Pattern Of Hespital Admissions Among Type 2 Diabetes Meliitus Patients In Ilorin Authors: Dr. Chijioke A, Dr, Adamu Dr. Makusidi A.M. Department of Medicine, University of Horin Teaching Hospital. Horin, Nigeria. Corresponding Author: Dr. A. Chijioke, Baboko Post office, P.O Box 13945, Hlorin. Abstract Introduction: People living with diabetes mellitus (DM) are prone to myriad of complications which often result in admission and premature death. The impact is greatest in type 2 DM because of larger numerical strength, insidious onset and late recognition especially in resource poot nations like Nigeria. Knowledge about morbidity pattern in type 2 DM will give insight into the disease burden and may provide effective tools for planning, delivery and evaluation of their health care needs. This study was designed to provide information on admission pattern among type 2 DM patients. Methods: Kt was a 10-year (Jan 1999 Dec 2009) retrospective analysis of cases and contributory factors for admission among type 2 DM patients into adult medical wards of University of Ilorin Teaching Hospital. Information was obtained from patient case files and admissions/discharges register. Uncontrolled hypertension and poor glycemic control were taken as BP>130/80mmHg and FBS>7mmol/L (average of three readings) respectively. Data analysis was done using SPSS, version 16. Results: Seven hundred and eight-five out of 15320 adult medical admissions were due to type 2 DM (5.12%). Age range was 35-86 years with majority aged between 35- 55 years. Overall mean age was 53.43415.07 with male and female mean ages of 53.86+13.44 and 52.19+17.43 respectively. Uncontrolled hypertension was observed in 246(52%) males and 137(44%) females with overall prevalence rate of 376(48%). Combination of uncontrolled hypertension and poor glycemic control was present in 165(21%) patients. The pattem of admission showed that hyperglycemic emergencies, septicemia and diabetic foot syndrome accounted for the highest number (30%, 22% and 17% respectively) while stroke(8.6%), hypoglycemia(7%), diabetic nephropathy(6.6%), meningitis(4.9%) and hypertensive encephalopathy(2.5%) were responsible for the rest. More females came in hyperglycemic emergencies while males accounted for the majority in stroke and diabetic foot syndrome. Conclusion: Type 2 DM is a common cause of morbidity with majority presenting in hyperglycemic emergencies, septicemia, diabetic foot syndrome and stroke. The contributory factors to admission were ignorance, poor hygiene, infections, lack of foot care and inadequate glycemic/blood pressure control. There is need for improved hygiene and provision of education programs targeted at DM patients on proper foot care and good glycemic/BP control. Gender specific attention to blood pressure and glycemic control in males and females is recommended. Keywords : Type 2 Diabetes, Admission pattern, Horin, Nigeria, Introduction The incidence and prevalence of diabetes mellitus Seen in patients with type 2 DM because of the (DM) has continued to increase globally, despite a Commonness of this type of DM, its insidious onset great deal of research, with the resulting burden and late recognition, especially in resource-poor resting more heavily on tropical, developing developing countries like Nigeria.” It is predicted ? Type 2 DM, which is the commonest of _ that prevalence of DM in adults will increase in the two basic types of DM, is increasingly being ext two decades and much of the increase will recognized in relatively young persons, due to the _ 9¢cur in developing countries where the majority of high prevalence of environmental and genetic risk patients are aged between 45 and 64.5. With the factors? People living with type 2 DM are more CU!Tent trend of transition from communicable to ‘vulnerable to varied forms of both short- and long- _0n-communicabie diseases, it is projected that the term complications, which often lead to hospital latter will equal or even exceed the former in admission and their premature death. This ‘eveloping nations, thus culminating in double ‘vulnerability to increased morbidity and mortality is burden.“ Knowledge about morbidity patterns in type 2 DM will give insight into the magnitude of ©2010 AACE Nigerian Chapter 6che disease and provide effective tools for slanning, delivery and evaluation of their health care needs. Although hospital-based studies have ‘heir limitations, as they may not reflect the actual agnitude of the disease, they nevertheless have he potential of providing information on the srent trends in morbidity pattern of diseases. This dy was undertaken to obiain data on pattern and contributory factors to admission in type.2 DM atients. The findings would form the basis for jufure research and provide strategic preventive -neasures against major complications that lead to *ospital admission in diabetic Nigerians. Subjects and methods This was a retrospective study carried out to Jetermine pattern of admissions among type 2 DM ratients into adult medical wards and the accident smergency unit of University of Morin Teaching 4ospital, Iorin, over a ten-year period (Jan “999Dec 2009). The hospital is a tertiary health ‘astitution strategically located in the north central ne of the Guinea savannah region in Nigeria. Data were collected from patient case files and :dmission/discharge register. Information btained included gender, age, occupation, Euration of illness, state of blood pressure and sugar control, duration of hospitalization and co- sorbid conditions. Most patients were referred Som primary and secondary health care centres ‘le some, particularly in emergency situations, ere brought by relatives. The diagnosis of type 2 M was made based on age>35years, dependence sn diet and/or oral hypoglycemic agents and new American Diabetes Association (ADA) criterion of fasting plasma glucose of27mmol/L controlled blood pressure (BP) and fasting ood sugar(FBS) were taken as BP > 130/80 mm. Agand FBS > 7 mmol/L. being average of readings three different occasions for the purpose of this dy. Facilities for measuring HbAIe were not lable in our centre. Resistant hypertension was en as failure to achieve treatment goal of 130/80 mmHg with the use of at least three ypertensive drugs, including a diuretic, for a inimum of one month.’ Analysis of data was done asing SPSS siatistical software version 16 and snean + SD was generated for continuous variables. The chi-square test was used to determine ignificance of difference between proportions, -vhile student t-test was utilized to compare means ef continuous variables. The level of statistical significance was taken as p<0.05. Results: Seven hundred and eight-five out of 15320 adult medical admissions were due to type 2 DM (5.12%). Age range was 35-86 years with majority aged between 35-55 years. Overall mean 7 age was 53.43+15.07 with male and female mean ages of 53.86+13.44 and 52.19+17.43 respectively. Uncontrolled hypertension was observed in 246(52%) males and 137(44%) females with overall prevalence rate of 376(48%). Combination of uncontrolled hypertension and poor glycemic control was present in 165(21%) patients. The pattern of admission showed that hyperglycemic emergencies, septicemia and diabetic foot syadrome accounted for the highest number (30%, 22%,and 17% respectively) while stroke(8.6%), hypoglycemia(7%), diabetic nephropathy(6.6%), meningitis(4.9%) and hypertensive encephalopathy(2.5%) were responsible for the rest. More females came in hyperglycemic emergencies while males accounted for the majority in stroke and diabetic foot syndrome. Discussion ‘Type 2 DM is the most prevalent form of diabetes mellitus and accounts for about 90% of cases. The WHO 2004 report estimates that 1.7 million people in Nigeria have diabetes, with the projection that, the number will triple by 2030.8 There is paucity of data on type 2 DM in Nigeria and what little is available showed crude prevalence rates of 2.2% and 6.8% in 1997 and 2003 respectively.9,10 Our study reveals a prevalence rate of 5.12%, which falls within the range observed in earlier studies. The study settings and methods used may have contributed to the varied rates, as 2.2% was a national survey and 6.8% was a hospital based prospective study, while our study was retrospective. Despite the differences, available data from other nations suggest that type 2 DM is fast becoming a major health issue in Africa." Contributory factors responsible for increased prevalence of type 2 DM inchide change in diagnostic criteria, increased public awareness, decreasing overall mortality, increase in frequency of obesity and widespread adoption of sedentary lifestyle. The pattern of type 2 DM admissions shows that diabetic hyperglycaemic emergencies, septicaemia and DFS accounted for the majority of admissions. This is not surprising, as severe infections were major precipitating factors in this population of patients with poor glycaemic control. Most of our patients were managed on oral hypoglycaemic agents that usually comprise sulphonylureas and biguanide, Many of these patients also patronize traditional medicine practitioners who claim to cure diabetes with herbal remedies, which may contain potent hypoglycaemic agents. Some patients combine both orthodox and unorthodox medicine ina bid to cure diabetes. Most of those patients that came in hypoglycaemia presented in coma after Nigerian Endocrine Practice Vol.4.No. 2 December 2010Table 1: Pattern of type 2 DM Admissions Cases Totals) Septicemia 175(22.2) Diabetic Ketoacidosis — 153(19.5) (Ka) Diabetic Foot 136(17.3) Syndrome (DFS) Hyperosmolar Non-_85(10.8) Ketotic State (HONK) ‘Stroke 68(8.6) Hypoglycemia 517.2) Diabetic Nephropathy —_ 52(6.6) Meningitis 3914.9) ‘Hypertensive 20(2.5) encephalopathy Total 785(100) taking oral agents, and their relations were unsure of the duration of loss of consciousness before presentation. It is possible that majority must have suffered irreversible brain damage from prolonged hypoglycaemia, which may explain why their condition did not improve on glucose administration. The contribution of herbal concoctions to the poor outcome of these hypoglycaemic patients is not clear, as the active ingredients are largely unknown. This underscores the need for the proper education of these patients on hypoglycaemic awareness and the steps required to prevent hypoglycaemic coma. Although diabetes, especially type 2 DM, is a major cause of morbidity and mortality world-wide, the associated burden is felt more in developing countries because of delays in diagnosis, and late presentation.’ The high prevalence of hyperglycaemic emergencies in association with septicaemia, as observed in this study, shows that poor glycaemic control, lack of foot care, low immune status and ignorance are contributory factors. Our findings are similar to other studies which demonstrated the interaction between ignorance, neuropathy, vasculopathy and infections, in the genesis of diabetic foot syndrome.’ Earlier studies have alluded to the fact, that severe infections in association with both hyperglycaemic emergencies, and diabetic foot syndrome are very important diabetic complications in Nigeria." The authors observed that diabetic foot ulceration and gangrene were responsible for 40% of limb amputations, with ©2010 AACE Nigerian Chapter Males(%6) Femates(%) 9820.7) 7124.6) 6012.7) 93(29.8) 1121.3) 3501.2) 37078) 48(15.4) 38(12.3) 103.2) 35(7.4) 22(6.1) 3369) 196.1) 296.1) 10.2) 142.9) (1.9) 473(100) 3120000) about 35% of these complicated by severe infection which accounted for 25% mortality in diabetic ketoacidosis,” The majority of our patients were traders and civil servants who were ignorant about foot care, which is in accord with earlier studies.”"*” Our study also shows that more males in their prime presented with DFS than females, which is in support.of earlier studies that lamented the enormous economic burden of DFS in Nigeria" Hypertensive stroke ranked 3rd to DFS and hyperglycemic emergencies as the commonest cause of hospital admissions in our study. This is not surprising as the majority of our patients were hypertensive, with more than 50% of the hypertensive males and more than 40% of hypertensive females being uncontrolled, which may explain the gender disparity observed. Studies have shown high prevalence of hypertension among type 2 DM patients in our environment.” This is in agreement with studies from other parts of the world that show a high prevalence of hypertension among type 2 DM patients.** Diabetes and hypertension potentiate each other in predisposing patients to atherosclerotic cardiovascular disease, and hypertension is twice as common in patients with diabetes as in the general population” "Majority of type 2 DM patients have essential hypertension and constitute more than 90% of people with dual diagnosis of both conditions. ** Diabetic nephropathy as a cause for admission was not uncommon (7%) in our study. This was 8expected, as hypertension contributes to the 4evelopment of nephropathy in type 2 DM and it can also complicate diabetic renal disease."*** It »pears from this study that majority of our patients could have presented earlier in sens related “perglycaemic emergencies and foot lesions, “fore the development of overt micro vascular cmplications of the disease. Our findings also gest that macro vascular complications develop earlier or faster than micro vascular lesion song type 2 DM patients, as prevalence of stroke 2shigher than diabetic nephropathy. study shows that type 2 DM isa common cause ‘morbidity with poor hygiene, infections, lack of ‘1 care and poor glycaemic/blood pressure control ing contributory factors for admission among our ents. There is a need for health care providers to znsify efforts in educating people living with type ~ Sabetes about good personal and environmental Jene. 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