as high as 60.3% of patients with associated HT had average BP more than target range. Unlike dyslipidemia, patients who took antihypertensives were not included as associated HT because many antihypertensives are prescribed for other indications. For example, ACEI or ARB may be prescribed for proteinuria, ACEI, ARB or beta-blockers for ischemic heart disease or congestive heart failure, Propanolol for history of variceal bleeding, etc. So the prevalence might even be an underestimate.

                Only 56.7% of patients were sent to any lipid test at least once in the year, which was inadequate. The primary target of lipid-lowering therapy is LDL-C. In diabetic patients, goal is below 100 mg/dL. Thus only 31.2% with diagnosis of associated dyslipidemia achieved the goal. However, success or failure cannot be measured by this fraction only. At any level of LDL-C, for a given mg/dL change in the LDL-C level, the change in relative risk of coronary heart disease is the same as at any other LDL-C level. Moreover, when baseline LDL-C were very high, if would be difficult to lower to 100 mg/dL because even with high dose statins or lipid-lowering drug combinations, LDL-C reductions > 50% often cannot be achieved13.

                Proteinuria instead of albuminuria was used to assume diabetic nephropahty (DN) at the clinic. False negative could be from insensitivity of the dipstick method where grade 1+ and 2+ imply proteinuria about 300 and 1,000 mg/day respectively in an average person with daily urine output 1,000 ml. False positive could be from non-glomerular proteinuria or other causes of glomerular proteinuria. The criteria excluded only-once 1+ proteinuria to rule out non-persistent proteinuria which could be from causes such as exercise within 24 hours, infection, fever, congestive heart failure, marked hyperglycemia, marked hypertension, pyuria and hematuria14.

Comparison of DN among various studies was difficult because of differences in method and definition. Some studies used grade 2+ 5,6,10 while other used grade 1+ 11 as cut-off point. This study mixed and complicated the criteria. Comparison of DN as well as DR was displayed on Table 10. Prevalence of DR in this study appeared lower than most other studies. Further pre-designed study is needed to confirm this information.

Table 3 : patients whose diabetic control was outside target range

Glycemic control

Total

Number

%

Average FBG 130 mg/dL

1,960

1,207

61.6

Average Hb A1C 7%

534

224

41.9

Blood pressure control

Number

Average BP 130/80 mmHg

%

Total

1,960

947

48.3

Diagnosis of HT

1,218

734

60.3

No diagnosis of HT

742

213

28.7

Lipid control

Number

Never sent for any lipid test

%

Average LDL-C 100 mg/dL

%

Total

1,960

849

43.3

712

36.3

Diagnosis of dyslipidemia

711

49

6.8

489

68.8

No diagnosis of dyslipidemia

1249

800

64.1

223

17.9

Table 4 : Overt proteinuria and retinopathy

Characteristics

Number

Per cent

Proteinuria status

 

 

No overt proteinuria

563

87.7

negative or trace

492

76.6

1+ only once

71

11.1

Overt proteinuria

79

12.3

1+ at least twice

33

5.1

2+ at least once

46

7.2

 

(n=642)

100

Fundoscopy

 

 

No DR

260

86.1

DR

42

13.9

NPDR

40

13.2

PDR

2

0.7

 

(n=302)

100

Table 5 : Prevalence of DN and DR among various studies (%)

 

number

DN

DR

Siriraj7

781

8.6

21.4

Chula8

469

17.1

3.2

Rajavithi9

1,171

11.2

23.8

Srinagarind6

207

12.5

25.1

Lerdsin5

420

16.7

28.8

Banphaeo10

158

8.2

30.4

Chonburi11

206

31.0

35.4

Petchabun (number)

 

12.3 (642)

13.9 (302)

 

Conclusion

In diabetes clinic at Petchabun Hospital, better control of fasting blood glucose, blood pressure and LDL-cholesterol were needed in 61.6, 48.3 and 36.3%, respectively. Prevalence of overt proteinuria and DR were 12.3% and 13.9%. There is room for improvement in diabetic control at the clinic.

 

Acknowledgement

                The author would like to thank the following persons for their support: Mrs. Ammala Pangkaew; Mrs. Piyathida Ruangjan; Mrs. Saithong Han-In; Mr. Pramote Sanguanvong; Mr.Sakchai Satthanont; Mrs. Mayuree Jantho; Dr. Bongkoj Jiramethathorn; Dr. Pisit Wathanawithookoon, Dr. Kobchai Jiracharnchai, Dr. Nantakorn Bunpan, Dr. Apichai Seehawong; Dr. Chaicharn Suebsurikul

 

References

1.Thai Multicenter / Research Group on Diabetes Mellitus. Vascular complications in NIDDM in Thailand. Diabetes Res Clin Pract 1994; 25: 61-9.

2.UK Prospective Diabetes Study Group. Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998; 352: 837-53.

3.UK Prospective Diabetes Study Group: Effect of intensive blood glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). Lancet 1998; 352:854-65.

4.Friedewald WT, Levy RS, Fredrickson DS. Estimation of the concentrations of low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge. Clin Chem 1972; 18: 499-502.

5.Tanamai J. Diabetic Control and Complications in Diabetic Clinic, Lerdsin Hospital. Bull Dept Med Serv 1995; 20: 147-154.

6.Bhuripanyo P, Graisopa S, Suwanwatana C, Prasertkaew S, Kiatsayompoo S, Bhuripanyo K, et al. Vascular complications in NIDDM in Srinagarind Hospital, Khon Kaen. J Med Assoc Thai 1992; 10: 570-7.

7.Tandhanand S, Nitiyanant W, Makarasara C, Vannasaeng S, Vichayanrat A. Chapter 6. Epidmiology of diabetes mellitus in Southeast Asia. In : Bajaj JS. ed. Diabetes mellitus in developing countries. New Delhi : Interprint 1984 p.51-4.

8.Bunnag SC, Chandraprasert S, Svetarundra B, et al. Prevalence of vascular complications in diabetes at Chulalongkorn University Hospital. J Asean Fed Endocr Soc 1982 ; 2 :13-8.

9.Serirat S, Kachaceewa U, Sunthornthepvarakul T, Watanachote S, Kalayanarooj S, Makarasara C, et al. Chronic complications in Thai patients with NIDDM. Intern Med 1990; 6: 124-7.

10.Siriwechadaruks P. Chronic complications in NIDDM at Banphaeo Hospital. Bull Dept Med Serv 1996; 21: 377-85.

11.Kwanjaipanich R, Tengtrirat C, Nanna K, Laiwatanapaisal S. Vascular complications in type 2 diabetes mellitus at Chonburi Hospital, Thailand. Intern Med J Thai 2002:18:122-30.

12.American Diabetes Association. Standards of medical care for patients with DM. Diabetes Care 2004; 27 (Suppl 1): S15-35.

13.National Cholesterol Education Program. Implications of Recent Clinical Trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines. Circulation. 2004; 110: 227-239.

14.American Diabetes Association. Nephropathy in Diabetes. Diabetes Care 2004; 27 (Suppl 1): S79-83.





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Diabetes
 
 
 
 
Srinagarind Medical Journal,Faculty of Medicine, Khon Kaen University. Copy Right © All Rights Reserved.
 
 
 
 

 


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