Prevalence of peripheral arterial disease and prognostic factors for amputation among type 2 diabetic patients in Mbujimayi

Prevalence of peripheral arterial disease and prognostic factors for amputation among type 2 diabetic patients in Mbujimayi | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Prevalence of peripheral arterial disease and prognostic factors for amputation among type 2 diabetic patients in Mbujimayi Trésor Kabuya Kabamba, Eugène Mukeba Bamusua, Séverin Uwonda Akinja, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7183952/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background: Peripheral arterial disease (PAD) is an atheromatous disease affecting one or more arteries of the lower limbs. It is frequently associated with type 2 diabetes mellitus, which is a strong risk factor and increases the incidence of lower limb amputations. This study aimed to determine the prevalence of PAD in type 2 diabetic patients as well as the prognostic factors for limb amputations in Mbujimayi. Methods: This was a multicenter cross-sectional study conducted in Mbujimayi (DR Congo) from September 2020 to December 2023. The study involved patients of both sexes, aged at least 18 years, who were diagnosed with type 2 diabetes mellitus. Results: A total of 237 type 2 diabetic patients were included in the study. The prevalence of PAD in these patients was 39.7%. The mean age was 59.8 ± 8.2 years. The mean duration of diabetes mellitus was 15.8 ± 8.8 years at the time of consultation. Intermittent claudication was found in 28.7% of the patients, and palpation revealed distal pulse abnormalities in 34.2% of the patients. The mean ABI was 0.88 ± 0.18. Compared with clinical assessment alone, ABI measurement was effective in detecting PAD in diabetic patients, including asymptomatic patients, with a sensitivity of 83.3% and a specificity of 84.3%. The frequency of amputations was 21.9%,with a 3-month postamputation mortality rate of 36.5%. Diabetes mellitus duration ≥ 20 years (p 0.009; OR 3.9), glycemic imbalance (p 0.033; OR 3.4), renal failure (p < 0.001; OR 9.0), ulcerations of the lower limbs (p 0.013; OR 3.7) and persistent leukocytosis (p < 0.001; OR 10.5) were found to be factors associated with the risk of amputation in diabetic patients in Mbujimayi. Conclusion: PAD is very common among type 2 diabetic patients in Mbujimayi, where it is responsible for a high rate of amputationand short-term mortality. ABI is a simple, inexpensive, and highly recommendable method for the early detection of PAD in underprivileged areas such as Mbujimayi. Prevalence peripheral arterial disease diabetes mellitus prognostic factors amputation Figures Figure 1 Figure 2 Introduction Peripheral arterial disease (PAD) is one of the clinical manifestations of macroangiopathy in diabetic patients [ 1 ]. Pathophysiologically, its occurrence is strongly correlated with an imbalance of glycoregulation (chronic hyperglycemia and insulin resistance) and a multifactorial prothrombogenic state (hypercoagulability and platelet activation), which characterize type 2 diabetes mellitus, especially when the latter has been evolving for a long time and is not regularly monitored [ 2 ]. PAD in diabetic patients has specific characteristics that distinguish it from classic PAD in nondiabetic patients [ 3 ]. It is often bilateral, remains asymptomatic for a long time and progresses quietly; thus, its typical clinical presentation is often serious from the outset, generally associated with severe distal multistage involvement with major trophic disorders requiring urgent revascularization to save the limb [ 4 , 5 ]. The prevalence of diabetes mellitus is steadily increasing, reaching more than 530 million patients worldwide [ 6 ]. Diabetes is an independent risk factor for vascular disease, increasing the risk of developing PAD by 2 to 4 times. It has been reported that, on the basis of the ankle‒brachial index threshold (ABI < 0.90), 20–30% of diabetic patients present with progressive PAD [ 7 , 8 ]. Indeed, PAD constitutes a real public health issue in diabetic patients, who often present a combination of cardiovascular risk factors that make their overall management complex and expensive [ 9 , 10 ]. The morbidity and mortality rates, both systemic and local, are very high in this category of patients, where we find the highest fraction of nontraumatic amputations of the lower limbs, which is the cause of more than 80% of cases [ 11 ]. In the Democratic Republic of the Congo (DRC), the ongoing epidemiological transition has led to the development of chronic noncommunicable diseases, among which diabetes mellitus has a high prevalence, reaching up to 3.5% of the general population in certain regions of the country [ 12 , 13 ]. Very few studies exist on PAD in the Congolese population, and the most recent, carried out in Mbujimayi on a sample of 506 patients at cardiovascular risk, revealed a hospital frequency of PAD of 36.4% on the basis of the ABI [ 14 ]. The lack of local data on PAD and its complications in the diabetic population motivated the realization of this work. The present study aimed to determine the prevalence of PAD using the ABI and identify prognostic factors for lower limb amputations in diabetic patients in Mbujimayi. Methods Study design and patients This was a multicenter cross-sectional study conducted in the surgery and internal medicine departments of Bonzola General Hospital, Megumi Medical Center, Kansele General Hospital and the university clinics of Mbujimayi in the Democratic Republic of the Congo from September 1, 2020, to December 31, 2023, with a duration of 3 years and 3 months. These structures were chosen as the study setting because of their geographical location, which makes them accessible to the population of the city of Mbujimayi. In addition, they have adequate equipment and qualified personnel, which makes them reference centers for diabetic patients throughout the region. The study involved 237 patients of both sexes, aged at least 18 years, who were diagnosed with type 2 diabetes mellitus (DM) and followed in the aforementioned departments during our study period. Not all patients who did not meet the inclusion criteria were included in this study; nor were patients with hemodynamic instability, those who had already undergone amputation of both lower limbs or a revascularization procedure. This study was approved by the Ethics Committee of the Official University of Mbujimayi, in accordance with the ethical principles governing biomedical research as reported in the Declaration of Helsinki, version 2013 [ 15 ]. Informed consent was obtained from all patients included in the study. All examination procedures complied with the ethical standards of the University Clinics of Mbujimayi Research Commission. Clinical data and ABI measurement All patients included in this study underwent a systematic clinical examination (history and physical examination) and measurement of the ABI. The anamnesis aimed to specify sociodemographic (age, sex, socioeconomic level) and anthropometric data (weight, height, body mass index, waist circumference), other cardiovascular risk factors (hypertension, smoking, dyslipidemia, sedentary lifestyle, etc.), characteristics of diabetes (duration, glycemic levels), complications of diabetes mellitus (neuropathy, retinopathy, nephropathy, diabetic foot), history of cardiovascular disease (stroke, coronary artery disease) or other chronic diseases. In addition, the Edinburgh questionnaire was used to search for symptomatic PAD in all patients. The physical examination consisted of searching for distal arterial pulses (posterior tibial artery and pedal artery), signs indicative of chronic ischemia (skin humidity, heat and discoloration; sparse hair growth, thick and brittle nails, edema, ulcers and dry gangrene), neuropathy (paresthesia, algothermic and vibrational hypo/anesthesia with a tuning fork, osteotendinous hypo/areflexia) and infection (wet gangrene). The diagnosis of PAD was made using ABI measurement. This was performed according to standard recommendations [ 16 ]. The patient was placed on an examination table at rest in the supine position for approximately 10–15 minutes. Blood pressure was measured in all four limbs using an aneroid sphygmomanometer and a pocket vascular Doppler from EDAN (SonoTrax with an 8 MHz probe). The measurement is first performed on both thoracic limbs on the brachial artery in the medial bicipital groove. On the pelvic limbs, the cuff is placed slightly below the calf, and the Doppler probe is positioned to perceive the posterior tibial pulse (in the medial retromalleolar groove) and/or the pedal pulse (on the dorsal surface of the foot). The ABI was calculated by considering the highest systolic blood pressure value at the ankle over that taken at the arm. It was considered normal (PAD absent) for values between 0.90 and 1.3 and abnormal for values outside this range. Thus, PAD was considered present if the ABI was 1.3 raised suspicion of mediacalcosis [ 17 ]. The ABI was performed by the same operator, using the same device, throughout the study to reduce interpersonal variability. Statistical analysis The data were analyzed via the Statistical Package for Social Sciences (IBM SPSS version 23.0) software. Categorical variables are presented as counts and percentages, whereas continuous variables are presented as the means and standard deviations. The results are presented in tables and graphs where appropriate. The sensitivity, specificity, positive predictive value, and negative predictive value of the ABI for the diagnosis of PAD, compared with clinical examination results, were calculated. Binary logistic regression was performed for prognostic factors for amputations. The significance level of the results was set at 0.05. Results Prevalence of PAD in diabetic subjects. A total of 94 diabetic patients out of 237 were diagnosed with PAD using ABI (< 0,90), representing a hospital prevalence of 39.7% in Mbujimayi. Sociodemographic characteristics of the patients. This study included 124 men (52.3%) and 113 women (47.7%). The mean age of the patients was 59.8 ± 8.2 years, and the age group between 60 and 74 years was the most represented, accounting for 57.8% of the cases (Table 1 ). Table 1 Sociodemographic characteristics (sex and age). Sociodemographic characteristics value (%) Sex Male 124 52.3 Female 113 47.7 Age (years) < 45 11 4.6 45–59 83 35.0 60–74 137 57.8 ≥ 75 6 2.5 Sex ratio M/F: 1.1. The mean age was 59.8 ± 8.2 years. Range: 40–82 years. Characteristics of diabetes mellitus (DM) and comorbidities Diabetes mellitus was generally long-standing, with a mean duration of 15.8 ± 8.8 years at the time of consultation, although its follow-up was not properly ensured in 63.3% of patients. High blood pressure (54.4%) and obesity (38.4%) were the most common comorbidities (Table 2 ). Table 2 Characteristics of diabetes mellitus and comorbidities. Variable value % Duration of DM development (years) < 20 102 43.0 ≥ 20 135 57.0 Regular monitoring of the DM Yes 87 36.7 No 180 63.3 High blood pressure Yes 129 54.4 No 108 45.6 Smoking Yes 64 27.0 No 173 73.0 Obesity Yes 91 38.4 No 146 61.6 Sedentary lifestyle Yes 47 19.8 No 190 80.2 The mean duration of DM progression since the first diagnosis was 15.8 ± 8.8 years. Clinical examination Intermittent claudication was noted in 28.7% of patients, and palpation revealed distal pulse abnormalities in 34.2% of patients. Ulcerations (22.4%) and gangrene (16.9%) were the most common trophic lesions of the limbs (Table 3 ). Table 3 Elements of the patient's clinical examination. Variable value (%) Intermittent claudication Yes 68 28.7 No 169 71.3 Distal pulses Weak and/or Absent 81 34.2 Normal 156 65.8 Limb ulcer Yes 53 22.4 No 184 77.6 Gangrene lesions Yes 40 16.9 No 197 83.1 Diagnostic performance of the ABI. Compared with clinical assessment alone, ABI measurement was effective in detecting PAD in diabetic patients, even in asymptomatic patients, with a sensitivity of 83.3%, a specificity of 84.3%, a positive predictive value of 74.5% and a negative predictive value of 90.2% (Table 4 ). Table 4 Performance of ABI measurement in the diagnosis of PAD in diabetic patients. Test Clinic + Clinic - Total Se. Sp. VPP VPN p value AUC CI (95%) ABI + 70 24 94 83.3 84.3 74.5 90.2 < 0.001 0.838 0.781 0.895 ABI - 14 129 143 Total 84 153 237 Mean ABI: 0.88 ± 0.18. Se: sensitivity; Sp: specificity; PPV: positive predictive value; NPV: negative predictive value; AUC: area under the curve. The area under the ROC curve was 0.838 (95% CI [0.781; 0.895], p < 0.001). This reflects the excellent ability of the ABI to distinguish patients with PAD from those without PAD (Fig. 1 ). Prevalence and predictive factors of lower limb amputations in the diabetic population. A total of 52 cases of lower limb amputations were documented in type 2 diabetic patients in Mbujimayi, representing a prevalence of 21.9%. A duration of diabetes mellitus ≥ 20 years (p 0.009; OR 3.9), glycemic imbalance (p 0.033; OR 3.4), renal failure (p < 0.001; OR 9.0), lower limb ulcerations (p 0.013; OR 3.7) and persistent leukocytosis (p < 0.001; OR 10.5) were reported as factors associated with the risk of amputation in diabetic patients (Table 5 ). The mortality rate was 36.5% at 3 months postamputation (Fig. 2). Table 5 Prevalence and predictors of amputation in diabetics. Variables Prevalence of amputation p value Odds ratio CI (95%) Sex Male 31/124 (25.0) 0.927 0.954 0.350 2,599 Female 21/113 (18.6) Duration of DM development (years) ≥ 20 39/135 (28.9) 0.009 3,914 1,399 10,948 < 20 13/102 (12.7 Glycemic balance No 45/151 (28.9) 0.033 3,345 1,105 10,131 Yes 7/86 (8.1) Smoking Yes 11/64 (17.2) 0.706 0.801 0.253 2,538 No 41/173 (23.7) High blood pressure Yes 34/159 (21.4) 0.126 0.438 0.152 1,261 No 18/78 (23.1) Kidney failure Presents 33/58 (56.9) < 0.001 9,007 3,218 25,209 Absent 19/179 (10.6) Sedentary lifestyle Yes 7/47 (14.9) 0,157 0.423 0.128 1,392 No 45/190 (23.7) Persistent leukocytosis Yes 39/62 (62.9) < 0.001 10,526 4,142 26,750 No 13/175 (7.4) Obesity Yes 22/87 (25.3) 0.263 1,766 0.652 4,787 No 30/150 (20.0) Limb ulcer Yes 26/53 (49.1) 0.013 3,743 1,327 10,559 No 26/184 (14.1) Discussion Frequency Peripheral arterial disease is a ubiquitous pathology strongly correlated with diabetes mellitus, which is a powerful risk factor. Its frequency in the diabetic population varies from one region to another, with an average of approximately 20% [ 18 , 19 ]. The high frequency of PAD (39.7%) reported in this study in the diabetic population of Mbujimayi is comparable to that reported in several other studies, both Western and African [ 5 , 20 ], although the literature review tends to indicate high prevalences in African regions, exceeding more than 40% in certain series, such as that of Kodjo (41.9%) in the city of Parakou (Benin) [ 21 ]. This finding could be explained by the ongoing epidemiological transition, which has resulted in cardiovascular risk factors gaining significant ground in Africa, whereas in several of these regions, particularly in Mbujimayi, cardiovascular prevention policies and guidelines are still struggling to be implemented. This predicts an ever-increasing trend in the incidence of PAD and its complications in this part of the world in the coming years. As previously discussed, PAD is particularly common in diabetic patients. The issue of screening for PAD has been the subject of several studies, and early screening helps improve risk stratification, structure prevention policies and optimize overall cardiovascular care in diabetic patients [ 22 – 25 ]. This observation is particularly relevant in regions that are undergoing major epidemiological transitions, such as Mbujimayi, where no usable data currently exist. The ABI has proven to be a simple, inexpensive and sensitive tool for detecting PAD with much better diagnostic performance [ 26 – 28 ]. The results of the present study are in line with those reported in several other studies. The ABI was effective for screening PAD in the diabetic population of Mbujimayi, with a sensitivity of 83.3%, a specificity of 84.3%, a positive predictive value of 74.5% and a negative predictive value of 90.2%. These results are comparable to those of Ejiofor [ 29 ]. This makes it a good and recommendable tool for screening for PAD in this underprivileged region, where access to cardiovascular health care is not guaranteed for the entire population. The clinical presentation of PAD in diabetic patients is unique, marked by long-term asymptomatic progression due to concomitant neuropathy, altering the pain perception of these patients, who ultimately see their podiatric risk explode and a high rate of major amputations of the lower limbs, ranging from 1 to 30%, or even more than 50%, depending on the studies and the population considered [ 30 – 32 ], with a one-year postamputation mortality of up to nearly 30% [ 33 ]. In the present series, the frequency of major amputations of the lower limbs in diabetic patients in Mbujimayi was 21.9%, with a three-month postamputation mortality of 36.5%. These more than alarming results demonstrate the delay in diagnosing PAD in Mbujimayi, especially in this category of patients where cardiovascular risk is cumulative in view of other frequently associated risk factors. Indeed, amputation is a major turning point in the development of PAD in diabetic patients and marks the beginning of a phase of both psychological and physiological exhaustion after many treatment procedures, which have proven unsuccessful given the progress of the lesions at the time of diagnosis [ 34 , 35 ]. The Fosse-Edorth study confirmed this finding and indicated that mortality was correlated with the level of amputation and that mortality increased as the degree of amputation increased proximally [ 36 ]. In Mbujimayi, the delay in diagnosis is also compounded by the lack of technical support and qualified human resources for the management of PAD; hence, there is particular interest in early detection, a fundamental pillar in the prevention of major cardiovascular events. Diabetes mellitus duration ≥ 20 years (p 0.009, OR 3.9), glycemic imbalance (p 0.033, OR 3.4), renal failure (p < 0.001, OR 9.0), lower limb ulcerations (p 0.013, OR 3.7) and persistent leukocytosis (p < 0.001, OR 10.5) were reported as predictive factors for amputation in diabetic patients in Mbujimayi. These factors have also been reported in several other studies [ 9 , 35 , 37 ]. As in this series, Bouzid reported no correlation between lower limb amputation and high blood pressure, tobacco intoxication or anthropometric parameters [ 38 ]. Paradoxically, some classic risk factors, such as smoking, which is known to increase the risk of limb amputation, were not found to be significant in this study. This discrepancy may be explained by the low prevalence of smoking in this study, considering the low proportion of smokers in Mbujimayi. Consequently, conducting additional studies with a larger sample size is necessary to confirm these findings and address this issue. The duration of the development of diabetes mellitus is an important prognostic factor for amputation, as confirmed by El Alami [ 39 ], because it alone explains the patient´s level of exposure to complications from other factors, which remain just as determining, without forgetting the direct impact of the socioeconomic situation, as aptly suggested by JL Richard [ 9 ]. It is therefore imperative to recall here the importance of regular monitoring of diabetic patients and, above all, maintaining a glycemic balance below the threshold chosen as the therapeutic objective, which remains a major challenge for a region such as Mbujimayi, in a country where precariousness is at its peak, with more than 50% of people living below the poverty line [ 40 ]. Limitations of the study Despite its diagnostic performance demonstrated in this work, the ABI has its limitations, particularly in cases of mediacalcosis, which can yield falsely reassuring values. Studies using other measurement tools, such as big toe systolic pressure and transcutaneous oxygen pressure, are necessary to assess, with even greater certainty, the prevalence of PAD among the diabetic population in Mbujimayi. Further work based on physiological tests and morphological and hemodynamic arterial data obtained by Doppler ultrasound on a larger sample could further contribute to the documentation of PAD in diabetic patients in Mbujimayi. Conclusion This study is the first to report local data on PAD in type 2 diabetic patients. This condition is highly prevalent in Mbujimayi, where it accounts for almost all limb amputations and is associated with high short-term mortality. Owing to its good diagnostic performance, measuring the ankle-brachial index is highly recommended as a simple and inexpensive tool for the early detection of PAD in order to optimize prevention and management protocols in Mbujimayi; this approach will significantly reduce the frequency of amputations and the associated mortality rate in this underprivileged region, where other diagnostic methods are generally lacking. Abbreviations ABI ankle‒brachial pressure index. AUC:Area under the curve. CI:confidence interval. DM:diabetes mellitus. DRC:Democratic Republic of the Congo. HBP:high blood pressure. NPV:Negative predictive value. OR:odds ratio. PAD:peripheral arterial disease. PPV:positive predictive value. ROC:receiver operating characteristic. Se:Sensitivity. Sp:specificity Declarations Ethics approval and consent to participate All procedures performed in this study involving human participants were approved by the Research and Ethics Committee of the Université Officielle de Mbujimayi in accordance with the 2013 Declaration of Helsinki. Informed consent was obtained from all study participants. Consent to publication Not applicable Competing interests The authors declare that they have no competing interests. Author´s contributions All the authors made substantial contributions to qualify for authorship of this study. TKK: Study protocol design, literature search, and manuscript writing. EMB: Data acquisition, analysis, and interpretation. SUA: Study protocol and data validation. CTL, JNT, and IB revised the manuscript for important intellectual content. All the authors have read and approved the final version of this manuscript. Clinical trial number Not applicable. Funding This study received no funding from any external source. Author Contribution All the authors made substantial contributions to qualify for authorship of this study. TKK: Study protocol design, literature search, and manuscript writing. EMB: Data acquisition, analysis, and interpretation. SUA: Study protocol and data validation. CTL, JNT, and IB: Revision of the manuscript for important intellectual content. All the authors have read and approved the final version of this manuscript. Acknowledgements Not applicable. Data Availability The data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request. References Yin J, Fu X, Luo Y, Leng Y, Ao L, Xie C. A Narrative Review of Diabetic Macroangiopathy: From Molecular Mechanism to Therapeutic Approaches. Diabetes Ther. 2024. https://doi.org/10.1007/s13300-024-01532-7 . Nativel M, Potier L, Alexandre L, Baillet–Blanco L, Ducasse E, Velho G, et al. Lower extremity arterial disease in patients with diabetes: a contemporary narrative review. Cardiovasc Diabetol. 2018. https://doi.org/10.1186/s12933-018-0781-1 . Pabon M, Cheng S, Altin SE, Sethi SS, Nelson MD, Moreau KL, et al. Sex Differences in Peripheral Artery Disease. Circ Res. 2022. https://doi.org/10.1161/CIRCRESAHA.121.320702 . Fredenrich A, Bouillanne PJ, Batt M. Lower limb arteriopathy in diabetic patients. EMC – Endocrinologie. 2004. https://doi.org/10.1016/j.emcend.2004.01.002 . Konin C, Essam N´loo AS, Adoubi A, Coulibaly NR, Boka B, N´djessan JJ, et al. Artériopathie des membres inférieurs du diabétique noir africain: aspects ultrasoniques et facteurs déterminants. J Mal Vasc. 2014. http://dx.doi.org/10.1016/j.jmv.2014.08.001 . Chuter V, Schaper N, Mills J, Hinchliffe R, Russell D, Azuma N, et al. Effectiveness of bedside investigations to diagnose peripheral artery disease among people with diabetes mellitus: a systematic review. Diabetes Metab Res Rev. 2024. https://doi.org/10.1002/dmrr.3683 . João SF, Franciane TC, Giovana MV, Vitória TA, Fernanda SP, Wanderson MS, et al. Peripheral arterial disease progression and ankle brachial index: a cohort study with newly diagnosed patients with type 2 diabetes. BMC Cardiovasc Disord. 2022. https://doi.org/10.1186/s12872-022-02722-6 . Ghirardini F, Martini R. Current Opinion on Diagnosis of Peripheral Artery Disease in Diabetic Patients. Medicina. 2024. https://doi.org/10.3390/medicina60071179 . Richard JL, Schuldiner S. Épidémiologie du pied diabétique. La revue de médecine interne. 2008; doi : http://france.elsevier.com/direct/REVMED/ Buso G, Collet TH, Wojtusciszyn A, Maufus M, Ney B, Mazzolai L. Should patients with type 2 diabetes be screened for lower extremity arterial disease? Rev Med Suisse. 2019; doi: https://pubmed.ncbi.nlm.nih.gov/31804035/ Barret A, Accadbled F, Bossavy JP, Garrigues D, Chaufour X. Amputation of lower limbs in occlusive arterial diseases. EMC – Chirurgie. 2005. https://doi.org/10.1016/j.emcchi.2005.01.004 . Mwana-Wabene AC, Lwamushi SM, Eboma CM, Lyabayungu PM, Cheruga B, Karemere H, et al. Choix thérapeutiques des hypertendus et diabétiques en milieu rural: Une étude mixte dans deux zones de santé de l'Est de la République Démocratique du Congo. Afr J Prim Health Care Fam Med. 2022. https://doi.org/10.4102/phcfm.v14i1.3004 . Katchunga PB, Malanda B, Mweze MC, Dupont B, M'Buyamba-Kabangu JR, Kashongwe Z, et al. Knowledge of the general population about hypertension and diabetes mellitus in South Kivu, Democratic Republic of Congo. Rev Epidemiol Sante Publique. 2012. https://doi.org/10.1016/j.respe.2011.10.005 . Eugène MB, Trésor KK, Tom MM, Dieudonné K, Claude TL, Séverin UA. Artériopathie oblitérante des membres inférieurs: résultats préliminaires d’un dépistage réalisé à Mbujimayi, en RDC. La Revue Int Médico-Chirurgicale. 2025. http://doi.org/10.70602/rimc.25.2.3.1.9 . World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA. 2013. http://doi.org/10.1001/jama.2013.281053 . Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, the ACC/AHA Task Force on Practice Guidelines. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation. 2006. https://doi.org/10.1161/CIRCULATIONAHA.106.174526 Poredos P, Stanek A, Catalano M, Boc V, Ankle-Brachial, Index. Diagnostic Tool of Peripheral Arterial Disease and Predictor of Cardiovascular Risk-An Update of Current Knowledge. Angiology. 2024. http://doi.org/10.1177/00033197241226512 . Oumar MA, Abdel-madjid ZZ, Abba O, Yaya KM, Adam AA, Deneube L et al. Artériopathie oblitérante des membres inférieurs chez le sujet diabétique noir africain: profil épidémioclinique, ultrasonographique et facteurs déterminants. Annales de Cardiologie et d'Angéiologie. 2024 ; doi : https://doi.org/10.1016/j.ancard.2024.101736 Sergent-Ferreri M, Malloizel-Delaunay J, Labrousse F, Gourdy P, Bura-Riviere A. Prévalence et facteurs de risque de l’artériopathie asymptomatique des membres inférieurs chez le diabétique: étude chez les patients hospitalisés en diabétologie au CHU de Toulouse. J Mal Vasc. 2014. http://dx.doi.org/10.1016/j.jmv.2014.07.089 . Aubert C, Le Doeuff J, Lajou J, Barthélémy O, Hartemann A, Bourron O. Le test Neuropad est-il utilisable chez les patients diabétiques avec une artériopathie oblitérante des membres inférieurs? Diabetes Metab. 2013;39(Suppl 1):26–9. https://doi.org/10.1016/S1262-3636(13)72047-0 . Codjo HL, Adoukonou TA, Wanvoegbe A, Dohou H, Bankolé C, Alassani A et al. Prévalence de l’artériopathie oblitérante des membres inférieurs et facteurs associés chez les diabétiques suivis en milieu hospitalier à Parakou en 2013. Annales de Cardiologie et d’Angéiologie. 2016; http://dx.doi.org/10.1016/j.ancard.2016.04.026 Fabrice B. Cardiovascular risk of the diabetic patient: which evidence? Bulletin de l'Académie Nationale de Médecine. 2018; https://doi.org/10.1016/S0001-4079(19)30254-7 Constantino MI, Molyneaux L, Limacher-Gisler F, Al-Saeed A, Luo C, Wu T, Twigg SM, et al. Long-term complications and mortality in young-onset diabetes: type 2 diabetes is more hazardous and lethal than type 1 diabetes. Diabetes Care. 2013. https://doi.org/10.2337/dc12-2455 . Aboyans V, Criqui MH, Abraham P, Allison MA, Creager MA, Diehm C, et al. Measurement and interpretation of the ankle-brachial index: a scientific statement from the American Heart. Association Circulation. 2012. https://doi.org/10.1161/CIR.0b013e318276fbcb . Horie K. Ankle Brachial Index: An Easy and First-Choice Screening Marker of Peripheral Artery Disease and Physical Function. J Atheroscler Thromb. 2024. https://doi.org/10.5551/jat.ED252 . Crawford F, Welch K, Andras A, Chappell FM. Ankle brachial index for the diagnosis of lower limb peripheral arterial disease. Cochrane Database Syst Reviews. 2016. https://doi.org/10.1002/14651858.CD010680.pub2 . Perez-Martin A. L’IPS est-il la solution pour le dépistage de l’AOMI? J Mal Vasc. 2014. http://dx.doi.org/10.1016/j.jmv.2014.07.006 . Mohammed A, Thomas MA, Ahmed H, Adeel SZ, Doireann PJ, Waqas M, et al. Diagnostic Performance of Ankle-Brachial Pressure Index in Lower Extremity Arterial Disease. Surg J. 2021. https://doi.org/10.1055/s-0041-1731444 . Ejiofor U, Anthony A, Michael O. Ankle branchial index as a surrogate to vascular imaging in evaluation of peripheral artery disease in patients with type 2 diabetes. BMC Cardiovasc Disord. 2021. https://doi.org/10.1186/s12872-020-01821-6 . Oliveira YS, Iba Ba J, Nsame D, Mba-Angoue JM, Lebane A, Minooee SK, et al. Les causes d’amputations des membres inférieurs en rééducation: impact de l’insuffisance artérielle et du diabète. J de réadaptation médicale. 2013. http://dx.doi.org/10.1016/j.jrm.2013.09.003 . Ben AA, Kacem M, Chaldi M, Ach K. Artériopathie oblitérante des membres inférieurs (AOMI) chez le diabétique tunisien. Ann Endocrinol. 2018. https://doi.org/10.1016/j.ando.2018.06.922 . Moxey PW, Gogalniceanu P, Hinchliffe RJ, Loftus IM, Jones KJ, Thompson MM, et al. Lower extremity amputations–a review of global variability in incidence. Diabet Med. 2011. https://doi.org/10.1111/j.1464-5491.2011.03279.x . Idam H. Facteurs de risque et prévalence d’amputation dans le pied diabétique. Ann Endocrinol. 2023. https://doi.org/10.1016/j.ando.2022.12.318 . Hart O, Bernau O, Khashram M. The Incidence and Outcomes of Major Limb Amputation in New Zealand from 2010 to 2021. J Clin Med. 2024. https://doi.org/10.3390/jcm13133872 . Walter N, Alt V, Rupp M. Lower Limb Amputation Rates in Germany. Medicina (Kaunas). 2022; https://doi.org/10.3390/medicina58010101 Fosse S, Hartemann-Heurtier A, Jacqueminet S, Ha Van G, Grimaldi A, Fagot-Campagna A. Incidence and characteristics of lower limb amputations in people with diabetes. Diabet Med. 2009. https://doi.org/10.1111/j.1464-5491.2009.02698.x . Aboyans V, Marie-Antoinette S, Iléana D, Philippe L, Gerry F, Michael C. Épidémiologie de l’artériopathie des membres inférieurs. La Presse Médicale. 2018. https://doi.org/10.1016/j.lpm.2018.01.012 . Bouzid C, Dorai A, Turki Z, Ben Salem S, Ben Slama C. Diabetes Metab. 2009;35. https://doi.org/10.1016/S1262-3636(09)71905-6 ., Suppl 1. El Alami L, Lazghad A, Chadli A, El Ghomari H, El Farouqi A, Marouan F, et al. Les facteurs pronostiques dans l’amputation du pied chez le diabétique. Med Chir Pied. 2005. https://doi.org/10.1007/s10243-005-0058-8 . Blessing C, Kouassi YRD, Congo. Special Report. ISS African Futures. 2024. https://futures.issafrica.org/special-reports/country/drc-french/ Accessed 20 Jul 2025. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 21 Sep, 2025 Reviews received at journal 15 Sep, 2025 Reviewers agreed at journal 07 Sep, 2025 Reviewers agreed at journal 05 Sep, 2025 Reviewers agreed at journal 27 Aug, 2025 Reviewers invited by journal 22 Aug, 2025 Editor invited by journal 01 Aug, 2025 Editor assigned by journal 31 Jul, 2025 Submission checks completed at journal 31 Jul, 2025 First submitted to journal 22 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7183952","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":508039252,"identity":"02890f3c-f29e-4323-a7d4-21423dbc9c94","order_by":0,"name":"Trésor Kabuya Kabamba","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA10lEQVRIiWNgGAWjYBADAwYJEFUB4UngU8qDquUMyVoY24jQYi99+PCHj3sYjPln95hJ/Jx3WE63gfnhDby28KWlSc54xmAmceeMmWTvtsPGZgfYjC3wauHhMWPmOcBgw3Ajx0yCd9vhxG0HeNjw+4WH//NnkBZ5oBbJv3OI0sLDIA3UYmYA1CLN20CMljNsZpIzDkgYG945Vmwtcyzd2OwwAb+w9zA//vDhgI3hvNvNG2++qbGWMzvejD/EoADsEhaIe5iJUA8DzB9IUDwKRsEoGAUjCAAANaNC2xKJ8AkAAAAASUVORK5CYII=","orcid":"","institution":"Université Officielle de Mbujimayi (UOM)","correspondingAuthor":true,"prefix":"","firstName":"Trésor","middleName":"Kabuya","lastName":"Kabamba","suffix":""},{"id":508039253,"identity":"b47bd88c-1a2d-424f-9e2a-0ff6bfd71f8a","order_by":1,"name":"Eugène Mukeba Bamusua","email":"","orcid":"","institution":"Université Officielle de Mbujimayi (UOM)","correspondingAuthor":false,"prefix":"","firstName":"Eugène","middleName":"Mukeba","lastName":"Bamusua","suffix":""},{"id":508039254,"identity":"bc2ae34e-5acf-4f32-8204-e344a471d52c","order_by":2,"name":"Séverin Uwonda Akinja","email":"","orcid":"","institution":"Université Officielle de Mbujimayi (UOM)","correspondingAuthor":false,"prefix":"","firstName":"Séverin","middleName":"Uwonda","lastName":"Akinja","suffix":""},{"id":508039255,"identity":"90db3bfd-3924-4b19-b3c0-9233b67281cd","order_by":3,"name":"Joseph Ngandu Tshilunda","email":"","orcid":"","institution":"Université Officielle de Mbujimayi (UOM)","correspondingAuthor":false,"prefix":"","firstName":"Joseph","middleName":"Ngandu","lastName":"Tshilunda","suffix":""},{"id":508039256,"identity":"44507dd2-cf7d-4e11-9bf4-d54a4b28025c","order_by":4,"name":"Claude Tshibangu Lukusa","email":"","orcid":"","institution":"Université Officielle de Mbujimayi (UOM)","correspondingAuthor":false,"prefix":"","firstName":"Claude","middleName":"Tshibangu","lastName":"Lukusa","suffix":""},{"id":508039257,"identity":"5676caa1-00f1-4609-a3e0-f4eb994ec9ba","order_by":5,"name":"Ivo Buschmann","email":"","orcid":"","institution":"Medizinische Hochschule Brandenburg Theodor Fontane","correspondingAuthor":false,"prefix":"","firstName":"Ivo","middleName":"","lastName":"Buschmann","suffix":""}],"badges":[],"createdAt":"2025-07-22 07:38:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7183952/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7183952/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":90380523,"identity":"4b254d17-86a4-4aba-8d5f-059e95effe24","added_by":"auto","created_at":"2025-09-02 06:43:53","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":14049,"visible":true,"origin":"","legend":"\u003cp\u003eReceiver operating characteristic (ROC) curve for the ABI versus clinical assessment.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7183952/v1/d523d5aa70b72ee01d4940a8.png"},{"id":90380521,"identity":"a45a8ee4-adb1-4c40-bc72-8bc73396caa0","added_by":"auto","created_at":"2025-09-02 06:43:52","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":34715,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7183952/v1/8e07f2324839247ce9b0b7e3.png"},{"id":90383482,"identity":"378dc49e-8b44-4002-9a47-d7544836dad0","added_by":"auto","created_at":"2025-09-02 06:59:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1034819,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7183952/v1/239c22e8-9a1c-4261-8219-e57f7b814529.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Prevalence of peripheral arterial disease and prognostic factors for amputation among type 2 diabetic patients in Mbujimayi","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePeripheral arterial disease (PAD) is one of the clinical manifestations of macroangiopathy in diabetic patients [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Pathophysiologically, its occurrence is strongly correlated with an imbalance of glycoregulation (chronic hyperglycemia and insulin resistance) and a multifactorial prothrombogenic state (hypercoagulability and platelet activation), which characterize type 2 diabetes mellitus, especially when the latter has been evolving for a long time and is not regularly monitored [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePAD in diabetic patients has specific characteristics that distinguish it from classic PAD in nondiabetic patients [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. It is often bilateral, remains asymptomatic for a long time and progresses quietly; thus, its typical clinical presentation is often serious from the outset, generally associated with severe distal multistage involvement with major trophic disorders requiring urgent revascularization to save the limb [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe prevalence of diabetes mellitus is steadily increasing, reaching more than 530\u0026nbsp;million patients worldwide [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Diabetes is an independent risk factor for vascular disease, increasing the risk of developing PAD by 2 to 4 times. It has been reported that, on the basis of the ankle‒brachial index threshold (ABI \u0026lt; 0.90), 20–30% of diabetic patients present with progressive PAD [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIndeed, PAD constitutes a real public health issue in diabetic patients, who often present a combination of cardiovascular risk factors that make their overall management complex and expensive [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The morbidity and mortality rates, both systemic and local, are very high in this category of patients, where we find the highest fraction of nontraumatic amputations of the lower limbs, which is the cause of more than 80% of cases [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn the Democratic Republic of the Congo (DRC), the ongoing epidemiological transition has led to the development of chronic noncommunicable diseases, among which diabetes mellitus has a high prevalence, reaching up to 3.5% of the general population in certain regions of the country [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Very few studies exist on PAD in the Congolese population, and the most recent, carried out in Mbujimayi on a sample of 506 patients at cardiovascular risk, revealed a hospital frequency of PAD of 36.4% on the basis of the ABI [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The lack of local data on PAD and its complications in the diabetic population motivated the realization of this work.\u003c/p\u003e\u003cp\u003eThe present study aimed to determine the prevalence of PAD using the ABI and identify prognostic factors for lower limb amputations in diabetic patients in Mbujimayi.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design and patients\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThis was a multicenter cross-sectional study conducted in the surgery and internal medicine departments of Bonzola General Hospital, Megumi Medical Center, Kansele General Hospital and the university clinics of Mbujimayi in the Democratic Republic of the Congo from September 1, 2020, to December 31, 2023, with a duration of 3 years and 3 months. These structures were chosen as the study setting because of their geographical location, which makes them accessible to the population of the city of Mbujimayi. In addition, they have adequate equipment and qualified personnel, which makes them reference centers for diabetic patients throughout the region.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e The study involved 237 patients of both sexes, aged at least 18 years, who were diagnosed with type 2 diabetes mellitus (DM) and followed in the aforementioned departments during our study period. Not all patients who did not meet the inclusion criteria were included in this study; nor were patients with hemodynamic instability, those who had already undergone amputation of both lower limbs or a revascularization procedure.\u003c/p\u003e\u003cp\u003eThis study was approved by the Ethics Committee of the Official University of Mbujimayi, in accordance with the ethical principles governing biomedical research as reported in the Declaration of Helsinki, version 2013 [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Informed consent was obtained from all patients included in the study. All examination procedures complied with the ethical standards of the University Clinics of Mbujimayi Research Commission.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eClinical data and ABI measurement\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eAll patients included in this study underwent a systematic clinical examination (history and physical examination) and measurement of the ABI.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe anamnesis aimed to specify sociodemographic (age, sex, socioeconomic level) and anthropometric data (weight, height, body mass index, waist circumference), other cardiovascular risk factors (hypertension, smoking, dyslipidemia, sedentary lifestyle, etc.), characteristics of diabetes (duration, glycemic levels), complications of diabetes mellitus (neuropathy, retinopathy, nephropathy, diabetic foot), history of cardiovascular disease (stroke, coronary artery disease) or other chronic diseases. In addition, the Edinburgh questionnaire was used to search for symptomatic PAD in all patients.\u003c/p\u003e\u003cp\u003eThe physical examination consisted of searching for distal arterial pulses (posterior tibial artery and pedal artery), signs indicative of chronic ischemia (skin humidity, heat and discoloration; sparse hair growth, thick and brittle nails, edema, ulcers and dry gangrene), neuropathy (paresthesia, algothermic and vibrational hypo/anesthesia with a tuning fork, osteotendinous hypo/areflexia) and infection (wet gangrene).\u003c/p\u003e\u003cp\u003eThe diagnosis of PAD was made using ABI measurement. This was performed according to standard recommendations [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The patient was placed on an examination table at rest in the supine position for approximately 10–15 minutes. Blood pressure was measured in all four limbs using an aneroid sphygmomanometer and a pocket vascular Doppler from EDAN (SonoTrax with an 8 MHz probe).\u003c/p\u003e\u003cp\u003eThe measurement is first performed on both thoracic limbs on the brachial artery in the medial bicipital groove. On the pelvic limbs, the cuff is placed slightly below the calf, and the Doppler probe is positioned to perceive the posterior tibial pulse (in the medial retromalleolar groove) and/or the pedal pulse (on the dorsal surface of the foot). The ABI was calculated by considering the highest systolic blood pressure value at the ankle over that taken at the arm. It was considered normal (PAD absent) for values between 0.90 and 1.3 and abnormal for values outside this range. Thus, PAD was considered present if the ABI was \u0026lt; 0.90. An ABI \u0026gt; 1.3 raised suspicion of mediacalcosis [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The ABI was performed by the same operator, using the same device, throughout the study to reduce interpersonal variability.\u003c/p\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eThe data were analyzed via the Statistical Package for Social Sciences (IBM SPSS version 23.0) software. Categorical variables are presented as counts and percentages, whereas continuous variables are presented as the means and standard deviations. The results are presented in tables and graphs where appropriate. The sensitivity, specificity, positive predictive value, and negative predictive value of the ABI for the diagnosis of PAD, compared with clinical examination results, were calculated. Binary logistic regression was performed for prognostic factors for amputations. The significance level of the results was set at 0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cb\u003ePrevalence of PAD in diabetic subjects.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA total of 94 diabetic patients out of 237 were diagnosed with PAD using ABI (\u0026lt;\u0026thinsp;0,90), representing a hospital prevalence of 39.7% in Mbujimayi.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSociodemographic characteristics of the patients.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study included 124 men (52.3%) and 113 women (47.7%). The mean age of the patients was 59.8\u0026thinsp;\u0026plusmn;\u0026thinsp;8.2 years, and the age group between 60 and 74 years was the most represented, accounting for 57.8% of the cases (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSociodemographic characteristics (sex and age).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSociodemographic characteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003evalue\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e124\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e52.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e113\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e47.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e45\u0026ndash;59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e35.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e60\u0026ndash;74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e137\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e57.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e2.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSex ratio M/F: 1.1. The mean age was 59.8\u0026thinsp;\u0026plusmn;\u0026thinsp;8.2 years. Range: 40\u0026ndash;82 years.\u003c/p\u003e\u003cp\u003e\u003cb\u003eCharacteristics of diabetes mellitus (DM) and comorbidities\u003c/b\u003e\u003c/p\u003e\u003cp\u003eDiabetes mellitus was generally long-standing, with a mean duration of 15.8\u0026thinsp;\u0026plusmn;\u0026thinsp;8.8 years at the time of consultation, although its follow-up was not properly ensured in 63.3% of patients. High blood pressure (54.4%) and obesity (38.4%) were the most common comorbidities (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCharacteristics of diabetes mellitus and comorbidities.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003evalue\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDuration of DM development (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e102\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e43.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e135\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e57.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRegular monitoring of the DM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e36.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e180\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e63.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHigh blood pressure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e129\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e54.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e108\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e45.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSmoking\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e27.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e173\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e73.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eObesity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e38.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e146\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e61.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSedentary lifestyle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e19.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e190\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e80.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe mean duration of DM progression since the first diagnosis was 15.8\u0026thinsp;\u0026plusmn;\u0026thinsp;8.8 years.\u003c/p\u003e\u003cp\u003e\u003cb\u003eClinical examination\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIntermittent claudication was noted in 28.7% of patients, and palpation revealed distal pulse abnormalities in 34.2% of patients. Ulcerations (22.4%) and gangrene (16.9%) were the most common trophic lesions of the limbs (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eElements of the patient's clinical examination.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003evalue\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntermittent claudication\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e28.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e169\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e71.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDistal pulses\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWeak and/or Absent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e34.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNormal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e156\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e65.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLimb ulcer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e22.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e184\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e77.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGangrene lesions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e197\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e83.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eDiagnostic performance of the ABI.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eCompared with clinical assessment alone, ABI measurement was effective in detecting PAD in diabetic patients, even in asymptomatic patients, with a sensitivity of 83.3%, a specificity of 84.3%, a positive predictive value of 74.5% and a negative predictive value of 90.2% (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePerformance of ABI measurement in the diagnosis of PAD in diabetic patients.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"12\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTest\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eClinic +\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eClinic -\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSe.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSp.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eVPP\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eVPN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003ep value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u003cp\u003eAUC\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u003cp\u003eCI (95%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eABI +\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e83.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e84.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e74.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e90.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.838\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0.781\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e0.895\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eABI -\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e129\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e143\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e153\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e237\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eMean ABI: 0.88\u0026thinsp;\u0026plusmn;\u0026thinsp;0.18.\u003c/p\u003e\u003cp\u003eSe: sensitivity; Sp: specificity; PPV: positive predictive value; NPV: negative predictive value; AUC: area under the curve.\u003c/p\u003e\u003cp\u003eThe area under the ROC curve was 0.838 (95% CI [0.781; 0.895], p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This reflects the excellent ability of the ABI to distinguish patients with PAD from those without PAD (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003ePrevalence and predictive factors of lower limb amputations in the diabetic population.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA total of 52 cases of lower limb amputations were documented in type 2 diabetic patients in Mbujimayi, representing a prevalence of 21.9%. A duration of diabetes mellitus\u0026thinsp;\u0026ge;\u0026thinsp;20 years (p 0.009; OR 3.9), glycemic imbalance (p 0.033; OR 3.4), renal failure (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; OR 9.0), lower limb ulcerations (p 0.013; OR 3.7) and persistent leukocytosis (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; OR 10.5) were reported as factors associated with the risk of amputation in diabetic patients (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). The mortality rate was 36.5% at 3 months postamputation (Fig.\u0026nbsp;2).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePrevalence and predictors of amputation in diabetics.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrevalence of amputation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ep value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eOdds ratio\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003eCI (95%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31/124 (25.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.927\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.954\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.350\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2,599\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21/113 (18.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDuration of DM development (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e39/135 (28.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.009\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3,914\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1,399\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e10,948\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13/102 (12.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGlycemic balance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e45/151 (28.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.033\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3,345\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1,105\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e10,131\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7/86 (8.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSmoking\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11/64 (17.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.706\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.801\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.253\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2,538\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e41/173 (23.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHigh blood pressure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e34/159 (21.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.126\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.438\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.152\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1,261\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18/78 (23.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKidney failure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePresents\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e33/58 (56.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9,007\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3,218\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e25,209\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAbsent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19/179 (10.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSedentary lifestyle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7/47 (14.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0,157\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.423\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.128\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1,392\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e45/190 (23.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePersistent leukocytosis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e39/62 (62.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10,526\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4,142\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e26,750\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13/175 (7.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eObesity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22/87 (25.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.263\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1,766\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.652\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4,787\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30/150 (20.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLimb ulcer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26/53 (49.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.013\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3,743\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1,327\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e10,559\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26/184 (14.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eFrequency\u003c/p\u003e\u003cp\u003ePeripheral arterial disease is a ubiquitous pathology strongly correlated with diabetes mellitus, which is a powerful risk factor. Its frequency in the diabetic population varies from one region to another, with an average of approximately 20% [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe high frequency of PAD (39.7%) reported in this study in the diabetic population of Mbujimayi is comparable to that reported in several other studies, both Western and African [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], although the literature review tends to indicate high prevalences in African regions, exceeding more than 40% in certain series, such as that of Kodjo (41.9%) in the city of Parakou (Benin) [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e This finding could be explained by the ongoing epidemiological transition, which has resulted in cardiovascular risk factors gaining significant ground in Africa, whereas in several of these regions, particularly in Mbujimayi, cardiovascular prevention policies and guidelines are still struggling to be implemented. This predicts an ever-increasing trend in the incidence of PAD and its complications in this part of the world in the coming years.\u003c/p\u003e\u003cp\u003eAs previously discussed, PAD is particularly common in diabetic patients. The issue of screening for PAD has been the subject of several studies, and early screening helps improve risk stratification, structure prevention policies and optimize overall cardiovascular care in diabetic patients [\u003cspan additionalcitationids=\"CR23 CR24\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. This observation is particularly relevant in regions that are undergoing major epidemiological transitions, such as Mbujimayi, where no usable data currently exist.\u003c/p\u003e\u003cp\u003eThe ABI has proven to be a simple, inexpensive and sensitive tool for detecting PAD with much better diagnostic performance [\u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The results of the present study are in line with those reported in several other studies. The ABI was effective for screening PAD in the diabetic population of Mbujimayi, with a sensitivity of 83.3%, a specificity of 84.3%, a positive predictive value of 74.5% and a negative predictive value of 90.2%. These results are comparable to those of Ejiofor [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. This makes it a good and recommendable tool for screening for PAD in this underprivileged region, where access to cardiovascular health care is not guaranteed for the entire population.\u003c/p\u003e\u003cp\u003eThe clinical presentation of PAD in diabetic patients is unique, marked by long-term asymptomatic progression due to concomitant neuropathy, altering the pain perception of these patients, who ultimately see their podiatric risk explode and a high rate of major amputations of the lower limbs, ranging from 1 to 30%, or even more than 50%, depending on the studies and the population considered [\u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], with a one-year postamputation mortality of up to nearly 30% [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. In the present series, the frequency of major amputations of the lower limbs in diabetic patients in Mbujimayi was 21.9%, with a three-month postamputation mortality of 36.5%. These more than alarming results demonstrate the delay in diagnosing PAD in Mbujimayi, especially in this category of patients where cardiovascular risk is cumulative in view of other frequently associated risk factors.\u003c/p\u003e\u003cp\u003eIndeed, amputation is a major turning point in the development of PAD in diabetic patients and marks the beginning of a phase of both psychological and physiological exhaustion after many treatment procedures, which have proven unsuccessful given the progress of the lesions at the time of diagnosis [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. The Fosse-Edorth study confirmed this finding and indicated that mortality was correlated with the level of amputation and that mortality increased as the degree of amputation increased proximally [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. In Mbujimayi, the delay in diagnosis is also compounded by the lack of technical support and qualified human resources for the management of PAD; hence, there is particular interest in early detection, a fundamental pillar in the prevention of major cardiovascular events.\u003c/p\u003e\u003cp\u003eDiabetes mellitus duration\u0026thinsp;\u0026ge;\u0026thinsp;20 years (p 0.009, OR 3.9), glycemic imbalance (p 0.033, OR 3.4), renal failure (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, OR 9.0), lower limb ulcerations (p 0.013, OR 3.7) and persistent leukocytosis (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, OR 10.5) were reported as predictive factors for amputation in diabetic patients in Mbujimayi. These factors have also been reported in several other studies [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. As in this series, Bouzid reported no correlation between lower limb amputation and high blood pressure, tobacco intoxication or anthropometric parameters [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eParadoxically, some classic risk factors, such as smoking, which is known to increase the risk of limb amputation, were not found to be significant in this study. This discrepancy may be explained by the low prevalence of smoking in this study, considering the low proportion of smokers in Mbujimayi. Consequently, conducting additional studies with a larger sample size is necessary to confirm these findings and address this issue.\u003c/p\u003e\u003cp\u003eThe duration of the development of diabetes mellitus is an important prognostic factor for amputation, as confirmed by El Alami [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], because it alone explains the patient\u0026acute;s level of exposure to complications from other factors, which remain just as determining, without forgetting the direct impact of the socioeconomic situation, as aptly suggested by JL Richard [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. It is therefore imperative to recall here the importance of regular monitoring of diabetic patients and, above all, maintaining a glycemic balance below the threshold chosen as the therapeutic objective, which remains a major challenge for a region such as Mbujimayi, in a country where precariousness is at its peak, with more than 50% of people living below the poverty line [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitations of the study\u003c/b\u003e\u003c/p\u003e\u003cp\u003eDespite its diagnostic performance demonstrated in this work, the ABI has its limitations, particularly in cases of mediacalcosis, which can yield falsely reassuring values. Studies using other measurement tools, such as big toe systolic pressure and transcutaneous oxygen pressure, are necessary to assess, with even greater certainty, the prevalence of PAD among the diabetic population in Mbujimayi. Further work based on physiological tests and morphological and hemodynamic arterial data obtained by Doppler ultrasound on a larger sample could further contribute to the documentation of PAD in diabetic patients in Mbujimayi.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003e This study is the first to report local data on PAD in type 2 diabetic patients. This condition is highly prevalent in Mbujimayi, where it accounts for almost all limb amputations and is associated with high short-term mortality. Owing to its good diagnostic performance, measuring the ankle-brachial index is highly recommended as a simple and inexpensive tool for the early detection of PAD in order to optimize prevention and management protocols in Mbujimayi; this approach will significantly reduce the frequency of amputations and the associated mortality rate in this underprivileged region, where other diagnostic methods are generally lacking.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eABI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eankle‒brachial pressure index. AUC:Area under the curve. CI:confidence interval. DM:diabetes mellitus. DRC:Democratic Republic of the Congo. HBP:high blood pressure. NPV:Negative predictive value. OR:odds ratio. PAD:peripheral arterial disease. PPV:positive predictive value. ROC:receiver operating characteristic. Se:Sensitivity. Sp:specificity\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\u003cp\u003e All procedures performed in this study involving human participants were approved by the Research and Ethics Committee of the Universit\u0026eacute; Officielle de Mbujimayi in accordance with the 2013 Declaration of Helsinki. Informed consent was obtained from all study participants.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent to publication\u003c/strong\u003e\u003cp\u003eNot applicable\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting interests\u003c/h2\u003e\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eAuthor\u0026acute;s contributions\u003c/h2\u003e\u003cp\u003eAll the authors made substantial contributions to qualify for authorship of this study. TKK: Study protocol design, literature search, and manuscript writing. EMB: Data acquisition, analysis, and interpretation. SUA: Study protocol and data validation. CTL, JNT, and IB revised the manuscript for important intellectual content. All the authors have read and approved the final version of this manuscript.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eClinical trial number\u003c/h2\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis study received no funding from any external source.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll the authors made substantial contributions to qualify for authorship of this study. TKK: Study protocol design, literature search, and manuscript writing. EMB: Data acquisition, analysis, and interpretation. SUA: Study protocol and data validation. CTL, JNT, and IB: Revision of the manuscript for important intellectual content. All the authors have read and approved the final version of this manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eYin J, Fu X, Luo Y, Leng Y, Ao L, Xie C. A Narrative Review of Diabetic Macroangiopathy: From Molecular Mechanism to Therapeutic Approaches. Diabetes Ther. 2024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s13300-024-01532-7\u003c/span\u003e\u003cspan address=\"10.1007/s13300-024-01532-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNativel M, Potier L, Alexandre L, Baillet\u0026ndash;Blanco L, Ducasse E, Velho G, et al. Lower extremity arterial disease in patients with diabetes: a contemporary narrative review. Cardiovasc Diabetol. 2018. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12933-018-0781-1\u003c/span\u003e\u003cspan address=\"10.1186/s12933-018-0781-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePabon M, Cheng S, Altin SE, Sethi SS, Nelson MD, Moreau KL, et al. Sex Differences in Peripheral Artery Disease. Circ Res. 2022. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1161/CIRCRESAHA.121.320702\u003c/span\u003e\u003cspan address=\"10.1161/CIRCRESAHA.121.320702\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFredenrich A, Bouillanne PJ, Batt M. Lower limb arteriopathy in diabetic patients. EMC \u0026ndash; Endocrinologie. 2004. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.emcend.2004.01.002\u003c/span\u003e\u003cspan address=\"10.1016/j.emcend.2004.01.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKonin C, Essam N\u0026acute;loo AS, Adoubi A, Coulibaly NR, Boka B, N\u0026acute;djessan JJ, et al. Art\u0026eacute;riopathie des membres inf\u0026eacute;rieurs du diab\u0026eacute;tique noir africain: aspects ultrasoniques et facteurs d\u0026eacute;terminants. J Mal Vasc. 2014. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://dx.doi.org/10.1016/j.jmv.2014.08.001\u003c/span\u003e\u003cspan address=\"10.1016/j.jmv.2014.08.001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChuter V, Schaper N, Mills J, Hinchliffe R, Russell D, Azuma N, et al. Effectiveness of bedside investigations to diagnose peripheral artery disease among people with diabetes mellitus: a systematic review. Diabetes Metab Res Rev. 2024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/dmrr.3683\u003c/span\u003e\u003cspan address=\"10.1002/dmrr.3683\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJo\u0026atilde;o SF, Franciane TC, Giovana MV, Vit\u0026oacute;ria TA, Fernanda SP, Wanderson MS, et al. Peripheral arterial disease progression and ankle brachial index: a cohort study with newly diagnosed patients with type 2 diabetes. BMC Cardiovasc Disord. 2022. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12872-022-02722-6\u003c/span\u003e\u003cspan address=\"10.1186/s12872-022-02722-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGhirardini F, Martini R. Current Opinion on Diagnosis of Peripheral Artery Disease in Diabetic Patients. Medicina. 2024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/medicina60071179\u003c/span\u003e\u003cspan address=\"10.3390/medicina60071179\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRichard JL, Schuldiner S. \u0026Eacute;pid\u0026eacute;miologie du pied diab\u0026eacute;tique. La revue de m\u0026eacute;decine interne. 2008; doi : \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://france.elsevier.com/direct/REVMED/\u003c/span\u003e\u003cspan address=\"http://france.elsevier.com/direct/REVMED/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBuso G, Collet TH, Wojtusciszyn A, Maufus M, Ney B, Mazzolai L. Should patients with type 2 diabetes be screened for lower extremity arterial disease? Rev Med Suisse. 2019; doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/31804035/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/31804035/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBarret A, Accadbled F, Bossavy JP, Garrigues D, Chaufour X. Amputation of lower limbs in occlusive arterial diseases. EMC \u0026ndash; Chirurgie. 2005. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.emcchi.2005.01.004\u003c/span\u003e\u003cspan address=\"10.1016/j.emcchi.2005.01.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMwana-Wabene AC, Lwamushi SM, Eboma CM, Lyabayungu PM, Cheruga B, Karemere H, et al. Choix th\u0026eacute;rapeutiques des hypertendus et diab\u0026eacute;tiques en milieu rural: Une \u0026eacute;tude mixte dans deux zones de sant\u0026eacute; de l'Est de la R\u0026eacute;publique D\u0026eacute;mocratique du Congo. Afr J Prim Health Care Fam Med. 2022. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4102/phcfm.v14i1.3004\u003c/span\u003e\u003cspan address=\"10.4102/phcfm.v14i1.3004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKatchunga PB, Malanda B, Mweze MC, Dupont B, M'Buyamba-Kabangu JR, Kashongwe Z, et al. Knowledge of the general population about hypertension and diabetes mellitus in South Kivu, Democratic Republic of Congo. Rev Epidemiol Sante Publique. 2012. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.respe.2011.10.005\u003c/span\u003e\u003cspan address=\"10.1016/j.respe.2011.10.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEug\u0026egrave;ne MB, Tr\u0026eacute;sor KK, Tom MM, Dieudonn\u0026eacute; K, Claude TL, S\u0026eacute;verin UA. Art\u0026eacute;riopathie oblit\u0026eacute;rante des membres inf\u0026eacute;rieurs: r\u0026eacute;sultats pr\u0026eacute;liminaires d\u0026rsquo;un d\u0026eacute;pistage r\u0026eacute;alis\u0026eacute; \u0026agrave; Mbujimayi, en RDC. La Revue Int M\u0026eacute;dico-Chirurgicale. 2025. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://doi.org/10.70602/rimc.25.2.3.1.9\u003c/span\u003e\u003cspan address=\"10.70602/rimc.25.2.3.1.9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA. 2013. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://doi.org/10.1001/jama.2013.281053\u003c/span\u003e\u003cspan address=\"10.1001/jama.2013.281053\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, the ACC/AHA Task Force on Practice Guidelines. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation. 2006. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1161/CIRCULATIONAHA.106.174526\u003c/span\u003e\u003cspan address=\"10.1161/CIRCULATIONAHA.106.174526\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePoredos P, Stanek A, Catalano M, Boc V, Ankle-Brachial, Index. Diagnostic Tool of Peripheral Arterial Disease and Predictor of Cardiovascular Risk-An Update of Current Knowledge. Angiology. 2024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://doi.org/10.1177/00033197241226512\u003c/span\u003e\u003cspan address=\"10.1177/00033197241226512\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOumar MA, Abdel-madjid ZZ, Abba O, Yaya KM, Adam AA, Deneube L et al. Art\u0026eacute;riopathie oblit\u0026eacute;rante des membres inf\u0026eacute;rieurs chez le sujet diab\u0026eacute;tique noir africain: profil \u0026eacute;pid\u0026eacute;mioclinique, ultrasonographique et facteurs d\u0026eacute;terminants. Annales de Cardiologie et d'Ang\u0026eacute;iologie. 2024 ; doi : \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ancard.2024.101736\u003c/span\u003e\u003cspan address=\"10.1016/j.ancard.2024.101736\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSergent-Ferreri M, Malloizel-Delaunay J, Labrousse F, Gourdy P, Bura-Riviere A. Pr\u0026eacute;valence et facteurs de risque de l\u0026rsquo;art\u0026eacute;riopathie asymptomatique des membres inf\u0026eacute;rieurs chez le diab\u0026eacute;tique: \u0026eacute;tude chez les patients hospitalis\u0026eacute;s en diab\u0026eacute;tologie au CHU de Toulouse. J Mal Vasc. 2014. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://dx.doi.org/10.1016/j.jmv.2014.07.089\u003c/span\u003e\u003cspan address=\"10.1016/j.jmv.2014.07.089\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAubert C, Le Doeuff J, Lajou J, Barth\u0026eacute;l\u0026eacute;my O, Hartemann A, Bourron O. Le test Neuropad est-il utilisable chez les patients diab\u0026eacute;tiques avec une art\u0026eacute;riopathie oblit\u0026eacute;rante des membres inf\u0026eacute;rieurs? Diabetes Metab. 2013;39(Suppl 1):26\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S1262-3636(13)72047-0\u003c/span\u003e\u003cspan address=\"10.1016/S1262-3636(13)72047-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCodjo HL, Adoukonou TA, Wanvoegbe A, Dohou H, Bankol\u0026eacute; C, Alassani A et al. Pr\u0026eacute;valence de l\u0026rsquo;art\u0026eacute;riopathie oblit\u0026eacute;rante des membres inf\u0026eacute;rieurs et facteurs associ\u0026eacute;s chez les diab\u0026eacute;tiques suivis en milieu hospitalier \u0026agrave; Parakou en 2013. Annales de Cardiologie et d\u0026rsquo;Ang\u0026eacute;iologie. 2016; \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://dx.doi.org/10.1016/j.ancard.2016.04.026\u003c/span\u003e\u003cspan address=\"10.1016/j.ancard.2016.04.026\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFabrice B. Cardiovascular risk of the diabetic patient: which evidence? Bulletin de l'Acad\u0026eacute;mie Nationale de M\u0026eacute;decine. 2018; \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S0001-4079(19)30254-7\u003c/span\u003e\u003cspan address=\"10.1016/S0001-4079(19)30254-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eConstantino MI, Molyneaux L, Limacher-Gisler F, Al-Saeed A, Luo C, Wu T, Twigg SM, et al. Long-term complications and mortality in young-onset diabetes: type 2 diabetes is more hazardous and lethal than type 1 diabetes. Diabetes Care. 2013. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2337/dc12-2455\u003c/span\u003e\u003cspan address=\"10.2337/dc12-2455\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAboyans V, Criqui MH, Abraham P, Allison MA, Creager MA, Diehm C, et al. Measurement and interpretation of the ankle-brachial index: a scientific statement from the American Heart. Association Circulation. 2012. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1161/CIR.0b013e318276fbcb\u003c/span\u003e\u003cspan address=\"10.1161/CIR.0b013e318276fbcb\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHorie K. Ankle Brachial Index: An Easy and First-Choice Screening Marker of Peripheral Artery Disease and Physical Function. J Atheroscler Thromb. 2024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.5551/jat.ED252\u003c/span\u003e\u003cspan address=\"10.5551/jat.ED252\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCrawford F, Welch K, Andras A, Chappell FM. Ankle brachial index for the diagnosis of lower limb peripheral arterial disease. Cochrane Database Syst Reviews. 2016. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/14651858.CD010680.pub2\u003c/span\u003e\u003cspan address=\"10.1002/14651858.CD010680.pub2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePerez-Martin A. L\u0026rsquo;IPS est-il la solution pour le d\u0026eacute;pistage de l\u0026rsquo;AOMI? J Mal Vasc. 2014. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://dx.doi.org/10.1016/j.jmv.2014.07.006\u003c/span\u003e\u003cspan address=\"10.1016/j.jmv.2014.07.006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMohammed A, Thomas MA, Ahmed H, Adeel SZ, Doireann PJ, Waqas M, et al. Diagnostic Performance of Ankle-Brachial Pressure Index in Lower Extremity Arterial Disease. Surg J. 2021. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1055/s-0041-1731444\u003c/span\u003e\u003cspan address=\"10.1055/s-0041-1731444\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEjiofor U, Anthony A, Michael O. Ankle branchial index as a surrogate to vascular imaging in evaluation of peripheral artery disease in patients with type 2 diabetes. BMC Cardiovasc Disord. 2021. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12872-020-01821-6\u003c/span\u003e\u003cspan address=\"10.1186/s12872-020-01821-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOliveira YS, Iba Ba J, Nsame D, Mba-Angoue JM, Lebane A, Minooee SK, et al. Les causes d\u0026rsquo;amputations des membres inf\u0026eacute;rieurs en r\u0026eacute;\u0026eacute;ducation: impact de l\u0026rsquo;insuffisance art\u0026eacute;rielle et du diab\u0026egrave;te. J de r\u0026eacute;adaptation m\u0026eacute;dicale. 2013. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://dx.doi.org/10.1016/j.jrm.2013.09.003\u003c/span\u003e\u003cspan address=\"10.1016/j.jrm.2013.09.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBen AA, Kacem M, Chaldi M, Ach K. Art\u0026eacute;riopathie oblit\u0026eacute;rante des membres inf\u0026eacute;rieurs (AOMI) chez le diab\u0026eacute;tique tunisien. Ann Endocrinol. 2018. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ando.2018.06.922\u003c/span\u003e\u003cspan address=\"10.1016/j.ando.2018.06.922\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMoxey PW, Gogalniceanu P, Hinchliffe RJ, Loftus IM, Jones KJ, Thompson MM, et al. Lower extremity amputations\u0026ndash;a review of global variability in incidence. Diabet Med. 2011. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1464-5491.2011.03279.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1464-5491.2011.03279.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIdam H. Facteurs de risque et pr\u0026eacute;valence d\u0026rsquo;amputation dans le pied diab\u0026eacute;tique. Ann Endocrinol. 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ando.2022.12.318\u003c/span\u003e\u003cspan address=\"10.1016/j.ando.2022.12.318\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHart O, Bernau O, Khashram M. The Incidence and Outcomes of Major Limb Amputation in New Zealand from 2010 to 2021. J Clin Med. 2024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/jcm13133872\u003c/span\u003e\u003cspan address=\"10.3390/jcm13133872\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWalter N, Alt V, Rupp M. Lower Limb Amputation Rates in Germany. Medicina (Kaunas). 2022; \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/medicina58010101\u003c/span\u003e\u003cspan address=\"10.3390/medicina58010101\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFosse S, Hartemann-Heurtier A, Jacqueminet S, Ha Van G, Grimaldi A, Fagot-Campagna A. Incidence and characteristics of lower limb amputations in people with diabetes. Diabet Med. 2009. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1464-5491.2009.02698.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1464-5491.2009.02698.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAboyans V, Marie-Antoinette S, Il\u0026eacute;ana D, Philippe L, Gerry F, Michael C. \u0026Eacute;pid\u0026eacute;miologie de l\u0026rsquo;art\u0026eacute;riopathie des membres inf\u0026eacute;rieurs. La Presse M\u0026eacute;dicale. 2018. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.lpm.2018.01.012\u003c/span\u003e\u003cspan address=\"10.1016/j.lpm.2018.01.012\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBouzid C, Dorai A, Turki Z, Ben Salem S, Ben Slama C. Diabetes Metab. 2009;35. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S1262-3636(09)71905-6\u003c/span\u003e\u003cspan address=\"10.1016/S1262-3636(09)71905-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e., Suppl 1.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEl Alami L, Lazghad A, Chadli A, El Ghomari H, El Farouqi A, Marouan F, et al. Les facteurs pronostiques dans l\u0026rsquo;amputation du pied chez le diab\u0026eacute;tique. Med Chir Pied. 2005. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10243-005-0058-8\u003c/span\u003e\u003cspan address=\"10.1007/s10243-005-0058-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBlessing C, Kouassi YRD, Congo. Special Report. ISS African Futures. 2024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://futures.issafrica.org/special-reports/country/drc-french/\u003c/span\u003e\u003cspan address=\"https://futures.issafrica.org/special-reports/country/drc-french/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e Accessed 20 Jul 2025.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Prevalence, peripheral arterial disease, diabetes mellitus, prognostic factors, amputation","lastPublishedDoi":"10.21203/rs.3.rs-7183952/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7183952/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003ePeripheral arterial disease (PAD) is an atheromatous disease affecting one or more arteries of the lower limbs. It is frequently associated with type 2 diabetes mellitus, which is a strong risk factor and increases the incidence of lower limb amputations. This study aimed to determine the prevalence of PAD in type 2 diabetic patients as well as the prognostic factors for limb amputations in Mbujimayi.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThis was a multicenter cross-sectional study conducted in Mbujimayi (DR Congo) from September 2020 to December 2023. The study involved patients of both sexes, aged at least 18 years, who were diagnosed with type 2 diabetes mellitus.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eA total of 237 type 2 diabetic patients were included in the study. The prevalence of PAD in these patients was 39.7%. The mean age was 59.8 ± 8.2 years. The mean duration of diabetes mellitus was 15.8 ± 8.8 years at the time of consultation. Intermittent claudication was found in 28.7% of the patients, and palpation revealed distal pulse abnormalities in 34.2% of the patients. The mean ABI was 0.88 ± 0.18. Compared with clinical assessment alone, ABI measurement was effective in detecting PAD in diabetic patients, including asymptomatic patients, with a sensitivity of 83.3% and a specificity of 84.3%. The frequency of amputations was 21.9%,with a 3-month postamputation mortality rate of 36.5%. Diabetes mellitus duration ≥ 20 years (p 0.009; OR 3.9), glycemic imbalance (p 0.033; OR 3.4), renal failure (p \u0026lt; 0.001; OR 9.0), ulcerations of the lower limbs (p 0.013; OR 3.7) and persistent leukocytosis (p \u0026lt; 0.001; OR 10.5) were found to be factors associated with the risk of amputation in diabetic patients in Mbujimayi.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003ePAD is very common among type 2 diabetic patients in Mbujimayi, where it is responsible for a high rate of amputationand short-term mortality. ABI is a simple, inexpensive, and highly recommendable method for the early detection of PAD in underprivileged areas such as Mbujimayi.\u003c/p\u003e","manuscriptTitle":"Prevalence of peripheral arterial disease and prognostic factors for amputation among type 2 diabetic patients in Mbujimayi","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-02 06:43:48","doi":"10.21203/rs.3.rs-7183952/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-09-21T19:31:39+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-15T06:31:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"285389171585878775680030537763603800421","date":"2025-09-07T21:47:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"282201899783805459596615050397165915431","date":"2025-09-05T12:09:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"133469239390353114486140674767683402675","date":"2025-08-27T19:13:50+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-22T11:14:28+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-01T11:10:55+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-31T12:01:28+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-31T12:00:27+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cardiovascular Disorders","date":"2025-07-22T07:28:41+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"504d5492-3c28-4ceb-9969-6c81042845ab","owner":[],"postedDate":"September 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-02T06:43:48+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-02 06:43:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7183952","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7183952","identity":"rs-7183952","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}