Lupine Publishers | Implementation of A Screening Checklist to Improve the Diagnosis of Chronic Kidney Disease in A Safety Net Clinic

  Lupine Publishers | Lupine Online Journal of Nursing & Health care (LOJNHC)

Abstract

Objective: To determine the risk for developing type 2 diabetes among population of Rawalpindi city.

Subjects & Methods: A cross-sectional descriptive study was conducted among 90 healthy attendants of the patients admitted in wards of Holy Family Hospital, Rawalpindi to assess their risk for developing type 2 diabetes. Data was gathered through consecutive sampling. All study participants knew they did not have any type of diabetes and they were not receiving anti-diabetic drugs. The data was collected during 2 weeks in July 2018 by means of structured questionnaire. The data was analyzed by using SPSS version 25.0

Results: Of the total 90 study subjects, 57 were females. Mean age of respondents was 44.6±5.78 years. About 10% respondents had Body Mass Index (BMI) greater than 35kg/m2 and had very high risk of developing type 2 diabetes within next 10 years. Daily consumption of fruits and vegetables seemed to have statistically insignificant relationship (P>0.20) with reduction in risk for type 2 diabetes. Only 01 respondent out of those physically active at work was at high risk for type 2 diabetes. About 27.8% respondents had positive family history. Risk of developing type 2 diabetes was insignificantly associated with gender (P>0.94). Overall, only 6 respondents predominantly females 55-64 years old had high to very high risk of developing type 2 diabetes.

Conclusion: Majority of the study participants had low to slightly elevated risk of developing type 2 diabetes. This risk can better be eliminated by lifestyle modification.

Keywords: Type 2 Diabetes; Risk Assessment; Body Mass Index; Family History

Introduction

Type 2 Diabetes is a chronic metabolic disorder showing enormously raised prevalence worldwide. Number of people affected by this epidemic is expected to double in next decade [1]. This disease is incurable. However, various treatment modalities endorsed are lifestyle modifications, reducing obesity, intake of oral hypoglycemic drugs and insulin sensitizers [1]. Type 2 Diabetes is among the greatest public health threats associated with drastic escalation of its incidence globally [2]. Type 2 Diabetes ought to investigate in overweight adults of any age with history of one or more risk factors [3]. This disease is attributed to amalgamation of numerous environmental and genetic risk factors [3]. However, investigation of type 2 diabetes should commence at age of 45 among people not having relevant risk factors [4].

Type 2 diabetes is found to be prevalent in certain races like African Americans, Hispanics and Native Americans who are more susceptible to diabetes than Caucasians [5] Even victims are unaware of their disease due to mildness of associated symptoms [5]. WHO has regarded population of developing countries as more prone to develop type 2 diabetes [6]? According to International Diabetes Federation Report 2015, 415 million people are suffering from this disease globally and about 642 million people are expected to be victimized by 20406. Proportion of diabetics is likely to double in near future primarily due to increased life expectancy and urbanization irrespective of the prevalence of obesity [7]. However, there is likelihood to arrest this increase by lifestyle modifications [8]. A systematic analytical study carried out among Pakistani population in 2015 showed 11.8% people with type 2 diabetes and situation was expected to be grave with passage of time [9]. The present study is intended to assess the risk factors for type 2 diabetes among Pakistani population specifically of Rawalpindi city to identify the risk factors for this disease. This research will provide useful information to our policy makers for strategic planning in this concern.

Subjects and Methods

A cross-sectional descriptive study was carried out among healthy attendants of the patients admitted in wards of Holy Family Hospital, Rawalpindi to determine their risk of developing type 2 diabetes. Information was gathered from 90 attendants not suffering from type 2 diabetes through consecutive sampling during two weeks in July 2018. Confirmed diagnosed cases of type-II diabetes were excluded from this study. The information was collected from study participants by using Type 2 diabetes risk assessment form designed by Prof. Jaakko, Department of Public Health, University of Helsinki. Data was collected from study participants pertinent to their demographic profile, BMI, waist circumference, physical activity, dietary habits, family history and relevant health profile. Waist circumference was measured by means of inch tape and weight was measured by weight machine. Data was analyzed by using SPSS version 25.0. Frequency and percentage were calculated for all variables. Gender based risk of type 2 diabetes was statistically confirmed by applying Fisher’s Exact test. Statistical association of type 2 diabetes risk with regular consumption of fruits and vegetables was verified by chi-square test. P-value≤0.05 was taken as significant.

Results

Majority of study participants (63.33%) were females. Mean age of respondents was 44.6±5.78 years. Most of the males (48.5%) were observed to have waist circumference less than 94cm while majority of female respondents (43.9%) had 80-88cm waist circumference. About 75.6% study subjects were under 45 years of age and only 2.2% respondents were above 64 years old. Age based gender distribution of the study subjects is shown in Figure 1. Fruits, vegetables, and berries were consumed every day by 44.4% of study subjects. Moreover, daily consumption of fruits and vegetables revealed statistically non-significant relationship (P>0.20) with reduction in risk of type 2 diabetes. Most of the females in comparison with males had BMI greater than 35kg/ m2 as depicted below in Figure 2. Out of 9 respondents with BMI>35kg/m2 only 3 were determined to be at high to very high risk (Risk score 15-20) of developing type 2 diabetes. Out of 90 study participants, 31.6% females had waist circumference more than 88cm while only 18.2% males had waist circumference more than 102cm. About 42% of females and 67% of males were found to have 30 minutes of daily physical activity at work. Only 1 study subject out of those engaged in daily physical activity at work was found to be at high risk of developing type 2 diabetes within 10 years as depicted below in Table 1. Only 16.7% respondents were taking medication for hypertension regularly while only 12.2% participants gave history of hyperglycemia during their lifetime out of which 54.5% were males. According to type 2 diabetes risk assessment scale designed by Prof. Jaakko, risk of developing type 2 diabetes within next 10 years among study subjects is illustrated below in Figure 3. However, risk of developing type 2 diabetes was found to be insignificantly associated with gender as depicted below in Table 2. 27.8% respondents had their immediate family members suffering from type 2 diabetes while 37.8% subjects had no relevant family history.

Discussion

The prevalence of diabetes mellitus is estimated to rise from 2.8% in 2000 to 4.4% in 2030. This means that about 366 million world population will be diabetic by the end of next 10 years [10]. This prevalence is more likely to grow exponentially in third world countries [11]. In response to the current scenario, implementation of primordial preventive measures to control this modern epidemic is the need of time. In present study, low risk of developing type 2 diabetes within next 10 years was found among 36 (40%) study subjects whereas high to very high risk was found among only 6 (7%) respondents out of which 5 were females. Another Asian study carried out in 2016 on 150 urban slum developers using Finnish Diabetes risk score showed 11.3% people at high to very high risk of developing type 2 diabetes within next 10 years [12]. The reason for low risk in current study might be inadequate sample size (90). Real picture could better be achieved by conduction of research on more individuals. The current study showed high risk (1%) of developing type 2 diabetes among 5% of study subjects found to be physically inactive and were taking medication for high blood pressure. Similarly, an Indian study showed about 11% risk of developing type 2 diabetes among 53.3% study subjects found to be physically inactive [12]. Both research showed proportionate relationship of lack of physical activity/exercise with risk of developing type 2 diabetes. Although social and print media is playing marvelous role in getting our people aware of diverse physical activities in accordance with their circumstances and workplace but apart from physical fitness people should also be sensitized specifically for their wellbeing. This study concluded high to very high risk of developing type 2 diabetes among 7% respondents with their positive family history, while a study by [13] among population of Bangladesh revealed 47.7% of participants with positive family history [13]. A similar Brazilian research carried out in 2013 reflected that 47% of respondents had positive family history of type 2 diabetes [14]. Contrary to international research, current study is depicting raised percentage of positive family history among Pakistani population. This factor can better be scrutinized by conduction of research on large number of individuals.

About 14% female study subjects in current study had BMI>35kg/m2. Another research revealed higher risk of type 2 diabetes among females due to greater tendency of putting weight among them. This feature is significantly attributed to variations in sex hormones in addition to genetics, familial tendency, and lifestyle [15]. There is need to do rigorous research on this aspect across countries by eliminating confounders to determine scientific association of obesity with hormones. According to our study, 5 females out of 6 were determined to be at high to very high risk of developing diabetes. Contrary to these results, an international study concluded the high risk for type 2 diabetes among males [16]. The reason for this variation might be the racial difference and social set up. However, these factors need in depth insight to reach the accurate conclusion. The present study revealed that consumption of fruits and vegetables is insignificantly associated with protection from risk of developing type 2 diabetes (P>0.20). Likewise, a study by [17] portrayed insignificant association (P>0.20) in this regard [17]. This aspect entails detailed elaboration of associated factors like intake of fatty foods and protein diet apart from consumption of fruits and vegetables. Our results showed that only 15 respondents were regularly taking medication for high blood pressure out of which 5 subjects were at high risk of developing type 2 diabetes within next 10 years. On the other hand, a prospective study carried out among hospitalized patients of Bulgaria revealed higher risk for developing type 2 diabetes among hypertensive patients [18]. As current study is cross-sectional descriptive and carried out among non-diabetics, this might be the reason for less individuals at high risk for developing type 2 diabetes within next 10 years.

Conclusion and Recommendation

High risk of developing type 2 diabetes was found among females 55-64 years of age with very high BMI, no physical activity and specifically with diabetic history of immediate family members. Considering study results, risk of developing type 2 diabetes in the community can be minimized by increased physical activity and weight reduction However, these study subjects should regularly be followed up for development of type 2 diabetes.

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Lupine Publishers | Locked Bridge Plating is a Suitable Option for Forearm Fractures Secondary to Civilian Low Velocity Gunshot Injuries

 Lupine Publishers | Orthopedics and Sports Medicine Open Access Journal (OSMOAJ)

Abstract

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Introduction: The purpose of this retrospective study is to compare the outcomes of low velocity gunshot fractures of the forearm treated with minimal debridement and locked bridge plating to patients treated with formal debridement and conventional plating.

Materials and Methods: A 10 year IRB approved retrospective review of our national trauma database was conducted. Initial treatment consisted of wound care and sterile dressing. Forearm radiographs were acquired to determine bony involvement. All patients received intravenous antibiotics upon presentation to the emergency department and for a minimum of forty-eight hours after admission or operative intervention. Patients were placed into two categories of operative or nonoperative treatment. Those placed into operative treatment were further divided into the subcategories of formal debridement and plating or minimal debridement and plating.

Results: 94 patients were included in the study. 29 were treated nonoperatively and 65 were treated operatively. Of those 65, 30 underwent minimal debridement and bridge plating and 35 were treated with formal debridement and bridge plating. All patient radiographs displayed fracture healing at latest follow-up with no evidence of infection or osteomyelitis. Nerve injuries were found among 15 patients and vascular injuries were present in 7.

Conclusions: Both methods of irrigation and debridement resulted in reliable osseous union with no instances of osteomyelitis. These results suggest that immediate locked bridge plating with minimal debridement is a suitable option for the treatment of forearm fractures following low velocity gunshot injuries.

Keywords: Irrigation; Debridement; Forearm; Gunshot; Fracture; Minimal

Introduction

There are 300,000 injuries and 30,000 hospitalizations from gunshot wounds annually in the United States [1-3] primarily from low-velocity handguns. These weapons produce less soft-tissue injury than high-velocity rifles or shotguns attributed to lower mass, velocity and energy transfer of the projectiles to surrounding tissues [4, 5]. Gunshot wounds of the forearm have been reported in several small series in the literature; however, no treatment guidelines backed by adequate scientific evidence exist. Prior studies with limited numbers have recommended debridement irrigation, antibiotics and compression plating for displaced fractures of one or both bones, and immobilization for undisplaced simple fractures of single bones. We feel that aggressive debridement and conventional compression plating may not be practical for these injuries which often have boney comminution but minimal soft tissue injury. A potential alternative is limited debridement and bridge plating. The purpose of this study is to compare the outcomes of low velocity gunshot fractures of the forearm treated with minimal debridement and locked bridge plating to patients treated with formal debridement and conventional plating.

Materials and Methods

An IRB approved 10-year retrospective review of our hospital trauma database revealed one-hundred and one patient admitted to the hospital with forearm fractures following gunshot wound (2000-2010). Seven patients were excluded from the study as their injuries were the result of a high-velocity firearm, leaving ninety-four patients treated for gunshot wounds of the forearm with hospitalization. Patients who were discharged from the emergency room with gunshot wounds with or without fractures and patients who left the hospital against medical advice prior to treatment were not captured in this database. There were eightythree males and eleven females. The average age was 27.7 years with a range of 16-52 years. The average duration of follow-up of all patients was 27.3 months with a range of 9 to 105 months. Treatment was initiated with wound care by applying a sterile dressing in the emergency department. Forearm radiographs were acquired to determine bony involvement. Clinical suspicion of limb ischemia by physical exam was an indication for angiography. All patients received intravenous antibiotics upon presentation to the emergency department and for a minimum of forty-eight hours after admission or operative intervention. The initial antibiotic selected was cefazolin with or without gentamicin, and some patients with concomitant thoracic or abdominal injuries received additional antibiotics for greater time periods. Patients with non-displaced or minimally displaced fractures were treated non-operatively with local wound care, antibiotics, and casting. Displaced fractures were divided into 2 groups.

During the first 5 years 35 patients underwent aggressive debridement and irrigation of wounds, fracture stabilization using compression plating techniques when feasible and bridge plating when there was bone loss. Antibiotic cement spacers were placed where there was bone loss followed by delayed grafting using iliac crest bone. Eight were stabilized with initial external fixation followed by plating and 27 had immediate plate fixation. The second 5 years included 30 patients treated with open reduction and internal fixation (ORIF) with a bridge plating technique, limited irrigation and debridement of entry and exit wounds locally at the level of skin and subcutaneous tissue without debridement of bone. This was intended to minimize soft tissue stripping around the fracture site. Bullet fragments were not disturbed unless they were superficial and easily removed without further damaging the surrounding soft tissues. Entrance and exit wounds were not closed primarily. Patients with non-displaced or minimally displaced fractures (29) were treated non-operatively with local wound care, antibiotics and casting. These were often admitted for concomitant injuries and thus were picked up in our database. We reviewed all radiographic images obtained at presentation and during treatment. Fractures were classified as radius, ulna or both (Figure 1). The fracture location was noted whether they were proximal, midshaft or distal and if they were non-displaced or minimally displaced versus comminuted and displaced. Radiographic data were used to determine the status of fracture healing or hardware failure. Patients were examined in the clinic (Figure 2) to assess for fracture healing, infection, presence of deformity, sensory or motor deficits, and range of motion. Range of motion was classified as good (<10 degrees flexion extension loss and <25 degree pronation/ supination loss), satisfactory (<30 degree flexion extension loss and <50 degree pronation/supination loss) or poor (>30 degree flexion extension loss or >50 degree pronation/supination loss)

Results

Operative Treatment

Sixty-five patients were treated operatively. Thirty patients underwent bridge plating and minimal debridement of the gunshot wounds without excision of only frankly necrotic tissue and minimal to no bone debridement and no bone grafting (Figure 3). Thirtyfive patients were treated with formal irrigation and debridement of the wounds and stabilization (Figure 4). Of the thirty patients with bridge plating and limited debridement twenty-nine patients displayed fracture healing at their latest follow up and one patient required revision surgery for delayed union. There were no signs of infection or osteomyelitis at final follow up. Of the thirty-five patients treated with more aggressive irrigation and debridement with fracture stabilization, seven patients were determined to have more extensive soft tissue injury requiring multiple surgeries and more aggressive debridement and eventual soft tissue coverage. Five of these seven required early bone grafting after original damage control surgery and prior to soft tissue reconstruction. All patients displayed radiologic evidence of healing at their latest follow up with no patient showing signs of infection or osteomyelitis.

Non-Operative Treatment

Twenty nine patients were treated non-operatively with local wound care and casting for forearm fractures. All patients had a single bone non-displaced or minimally displaced fracture. All patients displayed radiographic evidence of fracture healing at their latest follow up with no patient showing signs of infection or osteomyelitis. Range of motion in this subset was determined to be satisfactory or good at final follow up.

Nerve Injuries

There were fifteen patients with an associated nerve injury. The ulnar and median nerve were the most common nerves injured (six patients each) followed by the radial nerve in four patients and the palmar cutaneous nerve and anterior interosseous nerves in one patient each. Three patients had multiple nerve injuries. In seven patients the nerve injury resolved completely and in five patients a partial nerve deficit was observed. Three patients showed no recovery with one patient displaying a classical ulnar claw hand deformity.

Vascular Injury

Seven patients presented with signs of associated vascular injury of the forearm. There were four radial artery injuries and four ulnar artery injuries. One patient had both arteries injured and repaired. All patients had a viable limb on follow up. Three patients had nerve injury associated with vascular injury. One patient developed a compartment syndrome requiring fasciotomy.

Discussion

Early stabilization of forearm fractures is important after a gunshot injury and the management of the open wound and soft tissue injury is always an important consideration for surgical planning. In this study, we showed that minimal irrigation and debridement of the entrance and exit wounds is adequate for low velocity gunshot injuries to the forearm with minor visible soft tissue injury, and that bridge plating with minimal surgical dissection through the zone of injury is sufficient to achieve reliable union of these fractures. Dicpinigaitis, et al. showed that most non-displaced fractures of the radius or ulna can be effectively managed with casting al in their review of the literature addressing gunshot wounds to the extremities, but displaced fractures should be treated operatively with compression plating [4]. reported superior results in patients treated with delayed primary ORIF with displaced forearm fractures secondary to gunshot wounds [12]. In the same study, no patients treated by delayed ORIF went on to melanin or delayed union, but all patients did have decreased range-of-motion, particularly pronation and supination. Rodrigues, et al. recommended a treatment protocol involving early wound care and provisional stabilization followed by definitive treatment with internal fixation within one week [18-20]. In our review, thirty five patients were successfully treated with a more extensive soft tissue debridement with fracture stabilization, and thirty patients with comminuted and displaced fractures were effectively treated with local wound care followed by internal fixation with bridge plating.

Several studies have also examined the effectiveness of nonsurgical treatment in non-displaced or minimally displaced forearm fractures resulting from low-velocity firearms. Elstrom, et al. reported on fourteen patients that were treated with casting [12]. In eight non-displaced single bone fractures, seven had good outcomes. In six displaced fractures, closed reduction and casting lead to poor outcomes in four patients. Lenihan ,et al. reported on thirty-seven patients with civilian gunshot wounds to the radius and ulna [13]. Twenty-three patients with non-displaced fractures were treated by closed means with twenty-one showing good outcomes. However, in the fourteen patients with displaced fractures, the outcomes of the eight patients who had closed reduction were worse than the six patients treated surgically. Dickson, et al. prospectively evaluated patients with non-displaced fractures treated as outpatients with closed reduction and casting [3]. Only one patient in their study went on to delayed union [3]. also reported excellent results in patients of non-displaced fractures treated with closed reduction in a long arm cast, with seven of eight patients showing evidence of fracture healing and good functional outcome. The same study reported that four out of six patients with comminuted and displaced fractures treated with casting went on to malunion or delayed union resulting in a poor functional outcome. The authors concluded that closed reduction has satisfactory results in non-displaced fractures while displaced fractures require internal fixation to achieve superior outcomes. In our retrospective review we found similar results and agree that patients with minimally displaced or non-displaced extra-articular fractures can be adequately treated with closed reduction and casting without surgical debridement. We add to these findings that extensive surgical debridement can also be withheld with low risk of infection or nonunion after bridge plating for fracture stabilization.

Past studies have shown that bullets are not sterilized during discharge of the weapon and may act as a vector introducing pathogenic bacteria into the wound4. Controversy exists, however, as to the necessity of administering prophylactic antibiotics to this patient population. Patzakis, et al. demonstrated an infection rate of 13.9% in patients with open fractures resulting from gunshot wounds not treated with antibiotics and an infection rate of 2.3% in patients treated with cephalothin [7]. The study also showed no statistically significant difference in infection rate between the control group (13.9%) and a group treated with penicillin and streptomycin (9.7%) [7]. Conversely investigated the efficacy of antibiotics in a similar patient population and showed no significant difference in infection rate between the control group and the experimental group treated with at least twenty-four hours of intravenous cefazolin [2]. concluded in a prospective study that short-term intravenous antibiotics did not decrease the risk of infection [9]. recommended the use of prophylactic antibiotics in high-velocity and intra-articular injuries but did not support the use of prophylactic antibiotics for low-velocity injuries [10]. Howland and Ritchey in a retrospective analysis concluded that prophylactic antibiotics were unnecessary in the treatment of lowvelocity gunshot fractures [11-20]. In our study, all patients were treated with intravenous first generation cephalosporin antibiotics, and in some cases additional antibiotics to treat other concurrent injuries. As no patient in our review developed osteomyelitis even with a large subset undergoing limited debridement, we support the use of a first-generation cephalosporin for 48 hours in patients reporting with open forearm fractures secondary to low-velocity gunshot wounds.

We recognize the following limitations of our study. First, it is retrospective in nature and carries all the associated risks of bias. It is additionally possibly biased towards more severe injuries since all included patients were admitted for at least 48 hours. Patients with minor gunshot forearm injuries and treated as outpatients had variable antibiotic regimens or no antibiotics and were not captured in this database. Thirdly, the patient population of this study is small, although it is larger than previously published studies. Furthermore, we had difficulty in contacting patients in our study for longer term follow up.

Conclusion

Forearm fractures caused by low velocity gunshot wounds in a civilian setting are often comminuted single bone injuries with minor soft tissue injury. Both the aggressive and limited debridement regimens resulted in reliable osseous union and no instances of osteomyelitis. These results suggest that immediate locked bridge plating with minimal debridement is a suitable option for the treatment of forearm fractures following low velocity gunshot injuries.

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