Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
DOI: 10.5205/reuol.9199-80250-1-SM1006201601 ISSN: 1981-8963 Jose DP, Almeida JS de, Rodrigues CDS et al. patients... Sociodemographic and clinical factors of the ORIGINAL ARTICLE FATORES SOCIODEMOGRÁFICOS E CLÍNICOS DOS PACIENTES ATENDIDOS NO AMBULATÓRIO DO PÉ DIABÉTICO DE UM HOSPITAL ENSINO SOCIODEMOGRAPHIC AND CLINICAL FACTORS OF PATIENTS FROM A DIABETIC FOOT OUTPATIENT CLINIC AT A TEACHING HOSPITAL FACTORES SOCIODEMOGRÁFICOS Y CLÍNICOS DE PACIENTES TRATADOS EN UN AMBULATORIO DE PIE DIABÉTICO DE UN HOSPITAL UNIVERSITARIO Denilson Pereira Jose1, Jéssica Santos de Almeida2, Cléa Dometilde Soares Rodrigues3, Claudia Bernardi Cesarino4 RESUMO Objetivo: identificar os fatores sociodemográficos e clínicos dos pacientes com diagnóstico de diabetes tipo1 e 2. Método: estudo descritivo, com abordagem quantitativa, em 121 prontuários eletrônicos de pacientes com diabetes tipo1 e 2 atendidos no ambulatório do pé diabético de um hospital de ensino de São José do Rio Preto/SP. Os dados foram analisados pelo teste qui-quadrado, teste t Student e Análise de Variância (ANOVA); análise multivariada com a aplicação da Análise Múltipla de Correspondência. Resultados: dos 121 pacientes, 66,12% eram do sexo masculino, 32% residiam em São José do Rio Preto/SP, 38,02% tinham ensino fundamental incompleto, 71,07% apresentavam união estável, com idade média de 54,17±15,37 anos, sendo que a faixa etária variou de 21 a 60 anos. Quanto às características clinicas, verificou-se que 72,34% com DM do tipo 2, 56,19% apresentaram presença de feridas, 43,80% a Classificação de Wagner de grau 0 (risco elevado, porém ausência de úlcera). Conclusão: fazem-se necessários maiores investimentos em estratégias de educação em saúde, intensificando os programados por equipe multidisciplinar da área da saúde. Descritores: Diabetes Mellitus; Pé diabético; Enfermagem. ABSTRACT Objective: to identify the demographic and clinical factors of patients diagnosed with type 1 and type 2 diabetes. Method: descriptive study, with a quantitative approach, using the electronic records from 121 patients, receiving care at a diabetic foot clinic within a teaching hospital of São José do Rio Preto/SP, with type 1 and type 2 diabetes. The data were analyzed by the Chi-square test, the Student’s t-test, Analysis of Variance (ANOVA); Multivariate analysis along with the application of the Multiple Correspondence Analysis. Results: 66.12% of the 121 patients were male, 32% were living in São José do Rio Preto/SP, 38.02% had an incomplete elementary level education, and 71.07% were in a stable relationship, with an average age of 54.17±15.37 years, with the age group ranging from 21 to 60 years. In regards to the clinical features, 72.34% had type 2 DM, 56.19% presented evidence of lesions and 43.80% were classified at grade 0 on the Wagner scale (high risk, no obvious ulcer). Conclusion: more investment in health education strategies is required, as is intensifying those already administered by multidisciplinary healthcare teams. Descriptors: Diabetes Mellitus; Diabetic foot; Nursing. RESUMEN Objetivo: identificar los factores sociodemográficos y clínicos de los pacientes con diagnóstico de diabetes tipo 1 y 2. Métodos: investigación descriptiva con abordaje cuantitativa, cuyos datos fueron obtenidos por medio de búsqueda de 121 historiales electrónicos de pacientes con diagnóstico de diabetes tipo 1 y 2 tratados en el ambulatorio del pie diabético de un hospital universitario de São José do Rio Preto/SP desde julio de Português/Inglês Rev enferm UFPE on line., Recife, 10(6):680-5, jun., 2016 1 ISSN: 1981-8963 Jose DP, Almeida JS de, Rodrigues CDS et al. patients... DOI: 10.5205/reuol.9199-80250-1-SM1006201601 Sociodemographic and clinical factors of the 2010 hasta julio de 2012. Resultados: de los 121 pacientes, 66,12% eran del sexo masculino, 32% residían en São José do Rio Preto/SP, 38,02% tenían enseñanza primaria incompleta, 71,07% presentaban unión estable, con edad media de 54,17±15,37 años, siendo que el rango etaria varió de 21 a 60 años. Cuánto a las características clínicas, se ha verificado que 72,34% con DM de tipo 2, 56,19% presentaron presencia de heridas, 43,80% la Clasificación de Wagner de grado 0 (riesgo elevado, pero con ausencia de úlcera). Conclusión: Es necesario más investimento en estrategias de educación en salud, intensificando los programados por equipo multidisciplinar de la área de salud. Descriptores: Diabetes mellitus; Pie diabético; Enfermería. 1 Nurse, Master’s in Nursing, Postgraduate in Nursing, Faculty of Medicine at São José do Rio Preto/FAMERP. São José do Rio Preto (SP), Brazil. E-mail: [email protected] 2 Nursing Academic, Undergraduate Course in Nursing, Faculty of Medicine at São Jose do Rio Preto/FAMERP. São José do Rio Preto (SP), Brazil. E-mail: [email protected]; 3,4 Nurse, PhD lecturers, Department of General Nursing, Faculty of Medicine at São Jose do Rio Preto/FAMERP. São José do Rio Preto (SP), Brazil. E-mail: [email protected], [email protected]. INTRODUCTION Diabetes mellitus (DM) has become the epidemic of the century due to it being the most frequent chronic disease in our society. The disease is a serious public health problem because of its various complications, its increased prevalence with advancing age, in both sexes, and its characterization with hyperglycemia. This increase in blood glucose is due to insufficient production or decreased action of insulin.1-2 10 to 12 million people are estimated to have diabetes in Brazil, which is increasing in its prevalence along with the aging population, increased urbanization, sedentary lifestyles and obesity, all of which occur most frequently in the 45 to 64-year-old age group.3-4 In 2000, there were 171 million individuals with diabetes and the estimate for 2030 is approximately 438 million, 90% of which will have type 2 diabetes. Almost four million annual deaths are attributed to diabetes, which accounts for 6.8% of the total number of deaths worldwide.5 One of the most devastating chronic complications of DM is diabetic foot. Diabetic foot is defined as an infection, a deep tissue ulceration and neuropathy with varying degrees of peripheral vascular disease. These conditions often emerge after the individual has had DM for 10 years and are responsible for primary amputations and the reason why many are admitted to hospital, when compared with other problems related to diabetes, the result of which being increased morbidity and mortality.6-7 In patients with diabetes the possibility of developing ulcers on the feet is 15%, these being infected or ischemic lesions, in which the risk of amputation is 90 times greater compared to the diabetic patients with no infections or ischemia on the lower limbs.8 “The makeup of tissue lesions in diabetic patients can be very varied. There are some proposed classification systems whose purpose is to standardize the study of these lesions. The first system, designed by Wagner in 1979, is still in use today. Wagner’s classification groups the ulcerations in accordance with the depth of the skin damage and the presence of ischaemia”.9:83 Thus, the aim of our study is to identify the sociodemographic and clinical factors of patients diagnosed with type 1 and type 2 diabetes. METHOD This is a descriptive study with a quantitative approach. The data were obtained through research in electronic medical records spanning July 2010 to July 2012 in the municipality of São José do Rio Preto, in the Brazilian state of São Paulo. The chosen unit was a diabetic foot outpatient clinic. Records of patients who were diagnosed with type 1 and 2 diabetes and met the inclusion criteria were analyzed: all correctly completed records containing data, deemed important by the researcher, from patients over 18 years of age. All electronic records with incomplete data were excluded. Collecting the data involved the use of an instrument developed by the researchers, containing the following sociodemographic information: gender; age group; ethnicity; marital status; Português/Inglês Rev enferm UFPE on line., Recife, 10(6):680-5, jun., 2016 2 DOI: 10.5205/reuol.9199-80250-1-SM1006201601 ISSN: 1981-8963 Jose DP, Almeida JS de, Rodrigues CDS et al. patients... Sociodemographic and clinical factors of the educational level in addition to clinical data: type of diabetes; the presence of wounds and the Wagner classification.7 Grade 0 High risk, no obvious ulcer Grade 1 Superficial ulcer, not infected in clinical terms Grade 2 Deep ulcer, more or less cellulitis, with no abscess or osteomyelitis Grade 3 Deep ulcer with osteomyelitis or abscess formation Grade 4 Localized gangrene Grade 5 Gangrene covering the entire foot. Figure 1. Wagner Classification for diabetic foot lesions. The associative statistical analysis involved using the Chi-square test; comparative statistical analysis be means of the Student’s t-test for independent samples and for the Wagner classification, the Analysis of Variance (ANOVA) was used; multivariate analysis using Multiple Correspondence Analysis. All statistical tests were performed considering a significance level of P<0.05. This research project was approved under the protocol number-03829512.7.0000.5415 by the Committee of Ethics in Research with Human Beings at the institution where the study was conducted. RESULTS The survey results showed that our study investigated a population of 121 patients, aged between 21 and 60 years, with a mean age of 54.03± 15.42 years. 66.12 of the subjects were male, 41.32% lived in São José do Rio Preto, 50.41% had an incomplete elementary level education and 71.07% had a stable marital status (Table1). Table 1. Percentage of the sample’s characterization variables of the patients evaluated in the study. São José do Rio Preto (SP), Brazil. Characterization variables n % Gender 121 100 Female 41 33.88 Male 80 66.12 Marital status 121 100 With spouse 86 71.07 Without spouse 35 28.93 Color 121 100 White 112 92.56 Non-white 9 7.44 Origin 121 100 Macro-region 23 19.01 Micro-region 48 39.67 São José do Rio Preto Education Complete elementary Incomplete elementary Illiterate Complete university Profession Retired Retail Housewife Student Services 50 121 46 61 12 2 121 30 8 25 4 54 41.32 100 38.02 50.41 9.92 1.65 100 24.79 6.61 20.66 3.31 44.63 Table 2 shows the percentages referring to the clinical characteristics, the diseases related to diabetes, the risk factors and the hospitalizations resulting from the disease. In all cases, the patients showed no diseases associated to diabetes and, in addition, the majority of the patients showed no amputations resulting from the disease. With regards to the risk factors, most of the evaluated patients were not smokers, alcoholics and had not been hospitalizations as a result of the disease. Português/Inglês Rev enferm UFPE on line., Recife, 10(6):680-5, jun., 2016 3 DOI: 10.5205/reuol.9199-80250-1-SM1006201601 ISSN: 1981-8963 Jose DP, Almeida JS de, Rodrigues CDS et al. patients... Sociodemographic and clinical factors of the Table 2. Percentages for the clinical features, the diseases related to diabetes, the risk factors and the hospitalizations of the evaluated patients. São José do Rio Preto (SP), Brazil. Study variables n % Clinical characteristics and Neuropathy 121 100 related diseases No 81 66.94 Yes 40 33.06 Retinopathy 121 100 No 106 87.60 Yes 15 12.40 Nephropathy 121 100 No 103 85.12 Yes 18 14.88 Dyslipidemia 121 100 No 109 90.08 Yes 12 9.92 Hypertension 121 100 No 71 58.68 Yes 50 41.32 Osteomyelitis 121 100 No 100 82.64 Yes 21 17.36 Amputations 121 100 No 104 85.95 Yes 17 14.05 Risk factors Smoking 121 100 No 101 83.47 Yes 20 16.53 Alcoholism 121 100 No 112 92.56 Yes 9 7.44 Hospitalizations No 114 94.21 Yes 7 5.79 Type 2 diabetes and a grade 0 on the Wagner classification were prevalent in our study (Table 3). Table 3. Percentages of the key variables: type of diabetes and Wagner classification. São José do Rio Preto (SP), Brazil. Key variables n % Type of diabetes 94 100 Type 1 26 27.66 Type 2 68 72.34 Wagner classification 121 100 Grade 0 53 43.80 Grade 1 19 15.70 Grade 2 38 31.40 Grade 3 11 9.09 Associative tests were used to relate the qualitative variables. Thus, type of diabetes (Table 4) and the Wagner classification (Table 5) were associated with characterization variables such as gender, color, marital status, origin and education. The results show that there was no significant association between the type of diabetes and the Wagner classification with the sample characterization variables (P>0.050). Table 4. Associative results for the type of diabetes type compared with the sociodemographic sample characterization variables. São José do Rio Preto (SP), Brazil. Sample characterization variables Gender Color Marital status P-Value1 Type of diabetes Type 1 Type 2 Female 12 (46.15%) 21 (30.88%) Male 14 (53.85%) 47 (69.12%) White 24 (92.31%) 64 (94.12%) Non-white 2 (7.69%) 4 (5.88%) With spouse 17 (25.76%) 49 (74.24%) Português/Inglês Rev enferm UFPE on line., Recife, 10(6):680-5, jun., 2016 0.170 0.752 0.530 4 DOI: 10.5205/reuol.9199-80250-1-SM1006201601 ISSN: 1981-8963 Jose DP, Almeida JS de, Rodrigues CDS et al. patients... Origin Education Sociodemographic and clinical factors of the Without spouse 9 (32.14%) 19 (67.86%) Other States 6 (23.08%) 12 (17.65%) Region 9 (34.62%) 30 (44.12%) São Jose do Rio Preto 11 (42.31%) 26 (38.24%) Illiterate 5 (45.45%) 6 (54.55%) Less than 7 years 13 (28.26%) 33 (71.74%) Less than 7 years 8 (21.62%) 29 (78.38%) 0.676 0.317 1 P-Value referring to the Chi-square test (P<0.05). Table 5. Associative results from the Wagner classification compared with the sample characterization variables. São José do Rio Preto (SP), Brazil. Sample characterization variables Wagner classification P-Value1 Grade 0 Grade 1 Grade 2 Grade 3 Gender Female 19 (35.85%) 5 (26.32%) 14 (36.84%) 3 (27.27%) 0.170 Male 34 (64.15%) 14 (36.84%) 24 (63.16%) 8 (72.73%) Ethnicity White 49 (92.45%) 18 (94.74%) 36 (94.74%) 9 (81.82%) *** Non-white 4 (7.55%) 1 (5.26%) 2 (5.26%) 2 (18.18%) Marital status With spouse 36 (41.86%) 14 (16.28%) 29 (33.72%) 7 (8.14%) 0.771 Without spouse 17 (48.57%) 5 (14.29%) 9 (25.71%) 4 (11.43%) Origin Macro 10 (18.87%) 1 (5.26%) 11 (28.95%) 1 (9.09%) 0.346 Micro 21 (39.62%) 10 (52.63%) 13 (34.21%) 4 (36.36%) SJRP 22 (41.51%) 8 (42.11%) 14 (36.84%) 6 (54.55%) Illiterate 3 (25.00%) 3 (25.00%) 6 (50.00%) 0 (0.00%) 0.211 Education Less than 7 years 31 (50.82%) 9 (14.75%) 14 (22.95%) 7 (11.48%) Less than 7 years 19 (39.58%) 7 (14.58%) 18 (37.50%) 4 (8.33%) P-Value1 referring to the Chi-square test (P<0.05). * ** P-Value not determined due to lack of sampling representativeness. Table 6 shows the results from the association of the type of diabetes with the clinical variables and the diseases related to diabetes. The results show that the type of diabetes was significantly associated with dyslipidemia (P=0.019), given that all patients with type 1 diabetes did not show dyslipidemia, in other words, this type of disease is associated with type 2 diabetes. Table 6. Associative results of the type of diabetes type compared with the clinical variables and the associated diseases. São José do Rio Preto (SP), Brazil. P-Value1 Clinical variables and related diseases Type of diabetes Type 1 Type 2 Nephropathy No Yes No Yes No Yes No Yes No Yes No Yes No 17 (65.38%) 9 (34.62%) 24 (92.31%) 2 (7.69%) 22 (84.62%) 4 (15.38%) 26 (100%) 0 (0.00%) 18 (69.23%) 8 (30.77%) 23 (88.46%) 3 (11.54%) 25 (96.15%) 47 (69.12%) 21 (30.88%) 61 (89.71%) 7 (10.29%) 59 (86.76%) 9 (13.24%) 60 (88.24%) 8 (11.76%) 38 (55.88%) 30 (44.12%) 56 (82.35%) 12 (17.65%) 57 (83.82%) Yes 1 (3.85%) 11 (16.18%) Retinopathy Nephropathy Dyslipidemia SAH Osteomyelitis Amputations 0.729 0.696 0.789 0.019 0.233 0.457 0.077 1 P-Value referring to the Chi-square test (P<0.05). Table 7 shows the association between the Wagner classification compared with the clinical variables and the diseases associated with diabetes. Table 7. Associative results from the Wagner classification compared with the clinical variables and the associated diseases. São José do Rio Preto (SP), Brazil. Clinical variables and Wagner classification P-Value1 related diseases Grade 0 Grade 1 Grade 2 Grade 3 Nephropathy No 46 (44.66%) 16 (15.53%) 33 (32.04%) 8 (7.77%) 0.719 Yes 7 (38.89%) 3 (16.67%) 5 (27.78%) 3 (16.67%) Retinopathy No 51 (48.11%) 18 (16.98%) 29 (27.36%) 8 (7.55%) 0.010 Português/Inglês Rev enferm UFPE on line., Recife, 10(6):680-5, jun., 2016 5 ISSN: 1981-8963 Jose DP, Almeida JS de, Rodrigues CDS et al. patients... Yes 2 (13.33%) 1 (6.67%) No 46 (44.66%) 16 (15.53%) Yes 7 (38.89%) 3 (16.67%) Dyslipidemia No 47 (43.12%) 17 (15.60%) Yes 6 (50.00%) 2 (16.67%) SAH No 37 (52.11%) 7 (9.86%) Yes 16 (32.00%) 12 (24.00%) Osteomyelitis No 51 (51.00%) 16 (16.00%) Yes 2 (9.52%) 3 (14.29%) Amputations No 47 (45.19%) 18 (17.31%) Yes 6 (35.29%) 1 (5.88%) P-Value1 referring to the Chi-square test (P<0.05). Nephropathy DOI: 10.5205/reuol.9199-80250-1-SM1006201601 Sociodemographic and clinical factors of the 9 (60.00%) 33 (32.04%) 5 (27.78%) 36 (33.03%) 2 (16.67%) 23 (32.39%) 15 (30.00%) 28 (28.00%) 10 (47.62%) 31 (29.81%) 7 (41.18%) 3 (20.00%) 8 (7.77%) 3 (16.67%) 9 (8.26%) 2 (16.67%) 4 (5.63%) 7 (14.00%) 5 (5.00%) 6 (28.57%) 8 (7.69%) 3 (17.65%) 0.719 0.592 0.033 <0.001 0.290 Figure 1 shows a two-dimensional graph based on the Multiple Correspondence Analysis, showing the location of each of the evaluated variables in the study referring to Diabetes and the Wagner classification. Figure 2. Two-dimensional graph referring to the multiple correspondence analysis. São José do Rio Preto (SP), Brazil DISCUSSION According to the results in Table 1, most of the patients were male individuals of working age. These findings are in accordance with a study performed on patients admitted to the Hospital de Clínicas da Universidade Federal do Triângulo Mineiro in order to make a connection between amputations and diabetes.10 There was also a quantitative cross-sectional study, whose goal was to evaluate foot care in people with diabetes, that found a predominance of male individuals.11 However, these findings disagree with a study that evaluated quality of life and comorbidities in elderly residents of Uberaba city, which showed a predominance of female individuals. 12 Similar studies with a predominance of female individuals disagree with the findings from our study.13-14 In regards to the marital status results of our study, 71.07% of the evaluated individuals had a spouse, which is an important factor in terms of the care process for the disease, namely given that a supportive family structure reduces future complications and thusly improves quality of life for the sufferer. When the sufferer lives alone there is a strong presence of contributing factors in the genesis of diabetic foot ulcers.15-18 In regards to skin color there was an observed predominance of white individuals, which corroborates a study that identified a connection between white patient’s knowledge regarding DM and foot care2. These data disagree with a study conducted at a hospital in Salvador-BA, which was evidenced by the significantly higher number of non-white diabetic patients19. In terms of origin, Português/Inglês Rev enferm UFPE on line., Recife, 10(6):680-5, jun., 2016 6 ISSN: 1981-8963 Jose DP, Almeida JS de, Rodrigues CDS et al. patients... DOI: 10.5205/reuol.9199-80250-1-SM1006201601 Sociodemographic and clinical factors of the most of the patients were from São Jose do Rio Preto, which is possibly because where the specialist hospital is located. The patients involved in our study had an incomplete elementary school education level, which is important as poorly educated individuals are not aware of the contributing factors that trigger chronic complications due to their inability to read and write, as well as in terms of their awareness and adherence to treatment and self-care related to diabetes.2,13,20 As regards the profession, 44.63% of the individuals had an active working life, with the disease not being a contributing factor to not working. A cross-sectional study, which was performed on the adult population in the urban region of Pernambuco city in 2008 and 2009, demonstrated that there was no prevalence of diabetes in patients with hypertension, as was the case in our study.21 Analyzing the association between diabetes and hypertension in another cross-sectional study, using micro data from the Brazilian National Household Sample Survey in São Paulo, showed a disagreement with our findings in relation to this association, since insulin therapy does not respond well to the effects of vascular resistance in hypertensive patients, which is true even when antihypertensive medications are used, making hypertensive patients vulnerable to developing diabetes.22 The Brazilian Diabetes Society highlights that 90 to 95% of the clinical form of diabetes is the more common type 2.16,23 Findings from research conducted in Londrina Paraná highlighted that factors such as obesity and physical inactivity are associated with genetic factors and a longer-living population, thereby promoting conditions for the emergence of the disease.24 The Wagner classification in our study was grade 0, i.e., absence of ulcers. This fact provided us with information regarding the educational activities conducted in the aforementioned outpatient clinic, showing the importance of collaborating for self-care and treatment adherence. Studies indicate there are advantages in implementing education programs in diabetes, mainly in terms of group actions that are aimed at reducing costs and improving effectiveness. The guidelines from the Brazilian society of diabetes recommend that education in diabetes is the primary tool for ensuring self care. This education is concerned with patient self-control and extends to the family members and/or caregivers who have an affect on habit and behavior changes.16 It is worth highlighting that these actions must be performed by a multidisciplinary team in order that these actions provide maximum effectivity. In this sense, the treatment’s effectiveness is maximized, which confirms the improvement in clinical outcomes and quality of life.25 The results show that the grade of the wounds evaluated by the Wagner classification were associated with retinopathy (P=0.010), SAH (P=0.033) and osteomyelitis (P<0.001). Most of the patients with retinopathy showed a grade 2 on the Wagner classification, while most of those who did not show retinopathy had grade 0. There was a similar pattern for the patients with osteomyelitis, i.e., most patients with osteomyelitis were grade 2 in the Wagner wound classification. As regards hypertension, most patients who did not show this condition were grade 0 in the Wagner wound classification. These results demonstrate that alcoholism and smoking are neither significantly with the type of diabetes nor the Wagner classification. 2 million Brazilians are estimated to have some grade of diabetic retinopathy, and it is these individuals who are at risk of blindness. The fact is that if retinopathy is detected early then this could be reduced by at least 5%.26 Retinopathy is a serious problem in this population as it prevents or hinders evaluation. As regards the lesion condition, according to the Wagner classification, 44% of the patients under study were observed with at grade 0, i.e., an absence of wounds; 16% at grade 1; 31% at grade 2 and 9% at grade 3. These data disagree with a study conducted in the Brazilian state of Sergipe, within the Brazilian Unified Health System (Sistema Único de Saúde - SUS), to estimate the direct costs of hospitalizations in the SUS, which verified a wound predominance of grade 4 (45.9%) and grade 5 (18.3%) i.e. the patients’ wounds were in a more serious condition.17 During a descriptive cross-sectional study performed at a Basic health Unit-Saúde Escola Marco linked to the State University of Pará, which investigated all patients involved in the Hiperdia program, 72% of the participants were found to have plantar callosities while 44% had a history of previous ulcers on their feet.18 In another study with a quantitative descriptive approach, held at a Basic Health Unit in the State of Paraná, whose goal was to evaluate the risk for diabetic foot of people involved in the Hiperdia program, showed that 16% of patients had ulcers on their feet or had had amputations, which represents a approximate proportionality of one person with an ulcer or amputation for every six people evaluated.19 Figure 2 shows some interesting tendencies from a multivariate analysis point of view. Upon evaluating the location of the variables in the two-dimensional graph, it is possible to assume that a patient with grade 0 lesions on his/her diabetic foot will typically have type 1 diabetes. In addition, Português/Inglês Rev enferm UFPE on line., Recife, 10(6):680-5, jun., 2016 7 ISSN: 1981-8963 Jose DP, Almeida JS de, Rodrigues CDS et al. patients... DOI: 10.5205/reuol.9199-80250-1-SM1006201601 Sociodemographic and clinical factors of the patients with grade 2 lesions, according to the Wagner classification, are usually retinopathy sufferers. The presence of grade 3 lesions are related to hospitalization and amputation, i.e. the most serious grade in our study that is related to hospitalization and a greater likelihood for amputations. Grade 1 lesions are directly related to type 2 diabetes and patients with associated diseases such as nephropathy, SAH, neuropathy and dyslipidemia, as well as with risk factors such as smoking and alcoholism. Diabetic foot ulcers stem from a loss of protective sensation, factors such as wearing inappropriate shoes, falling, erratic nail cutting and walking barefoot also contribute to a high risker of developing ulcers.16,22-23. In regards to smoking, 16.53% of the participants were smokers, which is a lower prevalence compared to national rates and is a determining factor for the group under study. These risk factors have a gradual contribution towards the emergence and deterioration of lesions on the foot, smoking in turn releases nicotine and causes vasoconstriction within the blood vessel, thereby reducing the supply of oxygen and nutrients to the tissues, and can even affect micro- and macrocirculation. 16 As regards alcoholism, the recommendation is to totally restrict alcohol among diabetics, especially in people with diabetic neuropathy resulting from deleterious effects to the body.27 Smoking causes an increase of lipid concentration by reducing insulin sensitivity, therefore, tobacco consumption should be avoided, as information contained in the literature states that 95% of amputees are smokers.16 Dyslipidemia is certainly associated with type 2 diabetes, which acts directly on the pancreatic β-cells causing lipotoxicity and is present in hospitalized patients with diabetes and foot ulcers in the SUS, and hyperglycemia which increases the risk of cardiovascular diseases (CVD) by two to four times, as it causes atherosclerotic disease, which can include coronary heart disease (CHD), peripheral vascular disease (PVD), cerebrovascular disease that is responsible for 75% of deaths, and 50% by CHD. Other important issues related to dyslipidemia are related to the presence of essential fatty acids, which greatly contributes to the deterioration of Schuam cells’ function and triggers the emergence of diabetic neuropathy.28 There are very few research projects in Brazil that are related to amputation and diabetes. However, one study worth highlighting was performed in Sergipe that screened 109 patients in order to compare the amounts that SUS paid to clinics/hospitals, 39.4% of hospitalized individuals were discharged with no amputation; 47.7% discharged following amputation; 12.8% died. The average cost of hospitalization is also an important piece of data, which is seven times higher than the amount paid by SUS and reinforces the negative impact of complications stemming from diabetic foot.29 However, during a retrospective study conducted between 2009 and 2011 at a Chinese hospital on hospitalized individuals with ulcers on the feet, the highest level of amputations was found in patients with Wagner classification grade 3, which provides further evidence that there is no significant difference among the groups evaluated in relation to how long the individual has had diabetes and educational program.30 CONCLUSION The results from this study demonstrated that the sociodemographic and clinical factors of the patients, from our study, diagnosed with type 1 and type 2 diabetes are in agreement with those of other Brazilian studies. The diabetic patients were verified to be poorly educated white adult men of working age who were in a stable relationship at the time. In regards to the clinical characteristics, there was an observed predominance of type 2 diabetes, the Wagner classification of which was grade 0 (High risk, no obvious ulcer). Our study made it possible to characterize the population under investigation, which could assist professionals from the health care area. This contribution would permeate knowledge regarding the prevention of diabetic foot in terms of evaluating those at risk from diabetic foot, following the international prevention guidelines, as well as the educational measures. The results from our study indicate that it is necessary to have continuous educational interventions from the earliest time, which will strengthen the prevention of the risk factors mentioned here in programs performed by multidisciplinary teams from the healthcare profession. It is worth mentioning that future studies are needed to guide further interventionist strategies. REFERENCES 1. Najjar ECA, Najjar JA, Ferreira EAP, Albuquerque LC de. Análise dos pés diabéticos atendididos em unidade de saúde. Rev Para Med [Internet]. 2009 [cited 2013 Nov 30];23(2):1-9. Available from: http://files.bvs.br/upload/S/0101-5907/2009/v23n2/a2009.pdf 2. Martin VT, Rodrigues CDS, Cesarino CB. Conhecimento do paciente com diabetes mellitus sobre o cuidado com os pés. Rev enferm UERJ [Internet]. 2011 [cited 2013 Nov 30];19(4):621-5. Available from: http://www.facenf.uerj.br/v19n4/v19n4a20.pdf Português/Inglês Rev enferm UFPE on line., Recife, 10(6):680-5, jun., 2016 8 ISSN: 1981-8963 Jose DP, Almeida JS de, Rodrigues CDS et al. patients... DOI: 10.5205/reuol.9199-80250-1-SM1006201601 Sociodemographic and clinical factors of the 3. Ferreira CLRA, Ferreira MG. Características epidemiológicas de paciente diabético na rede pública de saúde: analise a partir do sistema do HiperDia. Arq Bras Endocrinol Metab [Internet]. 2009 [cited 2013 Nov 30];53(1):80-6. Available from: http://www.scielo.br/pdf/abem/v53n1/v53n1a12.pdf 4. Batista F, Pinzur M, Monteiro A, Taira R. Educação em pé diabética. Einstein (São Paulo) [Internet]. 2009 [cited 2013 Nov 30];7(1):24-7. Available from: http://www.drfabiobatista.med.br/arquivos/artigos/revista-einstein-educacao-pe-diabetico.PDF 5. Rawal LB, Tapp RJ, Williams ED, Chan C, Yasin S, Oldenburg B. Prevention of type 2 diabetes and its complications in developing countries: a review. Int J behav med [Internet]. 2012 [cited 2013 Nov 30];19(2):121-33. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3358560/pdf/12529_2011_Article_9162.pdf 6. Przysiezny A, Rodrigues KF, Santiago LH, Silva MCV. Características sociodemograficas de pacientes com diabetes mellitus portadores de pé diabético e ou retinopatia diabética atendidos em 16 unidades de Estratégia de Saúde da Família de Blumenau. ACM Arq Catarin Med [Internet]. 2013 [cited 2013 Nov 30];42(1):76-84. Available from: http://www.acm.org.br/revista/pdf/artigos/1216.pdf 7. Duarte N, Gonçalves A. Pé diabético. Angiol cir vasc [Internet]. 2011 [cited 2013 Nov 30];7(2):6579. Available from: http://www.scielo.mec.pt/pdf/ang/v7n2/v7n2a02.pdf 8. Silva EC, Haddad MCL, Rossaneis MA. Avaliação e de um programa sistematizado de cuidados com os pés na perspectiva dos pacientes com Diabetes mellitus. UNOPAR Cient Ciênc Biol Saúde [Internet]. 2013 [cited 2013 Nov 30];15(1):21-5. Available from: http://www.pgsskroton.com.br/seer/index.php/biologicas/article/view/770/73 9. De Luccia N. Amputação e reconstrução nas doenças vasculares e no pé diabético. Rio de Janeiro: Revinter; 2006. 10. Tavares DM dos S, Dias FA, Araujo LR, Pereira GA. Perfil de clientes submetidos a amputações relacionadas ao diabetes mellitus. Rev Bras Enferm [Internet]. 2009 [cited 2013 May 9];62(6):825-30. Available from: http://www.scielo.br/pdf/reben/v62n6/a04v62n6.pdf 11. Andrade NHS de, Sasso-Mendes KD, Faria HTG, Martins TA, Santos MA,Teixeira CR de S, et al. Pacientes com diabetes mellitus: cuidados e prevenção do pé diabético em atenção primaria a saúde. Rev enferm UERJ [Internet]. 2010 [cited 2013 May 9];18(4):616-21. Available from: http://www.facenf.uerj.br/v18n4/v18n4a19.pdf 12. Tavares DM dos S, Côrtes RM, Dias FA. Qualidade de vida e comorbidades entre os idosos diabéticos. Rev enferm UERJ [Internet]. 2010 [cited 2013 May 9];18(1):97-103. Available from: http://www.facenf.uerj.br/v18n1/v18n1a17.pdf 13. Scain SF, Franzen E, Santos LB dos, Heldt E. A acurácia das intervenções de enfermagem para pacientes com diabetes mellitus tipo 2 em consulta ambulatorial. Rev Gaucha Enferm [Internet]. 2013 [cited 2013 Nov 10];34(2):14-20. Available from: http://www.scielo.br/pdf/rgenf/v34n2/v34n2a02.pdf 14. Santos ICRV, Barros e Silva ACF de, Silva AP da, Melo LCP de. Condutas preventivas na atenção básica e amputação de membros inferiores em portadores de pé diabéticos. Rev Rene [Internet]. 2008 [cited 2013 Nov 10];9(4):40-8. Available from: http://www.redalyc.org/pdf/3240/324027964005.pdf 15. Laurindo CM, Recco CD, Roberti DB, Rodrigues CDS. Conhecimento das pessoas diabéticas acerca dos cuidados com os pés. Arq Ciênc Saúde [Internet]. 2005 [cited 2013 May 9];12(2):80-4. Available from: http://repositorio-racs.famerp.br/racs_ol/Vol-122/4.pdf 16. Sociedade Brasileira de Diabetes. Diretrizes da Sociedade Brasileira de Diabetes: 20132014. São Paulo: AC Farmacêutica; 2014. 17. Ministério da Saúde. Secretaria de Estado de Saúde do Distrito Federal. Consenso Internacional sobre Pé Diabético [monografia na Internet]. Brasília (DF): Ministério da Saúde; 2001 [cited 2014 Ago 12]. Available from: http://189.28.128.100/dab/docs/publicacoes/geral/conce_inter_pediabetico.pdf 18. Boulton AJ. The diabetic foot: from art to Science. 18th Camillo Golgi lecture. Diabetologia [Internet]. 2004 [cited 2013 May 9];47(8):1343-53. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15309286 19. Brito IC, Lopes AA, Araujo LMB. Associação da cor da pele com diabetes mellitus tipo 2 e intolerância a glicose em mulheres obesas de Salvador, Bahia. Arq Bras Endocrinol Metab [Internet]. 2001 [cited 2013 Nov 10];45(5):475-80. Available from: http://www.scielo.br/pdf/abem/v45n5/6864.pdf 20. Audi EG, Moreira RC, Moreira ACMG, Pinheiro EFC, Mantovani MF, Araújo AG de. Avaliação dos pés e classificação do risco para pé diabético: contribuições da enfermagem. Cogitare Enferm [Internet]. 2011 [cited 2013 Nov 10];16(2):240-6. Available from: http://ojs.c3sl.ufpr.br/ojs/index.php/cogitare/article/view/19975/15102 Português/Inglês Rev enferm UFPE on line., Recife, 10(6):680-5, jun., 2016 9 ISSN: 1981-8963 Jose DP, Almeida JS de, Rodrigues CDS et al. patients... DOI: 10.5205/reuol.9199-80250-1-SM1006201601 Sociodemographic and clinical factors of the 21. Lyra R, Silva RS, Montenegro Junior RM, Matos MVC, Cézar NJB, Silva LM. Prevalência de diabetes melito e fatores associados em população urbana adulta de baixa escolaridade e renda do sertão nordestino brasileiro. Arq Bras Endocrinol Metab [Internet]. 2010 [cited 2013 May 9];54(6):560-6. Available from: http://www.scielo.br/pdf/abem/v54n6/09.pdf 22. Armstrong DG. Loss of protective sensation: a practical evidence-based definition. J Foot Ankle Surg [Internet].1999 [cited 2013 Nov 10];38(1):79-80. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10028476 23. Gomes M de B, Gianella D, Faria M, Tambascia M, Fonseca RM, Réa R, et al. Prevalence of the Type 2 diabetic patients within thetargets of care guidelines in dailypractice: a multicenter study in Brazil. Rev Diabetic Stud [Internet]. 2006 [cited 2013 May 9];3(2):82-7. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1783582/pdf/RevDiabeticStud-03-082.pdf 24. Bortoletto MSS, Viude DF, Haddad M do CL, Karino ME. Caracterização dos portadores de diabetes submetidos à amputação de membros inferiores em Londrina, Estado do Paraná. Acta Sci Health Sci [Internet]. 2010 [cited 2013 Nov 10];32(2):205-13. Available from: http://periodicos.uem.br/ojs/index.php/ActaSciHealthSci/article/view/7754/7754 25. Loveman E, Frampton GK, Clegg AJ. The clinical effectiveness of diabetes education models for Type 2 diabetes: a systematic review. Health Technol Assess [Internet]. 2008 [cited 2013 May 9];12(9):1-116. Available from: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0015030/pdf/PubMedHealth_PMH001503 0.pdf 26. Ferris FL 3rd. How effective are treatments for diabetic retinopathy? JAMA [Internet]. 1993 [cited 2013 Nov 10];269(10):1290-1. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8437309 27. Kim SJ, Kim DJ. Alcoholism and diabetes mellitus. Diabetes Metab J [Internet]. 2012 [cited 2013 May 9];36(2):108-15. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3335891/pdf/dmj-36-108.pdf 28. Smith AG, Singleton JR. Diabetic neuropathy. Continuum (Minneap Minn) [Internet]. 2012 [cited 2013 Nov 10];18(1):60-84. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22810070 29. Rezende KF, Nunes MAP, Melo NH, Malerbi D, Chacra AR, Ferraz MB. Internações por Pé Diabético: comparação entre o custo direto estimado e o desembolso do SUS. Arq Bras Endrocrinol Metab [Internet]. 2008 [cited 2013 May 9];52(3):523-30. Available from: http://www.scielo.br/pdf/abem/v52n3/a13v52n3.pdf 30. Wang A, Sun X, Wang W, Jiang K. A study of prognostic factors in Chinese patients with diabetic foot ulcers. Diabetic Foot Ankle [Internet]. 2014 [cited 2013 Nov 10];5:1-5. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3955769/pdf/DFA-522936.pdf Submitted: 9/16/2015 Accepted: 4/28/2016 Published: 6/1/2016 Correspondence Denilson Pereira Jose Rua Professor Francisco Purita, 407, Ap.404 CEP 15084-090 São José do Rio Preto (SP), Brasil Português/Inglês Rev enferm UFPE on line., Recife, 10(6):680-5, jun., 2016 10