The Charcot Foot: An Emerging Public Health Problem for African Diabetes Patients.

Background: Although the awareness, diagnosis, management of the complications associated with diabetes have improved in African countries over the past decade, surveillance activities in Tanzania and anecdotal reports from other African countries have suggested an increased prevalence of Charcot Neuroarthropathy (CN) over the past few years. Aim: To characterize the epidemiology and the clinical burden of CN in a large diabetes population in Tanzania, and to evaluate outcomes of persons with the condition. Methods: This was a prospective analytic cohort study conducted between January 2013 through December 2015. Following informed consent, patients were followed at the outpatient clinic. Detailed clinical assessments and documented presence of diabetic peripheral neuropathy (DPN), macrovascular disease and microvascular disease were recorded. Education and counseling were part of the follow-up program. Results: 3271 ulcerations were presented at the clinic during the 3-year study period. 571 (18%) met the case definition for CN; all patients had Type 2 diabetes. The prevalence for each of the years 2013, 2014, and 2015 was 19/1192 (1.6%), 209/1044 (20%), and 343/1035 (34%), respectively; the increases in the slope of the trendline was statistically significant (P < .001). Conclusion: The prevalence of CN is increasing in the Tanzanian diabetes patient population, and is strongly associated with neuropathy. CN can lead to severe deformity, disability, and amputation. Due to the risk of limb amputation, patients with diabetes must seek immediate care if signs or symptoms appear and avoid delay in seeking medical attention. Early diagnosis of CN by caregivers is extremely important for successful outcomes.

Comparison of four systems of classification of diabetic foot ulcers in Tanzania.

AIMS: The aim was to compare the use of four different systems of foot ulcer classification in a consecutive population with diabetes presenting to a specialist clinic in Dar es Salaam, Tanzania. METHODS: Clinical data were collected prospectively in all patients presenting with foot ulcers between 3 January 2003 and 30 September 2005, and were used retrospectively to classify their ulcers using the Meggitt/Wagner, University of Texas (UT), Size (Area and Depth), Sepsis, Arteriopathy, and Denervation [S(AD)SAD] and Perfusion, Extent/size, Depth/tissue loss, Infection and Sensation (PEDIS) systems. Comparison was made between the strength of the associations between baseline characteristics of each system and outcome determined at 5 December 2005, using linear by linear association. RESULTS: The strongest statistical associations (P < 0.001) were observed between percent healing and Wagner score (chi(2)= 85.923), depth [S(AD)SAD, PEDIS and UT grade, 70.558], infection [S(AD)SAD, 61.774; PEDIS, 37.924] and UT stage (32.929). Weaker but significant (P < 0.001) associations were observed between percent healing and neuropathy [S(AD)SAD, PEDIS 12.475] and peripheral arterial disease [S(AD)SAD, PEDIS 10.799], as well as cross-sectional area [S(AD)SAD 4.387, P = 0.036]. CONCLUSION: The strength of the statistical association between outcome and both neuropathy and infection contrasts with findings in series previously reported from the USA and UK, and highlights the differences which may be found in different populations. These differences have implications for any system of classification chosen to compare the effectiveness of management in different centres in different countries.

Glucose tolerance during and after pregnancy in nondiabetic women in an urban population in Tanzania.

OBJECTIVE: It is generally accepted that glucose tolerance deteriorates during pregnancy in the developed world. Several small studies have suggested that this may not be the case in sub-Saharan Africa. This study was designed to investigate changes in glucose tolerance in nondiabetic African women during pregnancy in Dar es Salaam, Tanzania. RESEARCH DESIGN AND METHODS: Women (n = 89) seen before the 14th wk of pregnancy without known diabetes were recruited: 58 had a 75-g OGTT in the 1st, 2nd, and 3rd trimesters and postpartum. RESULTS: Mean FBG levels were 3.9, 3.5, 3.6, and 3.7 mM in the 1st, 2nd, and 3rd trimesters and postpartum period, respectively. Values were significantly lower in the 2nd and 3rd trimesters than in the 1st and 2nd trimesters compared with postpartum. Mean 2-h blood glucoses were 4.7, 4.4, 4.3, and 4.2 mM, respectively. The 1st trimester value was significantly higher than in the 3rd trimester and postpartum. Fifteen (26%) of the 58 women showed a decreased or unchanged 2-h blood glucose during the course of pregnancy, 5 (9%) showed an increase, and no clear pattern was seen in 38 (67%). Values for fasting glucose showed similar trends. CONCLUSIONS: We conclude that women during pregnancy in an urban African setting show little change in glucose tolerance. This contrasts with women in both the developed world, where glucose tolerance worsens, and in a rural African environment, where glucose tends to improve.

Comparison of post amputation outcome in patients with type 2 diabetes from specialized foot care centres in three developing countries.

OBJECTIVE: To evaluate post amputation outcome and associated complications in type 2 diabetic patients who had undergone major amputations in developing countries. PATIENTS AND METHODS: A total of 526 (M:F; 369:157) subjects from three centers [India (IND), n=194, Bangladesh (BAN) n=177 and Tanzania (TAN) n=155 who had undergone amputation and subsequently visited the hospital were included in this analysis. Details on foot problems and associated complications were recorded. RESULTS: The prevalence of amputations was similar in all centres. The history of minor amputation and foot deformity was high in BAN. Recurrence of foot ulceration was more in TAN (30%) than in IND (9%) and BAN (11%). Re-amputation rate was similar in all groups (3%). The use of artificial limb was most in BAN (97%). Myocardial infarction was more prevalent in IND (15%). In Tanzania, 31% had died during the follow-up period and it was 16% and 5% in IND and BAN. The causes of death were infection due to septicemia and cardiovascular events which finally led to multisystem organ failure. CONCLUSION: The outcome following a major diabetic foot amputation was compared in three developing countries. Recurrence of foot infection was common in Tanzania. The most frequent causes of death were infection and cardiovascular events.

Clinical outcome of diabetes patients hospitalized with foot ulcers, Dar es Salaam, Tanzania.

AIMS: To determine the prevalence rate, clinical features, risk factors, and clinical outcome of foot ulcers in diabetes patients admitted to Muhimbili National Hospital, Dar es Salaam, Tanzania. METHODS: A prospective cohort study of newly hospitalized, adult diabetes patients with foot ulcers was conducted during January 1997 to December 1998 (study period). Detailed clinical and epidemiological data were recorded for each patient, followed by a comprehensive physical examination. Clinical outcome was documented. RESULTS: Of 627 diabetes patients evaluated during the study period, 92 (15%) had foot ulcers. Of these 92 patients, 30 (33%) were selected for surgery (minor and major amputations); the rest were managed conservatively. Patients who underwent surgery were more likely than those who did not to have gangrene (P < 0.001) or neuropathy (P < 0.01). On stratification by severity of ulcers, patients with Wagner score > or = 4 were significantly more likely than those < 4 to have neuroischaemic foot lesions (P < 0.001) or delayed presentation to hospital (P < 0.001). The overall mortality rates for amputees and non-amputees were similar (29%); the highest in-patient mortality rate (54%) was observed among patients with severe (Wagner grade > or = 4) ulcers who did not undergo surgery. CONCLUSIONS: Diabetic foot ulcers are associated with significant morbidity and mortality in Tanzania. Mortality rates among patients with severe ulcers remain high despite surgery. Thus, surgery undertaken during the less severe stages of ulcers may improve patient outcome. Education of patients should underscore the importance of foot care and consulting a doctor during the early stages of foot ulcer disease.

Outcome of pregnancy in diabetic patients in Dar es Salaam, Tanzania.

Between 1 June 1986 and 31 August 1987 all 47 pregnant diabetic Tanzanian women attending Muhimbili Medical Centre, Dar es Salaam were seen and managed by a small team of interested physicians and obstetricians. Of the 50 pregnancies there were 44 (88%) live births, five (10%) perinatal deaths, and one (2%) spontaneous abortion. One child was born with a serious congenital abnormality. All five perinatal deaths were seen in women who presented late in pregnancy (three) or had poor blood glucose control (two). In 10 (36%) of the 28 pregnancies in the 25 patients with insulin-requiring diabetes, insulin requirements decreased greater than 8 U during the course of pregnancy. The present study suggests that with close supervision of the pregnant diabetic patient in Africa perinatal mortality rates approaching those seen in developed countries can be achieved, despite the lack of home blood glucose monitoring. Rates could be further reduced if medical services were more widely available, and if all patients were educated on the importance of early presentation in pregnancy.

Regional differences in risk factors and clinical presentation of diabetic foot lesions.

BACKGROUND: Problems associated with the diabetic foot are worldwide. However, there may be regional variation among risk factors and clinical presentation. Prospective comparative data concerning this topic are rare. AIM: To determine differences in underlying risk factors and clinical presentation of foot problems among people with diabetes in different regions. PATIENTS AND METHODS: Six hundred and thirteen consecutive patients with diabetic foot lesions from three centres [Soest-Germany (GER), Dar-es-Salaam, Tanzania (TAN) and Chennai, India (IND)] were included during the period June 1998 through December 1999. Diabetes-related data, risk-factor profiles, and lesion-related data were collected for each patient. Due to varying proportions of recurrent lesions among the centres, only data from patients with newly presenting diabetic foot lesion were analysed. RESULTS: Of the 613 patients sampled, 368 (60%) were treated for newly presenting diabetic foot lesion. In all three centres, patients were predominately male and had Type 2 diabetes. The average diabetes duration until the onset of the initial foot lesion was 14 years in GER and 12 years in IND, but only 5 years in TAN. The corresponding patient ages were 71, 56 and 51 years. Neuropathy was common to patients in all three centres. Peripheral vascular disease (PVD) was a frequent risk factor in GER (48%). In TAN and IND it was far less common (12 and 13%), probably due to younger patient populations, shorter diabetes duration and lower proportions of smokers. Inadequate footwear was the most common cause of foot lesions in GER (19%), while lack of footwear, irregular foot care and burns were the primary precipitating factors among patients in TAN and IND. CONCLUSION: Similarities in different regions of the world among people with diabetes suffering newly presenting foot lesions include a predominance of males and patients with Type 2 diabetes, as well as a high frequency of diabetic neuropathy. However, differences concerning age, diabetes duration, peripheral vascular disease, and precipitating factors contributing to injury are also observed.