Research presentation Group 6

1. Research presentationGroup 6 STUDY OF RELATION BETWEEN DIABETIC FOOT SYMPTOMS AND DIABETIC NEUROPATHY

2. Research members Mr. SonamDorji Student ID no. 50461274 Mr. ThanasitPrakobphon Student ID no. 51460834 Mrs. RuchjirinWongkhamlue Student ID no. 51461022 Research advisers Dr. RawisutDeoisares (Content Expert) Dr. SuwitLertkajornsin (Methodology Expert)

3. Rationale of the study • Diabetes mellitus is a non communicable chronic illness with its prevalence increasing at an alarming rate in Thailand. The prevalence of DM in Thai population increased from 4.4 in year 1997 to 6.9 in 2009. • According to Thai DM association the incidence and rate (per 100000 population) of DM for year 2008 and 2009 were 5200, 2672.12 and 5677, 2916.37 respectively. The prevalence of complication due to DM was 14.3% or 746 people.

4. Rationale of the study • Diabetic neuropathy is the most common complication found in DM type 2 patients. its prevalence of 23% leading poor quality of life for DM patients by its symptom and other related complication due to neuropathy like wounds, infection and amputation of leg. Diabetic neuropathy is also second leading cause of leg amputation.

5. Rationale of the study • According to Thai clinical practice guideline for DM 2011, DM patients should go through complete foot examination each year to assess risk of neuropathy to prevent DM foot ulcer and further complication, but due increasing number of DM patients and limitations in time.

6. Rationale of the study • The screening processes are limited to patient’s symptoms of neuropathy like “presence of numbness of feet”. There is also a knowledge gap about the reliability about using patient’s symptoms for screening of diabetic neuropathy. • Almost question that asked about the symptom such as “ Do you have feeling at finger tip and feet tip? ” but now no research support or guaranteefor diagnosis that use symptom shown are reliability or correctly and suitable for diagnosis enough.

7. Purpose of the study 1. To study the relationship between the sign and symptoms*of peripheral numbness in Type2 diabetic patient and diabetic neuropathy. • To study about the factors causing to diabetic neuropathy in Type2 diabetic patient such as sex, BMI, duration, associate disease, drinking , smoking and glucose level control. (sign and symptoms* including numbness, decrease level of consciousness, burning pain or electric shock feeling)

8. Research question Primary research question • Can patient’s symptom be used for screening of diabetic neuropathy ? Secondary research question • Other factor such as Age, Sex , Onset and duration, BMI, Smoking , Drinking , Co-morbidity, Blood sugar control have effect for diabetic neuropathy ? (sign and symptoms* including numbness, decrease level of consciousness, burning pain or electric shock feeling)

9. Research Questions P (Patient or Problem) Type2 diabetic patient who came for the screening test at Thaphoe primary care unit, diabetic clinic at Naresuan university hospital and Medical ward at Naresuan university hospital. I (Intervention or Exposure) Symptom of diabetic neuropathy C (Comparison intervention) Patients who have and don’t have symptoms of diabetic neuropathy O (Outcome) Result from screening Diabetic neuropathy at feet by monofilament

10. Methodology Study design • Cross sectional study Samples Inclusion criteria : • DM type2patients who came for screening of Diabetic neuropathy at Thaphoe PCU on 24 November 2011 • DM type 2 patients who agreed for screening of Diabetic neuropathy in IPD at Naresuan university hospital on 24 November2011 • DM type2patients who came for screening of Diabetic neuropathy in OPD at Naresuan university hospital on 28 November 2011

11. Methodology samples Exclusion criteria : • Neuropathy due to other causes • Foot ulcer, edema, hypothermia • Limb amputation due to diabetes mellitus • Neuromuscular deficit and other complication • Skin and soft tissue infection • Patient with psychiatric problem

12. Methodology Setting of research • Diabetic clinic at Naresuan university hospital • OPD medicine Naresuan university hospital • PCU Thaphoe Sources of information’s • History taking of patients. • 10 g monofilament examination of patients • OPD files of patients.

13. Methodology Tools of research • Questionnaire about general health and risk factors of diabetic neuropathy • 10 g monofilament • Program STATA, SPSS, EXCEL

14. Methodology Research process (in order) • Contemplate research topic and seek advice from counseling teacher . • Review articles related to the research topic. • Presentation of research topic to the research teachers. • Develop of research model. • Presentation of research model .

15. Methodology Research process (in order) • Planning and testing of research. • studying proper handling of10 g monofilament and the testing it with real patients. The test was carried out on 4 patients in medical ward at Naresuan hospital • contracting officials in Naresuan university hospital for facilitating patients and places for research.

16. Methodology Research process (in order) • contacting medical personals at Thaphoe PCU for appointment with patientscoming for diabetic neuropathy screening. • Introduction,explanation about our research, signing of agreement for research. • Asking patient risk factors for diabetic neuropathy • 10 g monofilament examination of patients feet.

17. Research timeline

18. Analyzing of data and statistics • Sensitivity • Specificity • Positive predictive value • Negative predictive value • Chi-square test and Fisher’s Exact Test • Odd Ratio

19. The ethics review • confidentiality of patients information was maintained by without using true name and keeping information within the research members. • patients were informed of the confidentiality measures before signing the research agreement’s. • patient don’t have financial benefit from this research but have the benefit of free screening of Diabetic neuropathy with10 g monofilament. Monofilament examination procedure doesn’t have any risk and is not painful to the patient

20. Research result Table1. Characteristics of the type 2 diabetic patients (n=106)

21. Research result Table1. Characteristics of the type 2 diabetic patients (n=106)

22. Research result Primary research question • Patient symptoms can be used for screening of Diabetic neuropathy or not ?

23. Research result • Sensitivity, Specificity • Positive & Negative predictive value

24. Research result Table 4. Univariate logistic regression

26. Research result Table 5. Multivariate logistic regression

27. Limitation and suggestion • we should have sample that follow by calculation formulas. • If possible, you should used the better standard test procedure for more accuracy result. • The test should be done in diversity people because this thesis was done in the hospital only and patient should be take care of themselves, so the information we got may be not match with fact.

28. Limitation and suggestion • We should used blood sugar control procedure and kept FBS/HbA1C then compare in each person for different result or not by 10g-monofilament • You should add special characteristic belong to each person in quiz. To let us know what clinical that effect with 10 g monofilament test and got result in positive • You should kept more information that relate with onset of clinical then compare to the duration from onset to the testing time was done.

29. References 1. Kärvestedt, L., E. Mårtensson, et al. (2010). "The prevalence of peripheral neuropathy in a population-based study of patients with type 2 diabetes in Sweden." Journal of Diabetes and its Complications25(2): 97-106. 2. Franse, L. V., G. D. Valk, et al. (2000). "‘Numbness of the feet’ is a poor indicator for polyneuropathy in Type 2 diabetic patients." Diabetic Medicine17(2): 105-110. 3. Mueller, M. J. (January 1996 ). "Identifying Patients With Diabetes Mellitus Who Are at Risk for Lower-Extremity Complications: Use of Semmes-Weinstein Monofilaments". 4. Valk, G. D., J. J. J. de Sonnaville, et al. (1997). "The assessment of diabetic polyneuropathy in daily clinical practice: Reproducibility and validity of Semmes Weinstein monofilaments examination and clinical neurological examination." Muscle & Nerve20(1): 116-118.

30. References 5. Bruce A. Perkins, F., David Olaleye, PHD, Bernard Zinman, FRCPC and Vera Bril, FRCPC (February 2001 ). "Simple Screening Tests for Peripheral Neuropathy in the Diabetes Clinic " 6. Rahman, M., S. J. Griffin, et al. (2003). "How should peripheral neuropathy be assessed in people with diabetes in primary care? A population-based comparison of four measures." Diabetic Medicine20(5): 368-374. 7. Nather, A., S. H. Neo, et al. (2008). "Assessment of sensory neuropathy in diabetic patients without diabetic foot problems." Journal of Diabetes and its Complications22(2): 126-131. 8. M Mafauzy, F., Z Hussein, MRCP**, S P Chan, FRCP*** (2008). "The Status of Diabetes Control in Malaysia: Results of Diabetic Care ". 9. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet 2004; 363:157-63

31. References 10. Boulton, A. J. M. (2010). "Chapter 4 Diagnosis of diabetic peripheral neuropathy-clinical practice and research". 11. American Diabetes Association (2011) 12. สำนักนโยบายและยุทธศาสตร์กระทรวงสาธารณสุข (2552). "รายงานผู้ป่วยใน(รง 505)." 13. สมาคมโรคเบาหวานแห่งประเทศไทยในพระราชูปถัมภ์สมเด็จพระเทพพระรัตนราชสุดาฯสยามบรมราชกุมารี (2554). "แนวทางเวชปฏิบัติสำหรับโรคเบาหวาน "