Characteristics of Inpatients with Diabetic Ulcers in Margono Soekarjo County Hospital, Indonesia: A Retrospective Study

ABSTRACT


INTRODUCTION
The International Diabetes Federation (IDF) states that globally in 2019 there were 463 million people in the world with diabetes melitus (DM). 1 Poorly managed diabetes mellitus often leads to complications, one of common complications is the diabetic ulcer.The resulting neuropathy in diabetes melitus (DM) patients with manifestation of diminished sensory and motoric weakness of the lower extremities is the trigger that makes diabetes melitus (DM) patients have higher risks for diabetic foot ulcers and even amputations.Data from Indonesian Endocrinology Society (PERKENI) suggested diabetic foot ulcers due to diabetic neuropathy often occur on the sole of the feet as they are the anatomical areas which experience physical contacts and receive the heaviest pressure during weight bearing. 2 One study revealed the prevalence of diabetic ulcers in Indonesia reached 15% of the total number of diabetics patients. 3Research at Cipto Mangunkusumo National General Hospital in 2014 showed the mortality rate and amputation rate in diabetic ulcer patients were 16% and 25% respectively with 14.3% woud die one year after amputation and 37% would die 3 years after amputation.Internal data from our Margono Soekarjo County Hospital, Indonesia showed that 389 hospitalized patients and 521 outpatients were diagnosed with diabetic ulcers in a 2-year span from Januari 2020 to December 2021.As diabetic ulcers represent a significant burden on healthcare systems worldwide, understanding the profile of affected individuals is crucial for effective management and prevention strategies.Considering that matter, we conducted this retrospective study aiming to comprehensively describe the demographic and clinical characteristics of inpatients diagnosed with diabetic ulcers in Margono Soekarjo County Hospital as one of the referral hospital in Indonesia.By Corresponding Author: Zafira Zahra Aulia Rahma examining specific factors such as age, sex, occupation, blood sugar levels, and the sites of the ulcers, our goal is to provide a detailed profiling of the population.This study also seeks to contribute valuable insights into the epidemiology and clinical presentation of diabetic ulcers in local-regional area of our hospital, ultimetely informing more effective prevention, management, and patient centered care strategies for individuals suffering from this debilitating compication of diabetes mellitus

METHODS
This study is a retrospective descriptive study using secondary data from patient medical record and a cross sectional approach.We collected data from inpatients with diabetic ulcers at Margono Soekarjo County Hospital, Indonesia in one-year span from 2020 to 2021.We profiled the characteristics in this study include age, gender, education, occupation, blood sugar level and sites of ulceration.Univariate analysis analyzes the data to determine the characteristics of the respondents.

RESULTS
We collected data from 319 inpatients with diabetic ulcers at Margono Soekarjo County Hospital, Indonesia in one-year span from 2020 to 2021, and we studied their characteristics include age, gender, education, occupation, blood sugar level and sites of ulceration.A groundbreaking investigation led by Witanto and a team of researchers at Immanuel Hospital, Bandung discerned a striking gender distribution among diabetic ulcer patients, with 63% being female and 37% male. 8Remarkably, their findings diverge substantially from the research conducted by Decroli and colleagues at M. Djamil Hospital, Padang in which the gender distribution exhibited an astonishing 71% male and 29% female prevalence. 9This incongruity underscores a compelling phenomenon: a pronounced predilection for diabetes mellitus among women, a phenomenon closely linked to the fact that the majority of diabetic ulcers manifesting in individuals aged 56-65, closely followed by those aged 46-55. 10This conspicuous age-related trend may also, in part, be attributed to the physiological implications of menopause in women, which in turn exerts a discernible impact on blood glucose regulation. 7Related to the strikingly different findings of Decroli and colleagues, we assume that, diabetic men were more susceptible to traumatic woundings due to their higher intensity of physical activity.
Our study also highlighted a predominant proportion of respondents who completed only elementary school as their highest level of education, comprising 33.9% of the sample.This finding aligns with prior investigations, such as studies by Husen and Basri in Ternate, Indonesia which similarly observed a majority of diabetic ulcer patients possessing elementary school education. 11Nonetheless, it is noteworthy that a 2014 study conducted by Sentana and colleagues at West Nusa Tenggara Provincial Hospital reported a contrasting trend, revealing that the majority of respondents in their cohort had attained a senior high school education level. 12The influence of education on fostering a healthconscious lifestyle cannot be understated, particularly in terms of motivating individuals to enhance their health status.A higher educational attainment is expected to facilitate better access to information, including crucial insights related to disease prevention, treatment, and overall health knowledge. 2A research by Yosmar and colleagues further supports this assertion, underscoring the role of education as a significant factor linked to diabetes mellitus, given its impact on an individual's knowledge base and decisionmaking capacity when addressing their health concerns. 13 prominent observation in our study showed the majority of respondents (25.4%) were unemployed.This observation aligns with research findings of Sentana and colleagues, 12 where a substantial 57.5% of diabetic ulcer patients were found to be non-working individuals.Occupation emerges as a pivotal social determinant impacting not only healthcare utilization but also the extent of health-related information assimilation, thus intricately linked to healthcare consultation outcomes. 14The repercussions of low income on the capacity to finance diabetic treatment further exacerbate the health challenges posed by diabetes mellitus.The inactive employment status of patients may also compound the severity of diabetes and heighten the susceptibility to diabetic ulcers due to its deleterious effect on physical activity and the routine body movements pivotal for facilitating blood sugar absorption by cellular mechanisms.Our study revealed a conspicuous pattern, with the preponderance of diabetic ulcers manifesting primarily on the feet, as evidenced by 294 respondents (comprising 91.8% of the sample).This finding aligns seamlessly with prior research by Fitria and colleagues, underscoring the predilection of diabetes mellitus (DM) patients for developing ulcers on the feet, specifically the prominent toes and plantar surfaces, owing to heightened mechanical pressure dynamics. 10Augmenting this insight, investigative endeavors by Agustianingsih and colleagues revealed that blood circulation, which entails the orchestrated conveyance of blood propelled by the heart throughout the entire vascular system, including the peripheral extremities, is subject to the modulating influences of three pivotal factors: blood viscosity, vessel length, and vessel diameter.In the context of diabetes mellitus (DM), the accrual of hyperglycemia within the vascular milieu exerts a discernible impact on blood flow dynamics through the viscosity factor.Elevated blood viscosity disrupts the hemodynamic equilibrium throughout the systemic circulation, precipitating a notable decline in tissue perfusion, most notably discernible within the distal inferior extremities, anatomically situated furthest from the cardiac epicenter. 17Corresponding Author: Zafira Zahra Aulia Rahma The lower incidence of diabetic ulcers or foot ulcers in developed countries, as compared to their developing counterparts like Indonesia, predominantly arises from the superior and expeditious therapeutic interventions employed.
Common problems in developed countries such as prolonged delays in foot ulcer management and suboptimal treatment regimens substantially elevate the likelihood of severe diabetic ulcers culminating in amputation, a phenomenon more prevalent in developing nations than their developed counterparts. 18However, the prevalence of diabetic ulcers in developed countries continues to exhibit variations, primarily attributed to lifestyle factors.North America, the most industrialized region, exhibits the highest prevalence at 13%, while Oceania, particularly Australia, reports the lowest incidence at 3%.Developed European nations similarly display a relatively low prevalence rate of 5%.In terms of gender disparities, females manifest a lower prevalence when contrasted with males.Perhaps diabetic men are more susceptible to traumatic woundings due to their higher intensity of of physical activity than women.Characteristically, foot ulcer patients in developed regions across the Americas, Asia, Europe, and Oceania tend to be aged over 60, have a protracted history of diabetes with elevated blood glucose levels exceeding 200 milligrams per deciliter, and exhibit diminished body mass.Occupational profiles exhibit nominal influence, with lifestyle factors, such as smoking, emerging as significant determinants.The prevalence of foot ulcers in North America is notably attributed to smoking habits.The prevalence of diabetes mellitus and its complications in most developed countries remains subdued due to the low cost of diabetes mellitus treatment as it is generally covered by the government. 19Conversely, a study conducted by Sriyani and colleagues concerning predictors of diabetic ulcers or foot ulcers in Srilanka, one of the developing nations, mirrors trends in developed countries, with a predominant patient demographic comprising individuals aged over 50, albeit with a slightly higher proportion of female patients.Education levels tend to be skewed towards junior high school and higher, with income levels playing a pivotal role, particularly among patients earning less than

CONCLUSION
In summary, our retrospective analysis sheds light on the complex factors driving diabetic ulcers in Indonesia, with a focus on the Banyumas region.Diabetic ulcers, a severe complication of diabetes mellitus, have wide-ranging physical, psychological, social, and economic impacts, causing foot deformities, persistent pain, and even amputation.
Our findings align with global trends, revealing that diabetic ulcers primarily affect elderly individuals over 60, especially females.Education and employment status play significant roles, with many patients having limited education and being unemployed, affecting healthcare access and outcomes.Effective blood glucose management is crucial, as elevated levels can compromise circulation, making individuals more prone to ulcers, especially in their lower extremities.To address this growing issue, comprehensive public health strategies focused on diabetes prevention, health education, and improved healthcare access are essential, tailored to the unique demographics and socio-economic factors of the affected population in the Banyumas region, with potential implications for global healthcare strategies.

Table 5 . Characteristic of Diabetic Ulcer Respondents based on Their Sites of Ulceration
deciliter.Moreover, as age advances, the susceptibility to elevated blood glucose levels and impaired glucose tolerance amplifies.This escalation can be attributed, in part, to the deteriorating functionality of organs such as pancreatic cells, leading to perturbations in insulin hormone production and consequent elevations in blood glucose concentrations. 7 Our study confirmed that diabetic foot ulcers were the dominant types of diabetic ulcers (293 patients, 91.9%).Although specific foot part or area like toes (34 patients, 10.6%) and sole of the foot (12 patients, 3.8%) contributed large proportions of the inpatients with diabetic ulcers, unspecified locations of the foot like the side parts (outer side or inner side), posterior parts and ankles contributed DISCUSSION Diabetic ulcers, a complication stemming from diabetes mellitus (DM), instigate multifaceted alterations and disruptions across the physical, psychological, social, and economic domains of afflicted individuals.This ailment exerts a profound impact on physical well-being, manifesting as deformities in foot morphology, persistent pain, malodorous discharges from foot infections, and, in severe instances, necessitating amputation.Notably, diabetic ulcers afflict 25% of the diabetes mellitus patient populace, precipitated by the deleterious effects of heightened blood glucose levels on nerves and vasculature, thereby compromising circulatory function.Furthermore, as elucidated by Setiawan and colleagues, the etiology of ulcers in DM patients hinges upon neuropathic and/or ischemic origins, coupled with infectious complications.4Ourstudy has unveiled a prevailing trend among respondents, with the majority of inpatients with diabetic ulcers exceeding 60 years of age (comprising 46.1% of the sample) and being predominantly female (constituting 56.1% of the cohort).This observation aligns harmoniously with prior research conducted by Madanchi and colleagues, as well as Llanes and colleagues, which corroborated a dominant age distribution among diabetic ulcer patients within the fifth and sixth decades of life. 5,6The World Health Organization (WHO) states that a person who has reached the age of 30 will experience an increase in blood sugar by 1 to 2 milligrams Corresponding Author: Zafira Zahra Aulia Rahma per diseases in the region, securing the sixth position in prevalence.Disaggregated data reveals that diabetes mellitus afflicted more women as opposed to men (755 to 604).24Data from the Kembaran I Public Health Center which served as one focal point of public health researches in Banyumas region, exhibited a pronounced predilection for elderly patients aged over 60, with females constituting 83% of the patient cohort.Remarkably, individuals with limited educational backgrounds, approximately 85.1%, exhibited the highest proclivity towards diabetes.25Thosefindingsecho congruent trends observed in a parallel investigation conducted in another focal point of public health researches in Banyumas region, Jatilawang Public Health Center, wherein the prevalence of foot ulcers was predominantly observed among the older adults and elderly demographic, with women comprising 71.4% of the affected cohort.The majority of the diabetic patients in Jatilawang were unemployed, and a staggering 78.6% held no higher than elementary school qualifications, while a significant proportion demonstrated elevated blood glucose levels exceeding 200 mg/dl.26 Notably, within the confines of Banyumas region, this incidence has displayed persistent annual increments.In 2017, diabetes mellitus accounted for 6.91% of all non-Corresponding Author: Zafira Zahra Aulia Rahma communicable