Osteoarticular Complications of Diabetes Mellitus in Bukavu: A Multicenter Retrospective Study

Osteoarticular Complications of Diabetes Mellitus in Bukavu: A Multicenter Retrospective Study | 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 Osteoarticular Complications of Diabetes Mellitus in Bukavu: A Multicenter Retrospective Study Rodrigue Mupenda Mwenibamba, Christian Bisimwa Wabene, Fabrice Kibukila, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7166903/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 13 You are reading this latest preprint version Abstract Background Osteoarticular complications of diabetes mellitus (DM) are underrecognized but significantly impact patient outcomes. This study evaluated their prevalence, characteristics, and predictors among diabetic patients in Bukavu, Democratic Republic of Congo. Methods This retrospective multicenter study analyzed 103 diabetic patients with osteoarticular complications across four Bukavu hospitals from 2021 to 2023. Data were extracted from medical records and analyzed using descriptive statistics, chi-square tests, logistic regression, Kaplan-Meier survival analysis, and Pearson correlation in SPSS. Results Among 694 diabetic patients, 103 (14.84%) had osteoarticular complications. Gender distribution was balanced (50.5% female, sex ratio of 0.98) was observed, with a mean age of 59.98 ± 10.5 years and BMI of 27.5 ± 8.6 kg/m². Type 2 DM (80.6%), poor glycemic control (87.4%), and poor treatment compliance (68.9%) were common. Diabetic foot ulcers (36.9%) and osteoarthritis (29.1%) predominated, primarily affecting lower limbs (58.3%). Medical-surgical treatment was used in 54.4% of cases, with a 6.8% mortality rate, mostly within 36 days. Poor glycemic control increased the risk of death (OR = 3.45, 95% CI: 1.12–10.63, p = 0.031), and disease duration correlated with severity (r = 0.31, p = 0.002). As a component of Survival, Time to death was shorter with poor compliance ( p = 0.048). Conclusions Osteoarticular complications are prevalent in Bukavu’s diabetic population, associated with poor glycemic control and longer disease duration. Enhanced screening and adherence strategies are critical for prevention and improved outcomes. Osteoarticular complications Diabetes mellitus Bukavu Glycemic control Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Introduction Diabetes mellitus (DM) is a chronic metabolic disorder marked by hyperglycemia due to defective insulin secretion, action, or both, affecting over 537 million adults globally in 2021, with projections exceeding 783 million, reaching 1,054 billion USD by 2045 [ 1 – 5 ]. This escalating burden disproportionately impacts low- and middle-income countries (LMICs), including sub-Saharan Africa, where healthcare systems struggle to address both the disease and its complications [ 6 – 8 ]. While cardiovascular, renal, and neuropathic sequelae of DM are well-documented, osteoarticular (OA) complications encompassing diabetic foot ulcers (DFU), osteoarthritis (OA), Charcot osteoarthropathy, and other musculoskeletal disorders, remain underappreciated despite their profound impact on quality of life and healthcare costs [ 9 , 10 ]. The musculoskeletal system is particularly vulnerable in DM due to multiple pathophysiological mechanisms. Chronic hyperglycemia leads to the accumulation of advanced glycation end-products (AGEs), which impair collagen integrity in tendons, ligaments, and bone [ 11 – 13 ]. Peripheral neuropathy and vascular insufficiency exacerbate risks of foot ulcers and infections, while insulin deficiency or resistance disrupts bone remodeling, increasing fracture susceptibility [ 14 – 16 ]. Recent evidence highlights that type 2 DM, predominant in older populations, is linked to a 20–40% higher risk of osteoarthritis due to systemic inflammation and obesity [ 17 , 18 ]. Meanwhile, type 1 DM, often diagnosed earlier, triples fracture risk through reduced bone mineral density [ 19 – 21 ]. Globally, DFU precede 85% of non-traumatic lower limb amputations, a statistic that underscores the urgency of addressing these complications [ 22 – 24 ]. In sub-Saharan Africa, the convergence of rising DM prevalence, estimated at 24 million cases in 2021, predicting to increase by 1242% reaching 60 million by 2050 [ 1 , 25 ], and limited diagnostic and therapeutic resources amplifies the burden of OA complications [ 7 , 10 , 26 ]. Studies from Nigeria and Ethiopia report prevalence rates of DFU ranging from 11–19%, often compounded by delayed presentation and poor glycemic control [ 7 , 26 – 30 ]. This study explores the prevalence of OA complications in Bukavu, hypothesized to be lower than regional estimates. In the Democratic Republic of Congo (DRC), where DM is increasingly reported in uncontrolled urbanized and clotted cities, data on musculoskeletal outcomes are scarce, particularly in regions like Bukavu, a city with growing healthcare demands but constrained infrastructure [ 31 – 36 ]. Socioeconomic factors, including poverty and limited access to specialized care, further complicate management, potentially elevating morbidity and mortality [ 37 , 38 ]. Emerging research emphasizes the interplay between DM duration, glycemic control, and OA outcomes [ 39 – 42 ]. A 2021 systematic review synthesizes data from 31 articles reporting that each additional year of DM increases the risk of diabetic foot complications [ 43 ], while a 2024 study linked poor HbA1c control to a twofold rise in osteoarthritis severity [ 44 ]. These findings, predominantly from high-income settings, may not fully reflect LMIC contexts, where infectious comorbidities (e.g., osteomyelitis) and treatment non-compliance add complexity [ 26 , 45 , 46 ]. In Bukavu, no prior studies have systematically explored these complications, leaving a critical knowledge gap. This study investigates the prevalence, characteristics, and predictors of OA complications among diabetic patients in Bukavu, aiming to inform local policy and clinical practice in a resource-limited environment. Methods Study Design and Setting This retrospective multicenter study was conducted across four hospitals in Bukavu: Bukavu University Clinics, Panzi Hospital, Dr. Rau/Ciriri General Referral Hospital, and 5è CELPA Hospital Centre, from January 2021 to December 2023. Population and Sampling We included diabetic patients with OA complications admitted to rheumatology or orthopedic departments, identified via consecutive sampling from medical records. Exclusion criteria were non-diabetic diabetes types (e.g., gestational), incomplete records, or admissions outside the study period. Data Collection Data were collected anonymously per the Declaration of Helsinki, with ethical approval waived due to the retrospective, anonymized design per local regulations. A standardized form captured sociodemographic (age, sex, occupation), anthropometric (BMI), and clinical data (DM type, duration, compliance, glycemic control, complication type, treatment, outcomes) from medical records and surgical reports. Statistical Analysis Data were entered into Microsoft Excel 365 and analyzed using SPSS v30. Descriptive statistics (means, standard deviations, percentages) summarized patient characteristics. Associations were tested with chi-square tests (e.g., sex vs. complication type). Logistic regression identified predictors (e.g., glycemic control) with odds ratios (ORs) and 95% confidence intervals (CIs). Kaplan-Meier survival analysis assessed time-to-death by compliance and glycemic control, with log-rank tests. Pearson correlation was used to assess relationships between disease duration and complication severity or hospital stay. Significance was set at p < 0.05. Results 1. Descriptive Statistics Prevalence and Patient Characteristics Of 694 diabetic patients, 103 (14.84%) had osteoarticular complications. Gender distribution was nearly equal (50.5% female, 49.5% male), with a sex ratio of 0.98 suggesting no strong sex bias in the sample. The majority (55.3%) were aged 50–70 years, with a Mean age of 59.98 ± 10.5 years indicating a predominance of middle-aged patients. The mean BMI was 27.5 ± 8.6 kg/m² (range: 10.3–44.7). Type 2 DM predominated (80.6%, n = 83), with poor glycemic control in 87.4% (n = 90) and poor compliance in 68.9% (n = 71). (Fig. 3) Osteoarticular Complications Diabetic foot ulcers (36.9%, n = 38) and osteoarthritis (29.1%, n = 30) were most common, primarily affecting lower limbs (58.3%, n = 60), reflecting the peripheral nature of diabetic complications. (Fig. 1 –3) Treatment and Outcomes Medical-surgical treatment was used in 54.4% (n = 56) of cases (Fig. 2 B). Healing without sequelae occurred in 52.4% of cases, a favorable outcome for over half the cohort. Persistent sequelae were observed in 29.1%, postoperative infection in 11.7%, and death in 6.8%, indicating significant morbidity and mortality risks. Most of patients (56.3%) had a hospital stay 70 days with a mean hospital stay of 36 ± 34.2 days, suggesting a range of severity and recovery times. (Fig. 3) 2. Analytic Statistics Chi-Square Tests No significant correlation between Gender and Complication Type (χ² = 0.35, p = 0.996), for instance DFU: 38.5% female vs. 35.3% male. Trend observed between Age and Death ( 70 years: 0%), but not significan (χ² = 3.5, p = 0.17). Lower limb involvement was strongly associated with DFU (χ² = 12.34, p < 0.001). No significant association between Glycemic Control and Death occurrence (Good: 0/13 died, Poor: 7/90 died; χ² = 0.60, p = 0.44), though Kaplan-Meier analysis showed shorter survival time with poor control (p = 0.041). There is an association between treatment type and postoperative infections (χ² = 6.784, p = 0.009), with medical-surgical cases more prone (8/56) vs. others (4/47). (Fig. 4 , Tables 1 ) Table 1 Associations table Osteoarticular complications and evolution of Diabetes mellitus Osteoarticular complications Affected Region Outcome Hospital Stay, days Diabetic Foot Osteo arthritis Osteo myelitis/ Osteitis Septic Arthritis Dupuytren’s Contracture Others Lower Limbs Spine Upper Limbs Multiple Regions Healing, No Sequelae Healing, With Sequelae Postop Infection Death Less than 36 days Between 36 and 70 days More than 70 days n(%) Female 20(19.4) 15(14.6) 5(4.9) 2(1.9) 3(2.9) 7(6.8) 31(30.1) 11(10.7) 9(8.7) 1(1.0) 27(26.2) 15(14.6) 6(5.8) 4(3.9) 29(28.2) 17(16.5) 6(5.8) 52(50.5) Male 18(17.5) 15(14.6) 5(4.9) 2(1.9) 3(2.9) 8(7.8) 29(28.2) 12(11.7) 9(8.7) 1(1.0) 27(26.2) 15(14.6) 6(5.8) 3(2.9) 29(28.2) 16(15.5) 6(5.8) 51(49.5) < 50 years 15(14.6) 10(9.7) 4(3.9) 1(1.0) 2(1.9) 3(2.9) 20(19.4) 8(7.8) 6(5.8) 1(1.0) 18(17.5) 10(9.7) 4(3.9) 3(2.9) 20(19.4) 11(10.7) 4(3.9) 35(34.0) 50–70 years 21(20.4) 16(15.5) 4(3.9) 2(1.9) 2(1.9) 12(11.7) 33(32.0) 12(11.7) 11(10.7) 1(1.0) 30(29.1) 17(16.5) 6(5.8) 4(3.9) 32(31.1) 18(17.5) 7(6.8) 57(55.3) > 70 years 2(1.9) 4(3.9) 2(1.9) 1(1.0) 2(1.9) 0(0.0) 7(6.8) 3(2.9) 1(1.0) 0(0.0) 6(5.8) 3(2.9) 2(1.9) 0(0.0) 6(5.8) 4(3.9) 1(1.0) 11(10.7) < 18.5 (Thin) 4(3.9) 3(2.9) 1(1.0) 0(0.0) 1(1.0) 1(1.0) 5(4.9) 2(1.9) 3(2.9) 0(0.0) 5(4.9) 3(2.9) 1(1.0) 1(1.0) 6(5.8) 3(2.9) 1(1.0) 10(9.7) 18.5–24.9 (Normal) 11(10.7) 9(8.7) 3(2.9) 1(1.0) 1(1.0) 5(4.9) 17(16.5) 7(6.8) 5(4.9) 1(1.0) 16(15.5) 9(8.7) 3(2.9) 2(1.9) 17(16.5) 10(9.7) 3(2.9) 30(29.1) 25.0–29.9 (Overwght) 12(11.7) 11(10.7) 3(2.9) 2(1.9) 2(1.9) 9(8.7) 23(22.3) 9(8.7) 6(5.8) 1(1.0) 21(20.4) 11(10.7) 4(3.9) 3(2.9) 22(21.4) 13(12.6) 4(3.9) 39(37.9) ≥ 30.0 (Obese) 11(10.7) 7(6.8) 3(2.9) 1(1.0) 2(1.9) 0(0.0) 15(14.6) 5 (4.9) 4(3.9) 0(0.0) 12(11.7) 7(6.8) 4(3.9) 1(1.0) 13(12.6) 7(6.8) 4(3.9) 24(23.3) Unemployed 20 (19.4) 17(16.5) 5(4.9) 2(1.9) 3(2.9) 11(10.7) 34(33.0) 13(12.6) 10(9.7) 1(1.0) 30(29.1) 17(16.5) 7(6.8) 4(3.9) 33(32.0) 18(17.5) 7(6.8) 58(56.3) Employed 18(17.5) 13(12.6) 5(4.9) 2(1.9) 3(2.9) 4(3.9) 26(25.2) 10(9.7) 8(7.8) 1(1.0) 24(23.3) 13(12.6) 5(4.9) 3(2.9) 25(24.3) 15(14.6) 5(4.9) 45(43.7) Type 1 7(6.8) 5(4.9) 2(1.9) 1(1.0) 2(1.9) 3(2.9) 11(10.7) 5(4.9) 3(2.9) 1(1.0) 10(9.7) 6(5.8) 2(1.9) 2(1.9) 11(10.7) 6(5.8) 3(2.9) 20(19.4) Type 2 31(30.1) 25(24.3) 8(7.8) 3(2.9) 4(3.9) 12(11.7) 49(47.6) 18(17.5) 15(14.6) 1(1.0) 44(42.7) 24(23.3) 10(9.7) 5(4.9) 47(45.6) 27(26.2) 9(8.7) 83(80.6) < 10 years 10(9.7) 8(7.8) 3(2.9) 1(1.0) 2(1.9) 3(2.9) 15(14.6) 6(5.8) 5(4.9) 1(1.0) 14(13.6) 8(7.8) 3(2.9) 2(1.9) 15(14.6) 9(8.7) 3(2.9) 27(26.2) 10–20 years 25(24.3) 20(19.4) 6(5.8) 3(2.9) 3(2.9) 12(11.7) 41(39.8) 16(15.5) 11(10.7) 1(1.0) 36(35.0) 20(19.4) 8(7.8) 5(4.9) 39(37.9) 22(21.4) 8(7.8) 69(67.0) > 20 years 3(2.9) 2(1.9) 1(1.0) 0(0.0) 1(1.0) 0(0.0) 4(3.9) 1(1.0) 2(.9) 0(0.0) 4(3.9) 2(1.9) 1(1.0) 0(0.0) 4(3.9) 2(1.9) 1(1.0) 7(6.8) Good Control 4(3.9) 3(2.9) 1(1.0) 0(0.0) 1(1.0) 4(3.9) 7(6.8) 3(2.9) 2(1.9) 1(1.0) 8(7.8) 4(3.9) 1(1.0) 0(0.0) 8(7.8) 4(3.9) 1(1.0) 13(12.6) Poor Control 34(33.0) 27(26.2) 9(8.7) 4(3.9) 5(4.9) 11(10.7) 53(51.5) 20(19.4) 16(15.5) 1(1.0) 46(44.7) 26(25.2) 11(10.7) 7(6.8) 50(48.5) 29(28.2) 11(10.7) 90(87.4) Good Compliance 11(10.7) 9(8.7) 3(2.9) 1(1.0) 2(1.9) 6(5.8) 18(17.5) 7(6.8) 6(5.8) 1(1.0) 18(17.5) 10(9.7) 3(2.9) 1(1.0) 18(17.5) 10(9.7) 4(3.9) 32(31.1) Poor Compliance 27(26.2) 21(20.4) 7(6.8) 3(2.9) 4(3.9) 9(8.7) 42(40.8) 16(15.5) 12(11.7) 1(1.0) 36(35.0) 20(19.4) 9(8.7) 6(5.8) 40(38.8) 23(22.3) 8(7.8) 71(68.9) Medical-Surgical 18(17.5) 17(16.5) 6(5.8) 2(1.9) 3(2.9) 10(9.7) 33(32.0) 11(10.7) 11(10.7) 1(1.0) 30(29.1) 15(14.6) 8(7.8) 3(2.9) 32(31.1) 18(17.5) 6(5.8) 56(54.4) Medical-Orthopedic 10(9.7) 8(7.8) 3(2.9) 1(1.0) 2(1.9) 5(4.9) 15(14.6) 8(7.8) 5(4.9) 1(1.0) 15(14.6) 10(9.7) 3(2.9) 1(1.0) 16(15.5) 9(8.7) 4(3.9) 29(28.2) Medical Only 8(7.8) 4(3.9) 1(1.0) 1(1.0) 0(0.0) 0(0.0) 10(9.7) 3(2.9) 1(1.0) 0(0.0) 8(7.8) 4(3.9) 1(1.0) 1(1.0) 8(7.8) 4(3.9) 2(1.9) 14(13.6) Treatment Rejection 2(1.9) 1(1.0) 0(0.0) 0(0.0) 1(1.0) 0(0.0) 2(1.9) 1(1.0) 1(1.0) 0(0.0) 1(1.0) 1(1.0) 0(0.0) 2(1.9) 2(1.9) 2(1.9) 0(0.0) 4(3.9) n (%) 38(36.9) 30(29.1) 10(9.7) 4(3.9) 6(5.8) 15(14.6) 60(58.3) 23(22.3) 18(17.5) 2(1.9) 54(52.4) 30(29.1) 12(11.7) 7(6.8) 5(56.3) 33(32.0) 12(11.6) • Chi-Square : No significant sex-based differences in complications (p = 0.996), but glycemic control trends toward worse outcomes (p = 0.078). • Logistic Regression : Poor glycemic control is a key predictor of death (p < 0.05), with compliance showing a non-significant trend (p = 0.31). • Kaplan-Meier : Poor control and compliance reduce survival time (p = 0.041, p = 0.048), emphasizing their role in mortality. • Correlation : Disease duration correlated with hospital stay (r = 0.314, p = 0.002), indicating a moderate relationship, while its link to complication severity was similar (r = 0.31, p = 0.002) Logistic Regression Death : Poor glycemic control significantly increased the odds of death (OR = 3.45, 95% CI: 1.12–10.63, p = 0.031), while poor treatment compliance tripled the odds (OR = 3.0, 95% CI: 1.03–8.75, p = 0.03). The OR of 2.5 (p = 0.12) for glycemic control appears underpowered due to few deaths. The lack of deaths in > 70 years (OR = 0.5) reinforces the chi-square trend but lacks significance. (Fig. 3, Tables 1 ) Healing with Sequelae Poor glycemic control doubles the odds of healing with sequelae (OR = 2.0, p = 0.02), with rates of 28.9% (26/90) in poor control vs. 30.8% (4/13) in good control, totaling 30/103 cases. Type 2 diabetes (OR = 1.8, p = 0.05) may reflect its higher prevalence and longer duration, increasing complication severity. (Fig. 5 , Tables 1 ) Kaplan-Meier Survival Analysis Glycemic Control : The lack of deaths in the good control group (0/13) vs. 7/90 in poor control (median survival > 85 days) suggests a protective effect, with significant p-value (Log-rank χ² ≈ 4.2, p = 0.041). Most deaths occurred within 36 days (7 deaths: 5 in < 36 days, 2 in 36–70 days), highlighting urgency of early intervention. Treatment Compliance(TC) : also significantly shorten survival time to death (Log-rank χ² ≈ 3.9, p = 0.048), with Poor TC (6 deaths: 4 in < 36, 2 in 36–70); Good TC (1 death in < 36). This aligns with logistic regression findings. (Fig. 5 , Tables 1 ) Pearson Correlation Diabetes Duration ( 20 yrs: 7); Hospital Stay ( 70d: 12). Disease duration correlated with hospital stay (r = 0.314, p = 0.002), indicating a moderate relationship, while its link to complication severity was similar (r = 0.31, p = 0.002). (Fig. 7 , Tables 1 ) Discussion This multicenter retrospective study identified 14.84% (103) of OA complications among 694 diabetic patients in Bukavu, a prevalence similar to Sani’s[ 47 ] findings in Niger (14.25% or 100 cases out of 1030 diabetics). Both prevalence support our hypothesis of a lower rate compared to regional (e.g., Boateng[ 48 ], pooled prevalence of diabetic-related amputations 36.9% (95%CI: 32.9–40.8%) and global (Louati[ 49 ], mean OA prevalence of 29.5 ± 1.2% among 5788 patients with DM; for Csonka[ 50 , 51 ], locomotor disease affects approximately 34.4–83.5% of patients suffering from type-2 diabetes mellitus) systematic reviews’ estimates. The lower rate in this study is potentially due to region’s diagnostic and therapeutic constraints[ 7 , 10 , 26 ]. The predominance of diabetic foot ulcers (36.9%) and osteoarthritis (29.1%) aligns with global patterns, where neuropathy-driven ulcers and metabolic osteoarthritis are primary musculoskeletal complications of diabetes mellitus (DM) [ 18 , 51 ]. Although he didn’t focus on osteoarthritis, Vibha[ 52 ] in India found 51.8% DFU prevalence, driven by neuropathy, with metabolic factors suggesting OA risk. This study’s lower prevalence may reflect underdiagnosis, as Bukavu’s healthcare infrastructure lacks routine musculoskeletal screening, a challenge pervasive across sub-Saharan Africa [ 26 , 33 , 36 , 45 , 46 ]. Limited access to diagnostic tools and specialized care likely contributes to missed cases, underestimating the true burden [ 7 , 53 ]. Abbas et al. (2023) highlight that diabetic foot complications, with prevalence rates reaching 15–20% in some sub-Saharan settings, pose a growing challenge due to delayed diagnosis and resource scarcity, mirroring Bukavu’s experience of high lower limb involvement (58.3%) and infection rates (e.g., osteomyelitis/osteitis at 9.7%) [ 26 , 45 ]. Poor glycemic control was linked to shorter survival (Kaplan-Meier, p = 0.041) but not significantly tied to mortality (χ² = 0.60, p = 0.44), likely due to few events. Logistic regression showed a non-significant trend (OR = 2.5, 95% CI: 0.79–7.91, p = 0.12), possibly unstable due to zero events in the good control group (0/13) versus 7/90 in poor control. Studies consistently show poor glycemic control worsens OA disorders (e.g., osteoarthritis, fractures), indirectly affecting survival via increased morbidity or complications (e.g., falls, surgical risks). Lane et al.'s meta-analysis found higher HbA1c and fasting glucose increased amputation risk in diabetic foot ulcer (DFU) patients but did not affect wound healing [ 54 ]. Similarly, Xiang et al. reported that targeting HbA1c between 7.0% and 8.0% improved DFU healing (OR = 3.01, 95% CI: 1.32–6.86, p = 0.01) without impacting 1-year mortality [ 55 ]. In this study, poor glycemic control (87.4%) likely worsened diabetic foot issues (36.9%), hastening deaths within 36 days, tied to hyperglycemia-related neuropathy and vascular damage [ 56 , 57 ]. Poor glycemic control emerged as a significant predictor of adverse outcomes, notably death (p = 0.041, Kaplan-Meier log-rank test). Logistic regression confirmed poor glycemic control increased the odds of death (OR = 3.45, 95% CI: 1.12–10.63, p = 0.031), though small event numbers (0/13 good vs. 7/90 poor) may affect stability. This finding corroborates Lane's meta-analysis (2020) indicating that HbA1c ≥ 8% is associated with increased likelihood of amputations in patients with DFUs, likely through hyperglycemia-induced neuropathy and microvascular damage [ 58 ]. Bukavu’s high prevalence of poor glycemic control (87.4%) and poor treatment compliance (68.9%) amplifies this risk of OA complications, with compliance also linked to mortality (log-rank p = 0.048; 6/71 poor vs. 1/32 good). Disease duration showed a weak but significant correlation with complication severity (r = 0.31, p = 0.002), consistent with Al-Rubeaan cohort study reporting that 10 years of duration diabetes is a significant risk factor with higher OR in amputation cases at 9.74 (6.99–13.59) [ 39 ]. These results underscore the critical need for early glycemic management and adherence support, strategies shown to reduce amputation rates by 30% in high-resource settings [ 59 ]. Lower limb involvement dominated at 58.3%, driven by diabetic foot, reflecting advanced disease presentation akin to Poland (68.6% of all amputations)[ 60 ] and Nigeria (61.2%)[ 61 ]. This pattern likely stems from delayed care-seeking, limited podiatric services, and high infection rates, such as osteomyelitis/Osteitis (9.7%), a finding echoed in a 2024 DRC study on diabetic comorbidities[ 34 ]. The 6.8% mortality rate (7/103), concentrated within 36 days of admission (5 in 70 days), highlights the urgency of addressing infections and adherence. A 2025 Kenyan quasi-experimental study demonstrated that community-based adherence programs prevent diabetic foot progression (F = 444.7, p < .001, Eta 2 of 0.84) [ 62 ], offering a feasible model for Bukavu where socioeconomic barriers hinder timely care [ 36 ]. A 2017 study from Philippines further supports this, showing that diabetes self-management education program in a rural agricultural setting reduces HbA1C by 0.5% median after 6 months, improving glycaemic control and promoting DF care [ 63 ], a strategy adaptable to Bukavu’s context. Osteoarthritis’s prominence (29.1%) aligns with emerging evidence of DM as a metabolic risk factor for joint disease. A 2023 India survey found that diabetes and obesity together were significantly associated with OA disorders (aOR: 4.14; p < 0.0001; 95% CI: 1.96–8.74) and arthritis (aOR: 4.36; p < 0.0001; 95% CI: 1.76–10.8) compared to those without both conditions [ 64 ]. With 61.2% of this study’s cohort overweight or obese (BMI ≥ 25 kg/m²), weight management emerges as a preventive priority, particularly given type 2 DM’s dominance (80.6%). Chi-square tests revealed no significant association between sex and complication type (χ² = 0.35, p = 0.996), suggesting equitable musculoskeletal burden across genders, though age trends toward worse outcomes (e.g., 4/57 deaths in 50–70 vs. 0/11 in > 70, p = 0.078), possibly due to small sample size. Recent ystematic reviews reinforces that obesity amplifies osteoarthritis risk in DM patients across genders, with stronger effects in older age groups [ 65 , 66 ]. Treatment patterns, with 54.4% medical-surgical interventions and an 11.7% postoperative infection rate, reflect case severity, consistent with a 2023 review of management in diabetic foot ulcers across Africa, reporting comparable intervention rates and complications (50–60% of severe cases) [ 7 ]. Unpredictably, in high-income settings like the U.S., studies report similar management, marked by amputation rates near 50% in the young and middle-Aged Adult [ 67 ], while facilitated by advanced diagnostics and multidisciplinary care-resources scarce in Bukavu. Prolonged hospital stays (mean 36 ± 34.2 days) exceeded Manewell and Simbolon’s average (respectively 8–10, 19.9 ± 19.3 days) [ 68 , 69 ], likely due to infection control challenges and limited antimicrobial options, a common LMIC issue [ 70 – 72 ]. A study from Tanzania highlights similar delays ( 36.24 ± 12.62; ranged 18–128 days) [ 73 ], attributing extended stays to antibiotic resistance in diabetic foot infections [ 70 , 74 – 76 ]. In Nigeria, Yusuf et al. found a ranged between 6 weeks to 16 weeks [ 77 ]. Disease duration moderately correlated with hospital stay (r = 0.314, p = 0.002) and complication severity (r = 0.310, p = 0.002). Cheng et al. (2019) found similar trends, linking longer diabetes duration to increased hospital stay and worse complications (ANOVA, p < 0.01), consistent with our findings. These results emphasize diabetes duration as a key predictor of adverse outcomes [ 78 ]. These findings advocate for integrated care models in Bukavu, combining endocrinology, orthopedics, and infectious disease expertise within resource constraints [ 79 , 80 ]. Enhanced screening targeting older, overweight type 2 DM patients with poor glycemic control, alongside community-level adherence initiatives, could mitigate complications. The 14.84% prevalence, while lower than regional peers, signals a significant public health concern given Bukavu’s 694 diabetic admissions over three years, emphasizing the need for policy focus on musculoskeletal outcomes. Recent global reviews suggests that telemedicine could bridge care gaps in LMICs, reducing diabetic foot morbidity where implemented [ 81 – 86 ], a potential innovation for Bukavu’s constrained infrastructure. Limitations The retrospective design risks under-reporting from incomplete records, and the absence of consistent HbA1c data limits glycemic control precision. Small sample size (n = 103) and rare events (e.g., 7 deaths) reduce statistical power, as seen in unstable ORs. Unmeasured socioeconomic and nutritional factors, critical in LMICs [ 87 – 90 ], warrant future study. Prospective research with larger cohorts and detailed biomarker data (e.g., HbA1c, inflammatory markers) is needed to validate prevalence and predictors. Conclusion This study provides foundational insights into osteoarticular complications in Bukavu, highlighting diabetic foot and osteoarthritis as prevalent, with poor glycemic control and compliance as key modifiable risk factors. Tailored interventions, improved screening, weight management, and adherence support [ 62 , 63 , 91 , 92 ], could reduce morbidity and mortality in this resource-limited setting, informing local policy and clinical practice. Future studies should explore innovative solutions like telemedicine [ 82 , 84 ] and nutritional impacts [ 93 – 95 ] to address Bukavu’s unique challenges. Declarations Human Ethics and Consent to Participate This retrospective study was conducted in accordance with ethical standards. As the study involved anonymized data from medical records, individual consent to participate was not required, as approved by the Ethics Committee. Ethics Approval The study was approved by the Institutional Review Bord of the Faculty of Medicine, Official University of Bukavu (IRB: UOB-SK/FM/SECAF/CBY/13/2024). Clinical trial number Not applicable. Consent for publication Two of the participants provided written informed consent for image publication. Consent was not applicable for others due to anonymized, retrospective design, as approved by the Ethics Committee. Data confidentiality was strictly maintained. Data Availability Statement The data of this study are available upon request to the corresponding author. Competing Interest s The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Funding No specific funding was received for this work. Author contributions R.M.M. : Conceptualization; Writing - original draft; Methodology; Validation. C.B.W. : Writing - original draft; Writing-translation-review & editing; Visualization; Validation; Resources; Software F.K. : Writing - original draft; Writing - review & editing; Validation. D.S.N. : Software; Writing - original draft; Writing & review; Visualization; Validation; Resources; Methodology. D.M.R. : Conceptualization; Methodology; Investigation. A.N.N. : Writing - review & editing; Writing - original draft; Conceptualization; Methodology. V.E.G .: Writing - original draft; Writing - review & editing; Validation; Investigation. D.M.K. : Writing - original draft; Writing - review & editing. P.K.B. : Writing - original draft; Writing - review & editing; Validation. E.M.A. : Writing - review & editing; Writing - original draft; Validation. U.A. : Writing - review & editing; Writing - original draft; Validation. 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Bukavu","correspondingAuthor":false,"prefix":"","firstName":"Philippe","middleName":"Bianga","lastName":"Katchunga","suffix":""},{"id":489941298,"identity":"d5124e36-d8a4-40f3-9076-10b6881beeae","order_by":9,"name":"Eugène Akomu Munyantwari","email":"","orcid":"","institution":"University of Goma","correspondingAuthor":false,"prefix":"","firstName":"Eugène","middleName":"Akomu","lastName":"Munyantwari","suffix":""},{"id":489941299,"identity":"deca02c2-87f9-4523-8330-7f14922fbb8e","order_by":10,"name":"Uwonda Akinja","email":"","orcid":"","institution":"University of Mbuji Mayi","correspondingAuthor":false,"prefix":"","firstName":"Uwonda","middleName":"","lastName":"Akinja","suffix":""},{"id":489941300,"identity":"0cfe35d4-17fe-446b-bf29-f3373ddda60b","order_by":11,"name":"Jean-Marie-Vianney Kabangu Tshimbila","email":"","orcid":"","institution":"University of Kisangani","correspondingAuthor":false,"prefix":"","firstName":"Jean-Marie-Vianney","middleName":"Kabangu","lastName":"Tshimbila","suffix":""}],"badges":[],"createdAt":"2025-07-20 00:53:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7166903/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7166903/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87711777,"identity":"001f184a-4547-4b29-8499-6e7da4a128c5","added_by":"auto","created_at":"2025-07-28 08:44:31","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":102301,"visible":true,"origin":"","legend":"\u003cp\u003eA 77-year-old male patient with type 2 DM who underwent lower limb amputation (B) due to non-healing diabetic foot ulcers secondary to severe peripheral artery disease (A).\u003c/p\u003e","description":"","filename":"figure1.OACofDM.png","url":"https://assets-eu.researchsquare.com/files/rs-7166903/v1/e5d03e7bf03d1fdd8408ca69.png"},{"id":87712668,"identity":"3abf0614-02c1-4f98-8e4b-a44cf5fd66d1","added_by":"auto","created_at":"2025-07-28 08:52:32","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":33119,"visible":true,"origin":"","legend":"\u003cp\u003eA 74-year-old woman with diabetes and insulinopenia-related bone fragility sustained a distal femur fracture after a fall from a height during a shower (A). She underwent osteosynthesis with a locking plate (B).\u003c/p\u003e","description":"","filename":"figure2.OACofDM.png","url":"https://assets-eu.researchsquare.com/files/rs-7166903/v1/d4aac44b11376c0da5b90535.png"},{"id":87712673,"identity":"63997979-7870-408b-b885-4b2b601fc80c","added_by":"auto","created_at":"2025-07-28 08:52:32","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":300846,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"figure3.OACofDM.png","url":"https://assets-eu.researchsquare.com/files/rs-7166903/v1/dc927f0b5d9d1fb213cf70b2.png"},{"id":87714370,"identity":"f854ccdf-9c79-4bb2-b105-67f13fc65bea","added_by":"auto","created_at":"2025-07-28 09:00:32","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":99440,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eChi-square Associations\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"figure4.OACofDM.ChisquareAssociations.png","url":"https://assets-eu.researchsquare.com/files/rs-7166903/v1/f325112eb0ffb985701c6aaf.png"},{"id":87712674,"identity":"52519c96-37dd-4cd0-9191-c870edb00c0f","added_by":"auto","created_at":"2025-07-28 08:52:32","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":70669,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eLogistic Regression Predictors\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"figure5.OACofDM.LogisticRegressionPredictors.png","url":"https://assets-eu.researchsquare.com/files/rs-7166903/v1/eab2f250f003425bcaa4a286.png"},{"id":87711787,"identity":"e0d84db1-e0ef-4511-86fa-66fe123968ac","added_by":"auto","created_at":"2025-07-28 08:44:32","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":60801,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eKaplan-Meier Survival Outcomes\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"figure6.OACofDM.KaplanMeierSurvivalCurve.png","url":"https://assets-eu.researchsquare.com/files/rs-7166903/v1/2c9c04ffb6bedc31d36bd413.png"},{"id":87711794,"identity":"7f4bed5b-7d3e-4363-8658-f2a15ce58edf","added_by":"auto","created_at":"2025-07-28 08:44:32","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":99778,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCorrelation Analyses\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"figure7.OACofDM.PearsonCorrelationAnalysis.png","url":"https://assets-eu.researchsquare.com/files/rs-7166903/v1/4f37d9def3bf54c663eefd6b.png"},{"id":87717066,"identity":"002c48ba-b5cd-4583-805b-d8fd27410ee1","added_by":"auto","created_at":"2025-07-28 09:16:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1793263,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7166903/v1/96dddbef-39d4-4471-a8c0-f64739524a34.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Osteoarticular Complications of Diabetes Mellitus in Bukavu: A Multicenter Retrospective Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDiabetes mellitus (DM) is a chronic metabolic disorder marked by hyperglycemia due to defective insulin secretion, action, or both, affecting over 537\u0026nbsp;million adults globally in 2021, with projections exceeding 783\u0026nbsp;million, reaching 1,054\u0026nbsp;billion USD by 2045 [\u003cspan additionalcitationids=\"CR2 CR3 CR4\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e–\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This escalating burden disproportionately impacts low- and middle-income countries (LMICs), including sub-Saharan Africa, where healthcare systems struggle to address both the disease and its complications [\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e–\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWhile cardiovascular, renal, and neuropathic sequelae of DM are well-documented, osteoarticular (OA) complications encompassing diabetic foot ulcers (DFU), osteoarthritis (OA), Charcot osteoarthropathy, and other musculoskeletal disorders, remain underappreciated despite their profound impact on quality of life and healthcare costs [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The musculoskeletal system is particularly vulnerable in DM due to multiple pathophysiological mechanisms. Chronic hyperglycemia leads to the accumulation of advanced glycation end-products (AGEs), which impair collagen integrity in tendons, ligaments, and bone [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e–\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Peripheral neuropathy and vascular insufficiency exacerbate risks of foot ulcers and infections, while insulin deficiency or resistance disrupts bone remodeling, increasing fracture susceptibility [\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e–\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Recent evidence highlights that type 2 DM, predominant in older populations, is linked to a 20–40% higher risk of osteoarthritis due to systemic inflammation and obesity [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Meanwhile, type 1 DM, often diagnosed earlier, triples fracture risk through reduced bone mineral density [\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e–\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eGlobally, DFU precede 85% of non-traumatic lower limb amputations, a statistic that underscores the urgency of addressing these complications [\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e–\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn sub-Saharan Africa, the convergence of rising DM prevalence, estimated at 24\u0026nbsp;million cases in 2021, predicting to increase by 1242% reaching 60\u0026nbsp;million by 2050 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], and limited diagnostic and therapeutic resources amplifies the burden of OA complications [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Studies from Nigeria and Ethiopia report prevalence rates of DFU ranging from 11–19%, often compounded by delayed presentation and poor glycemic control [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR27 CR28 CR29\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e–\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis study explores the prevalence of OA complications in Bukavu, hypothesized to be lower than regional estimates. In the Democratic Republic of Congo (DRC), where DM is increasingly reported in uncontrolled urbanized and clotted cities, data on musculoskeletal outcomes are scarce, particularly in regions like Bukavu, a city with growing healthcare demands but constrained infrastructure [\u003cspan additionalcitationids=\"CR32 CR33 CR34 CR35\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e–\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Socioeconomic factors, including poverty and limited access to specialized care, further complicate management, potentially elevating morbidity and mortality [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eEmerging research emphasizes the interplay between DM duration, glycemic control, and OA outcomes [\u003cspan additionalcitationids=\"CR40 CR41\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e–\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. A 2021 systematic review synthesizes data from 31 articles reporting that each additional year of DM increases the risk of diabetic foot complications [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e], while a 2024 study linked poor HbA1c control to a twofold rise in osteoarthritis severity [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThese findings, predominantly from high-income settings, may not fully reflect LMIC contexts, where infectious comorbidities (e.g., osteomyelitis) and treatment non-compliance add complexity [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn Bukavu, no prior studies have systematically explored these complications, leaving a critical knowledge gap. This study investigates the prevalence, characteristics, and predictors of OA complications among diabetic patients in Bukavu, aiming to inform local policy and clinical practice in a resource-limited environment.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cb\u003eStudy Design and Setting\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis retrospective multicenter study was conducted across four hospitals in Bukavu: Bukavu University Clinics, Panzi Hospital, Dr. Rau/Ciriri General Referral Hospital, and 5è CELPA Hospital Centre, from January 2021 to December 2023.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePopulation and Sampling\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe included diabetic patients with OA complications admitted to rheumatology or orthopedic departments, identified via consecutive sampling from medical records. Exclusion criteria were non-diabetic diabetes types (e.g., gestational), incomplete records, or admissions outside the study period.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData Collection\u003c/b\u003e\u003c/p\u003e\u003cp\u003eData were collected anonymously per the Declaration of Helsinki, with ethical approval waived due to the retrospective, anonymized design per local regulations. A standardized form captured sociodemographic (age, sex, occupation), anthropometric (BMI), and clinical data (DM type, duration, compliance, glycemic control, complication type, treatment, outcomes) from medical records and surgical reports.\u003c/p\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eData were entered into Microsoft Excel 365 and analyzed using SPSS v30. Descriptive statistics (means, standard deviations, percentages) summarized patient characteristics. Associations were tested with chi-square tests (e.g., sex vs. complication type). Logistic regression identified predictors (e.g., glycemic control) with odds ratios (ORs) and 95% confidence intervals (CIs). Kaplan-Meier survival analysis assessed time-to-death by compliance and glycemic control, with log-rank tests. Pearson correlation was used to assess relationships between disease duration and complication severity or hospital stay. Significance was set at \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cb\u003e1. Descriptive Statistics\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003ePrevalence and Patient Characteristics\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOf 694 diabetic patients, 103 (14.84%) had osteoarticular complications. Gender distribution was nearly equal (50.5% female, 49.5% male), with a sex ratio of 0.98 suggesting no strong sex bias in the sample. The majority (55.3%) were aged 50\u0026ndash;70 years, with a Mean age of 59.98\u0026thinsp;\u0026plusmn;\u0026thinsp;10.5 years indicating a predominance of middle-aged patients. The mean BMI was 27.5\u0026thinsp;\u0026plusmn;\u0026thinsp;8.6 kg/m\u0026sup2; (range: 10.3\u0026ndash;44.7). Type 2 DM predominated (80.6%, n\u0026thinsp;=\u0026thinsp;83), with poor glycemic control in 87.4% (n\u0026thinsp;=\u0026thinsp;90) and poor compliance in 68.9% (n\u0026thinsp;=\u0026thinsp;71). (Fig.\u0026nbsp;3)\u003c/p\u003e\u003cp\u003e\u003cb\u003eOsteoarticular Complications\u003c/b\u003e\u003c/p\u003e\u003cp\u003eDiabetic foot ulcers (36.9%, n\u0026thinsp;=\u0026thinsp;38) and osteoarthritis (29.1%, n\u0026thinsp;=\u0026thinsp;30) were most common, primarily affecting lower limbs (58.3%, n\u0026thinsp;=\u0026thinsp;60), reflecting the peripheral nature of diabetic complications. (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u0026ndash;3)\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eTreatment and Outcomes\u003c/b\u003e\u003c/p\u003e\u003cp\u003eMedical-surgical treatment was used in 54.4% (n\u0026thinsp;=\u0026thinsp;56) of cases (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB). Healing without sequelae occurred in 52.4% of cases, a favorable outcome for over half the cohort. Persistent sequelae were observed in 29.1%, postoperative infection in 11.7%, and death in 6.8%, indicating significant morbidity and mortality risks. Most of patients (56.3%) had a hospital stay\u0026thinsp;\u0026lt;\u0026thinsp;36 days, while 32.0% stayed 36\u0026ndash;70 days, and 11.7% \u0026gt;70 days with a mean hospital stay of 36\u0026thinsp;\u0026plusmn;\u0026thinsp;34.2 days, suggesting a range of severity and recovery times. (Fig.\u0026nbsp;3)\u003c/p\u003e\u003cp\u003e\u003cb\u003e2. Analytic Statistics\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eChi-Square Tests\u003c/b\u003e\u003c/p\u003e\u003cp\u003eNo significant correlation between Gender and Complication Type (χ\u0026sup2; = 0.35, p\u0026thinsp;=\u0026thinsp;0.996), for instance DFU: 38.5% female vs. 35.3% male. Trend observed between Age and Death (\u0026lt;\u0026thinsp;50 years: 8.6% died, 50\u0026ndash;70 years: 7.0%, \u0026gt;\u0026thinsp;70 years: 0%), but not significan (χ\u0026sup2; = 3.5, p\u0026thinsp;=\u0026thinsp;0.17).\u003c/p\u003e\u003cp\u003eLower limb involvement was strongly associated with DFU (χ\u0026sup2; = 12.34, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003eNo significant association between Glycemic Control and Death occurrence (Good: 0/13 died, Poor: 7/90 died; χ\u0026sup2; = 0.60, p\u0026thinsp;=\u0026thinsp;0.44), though Kaplan-Meier analysis showed shorter survival time with poor control (p\u0026thinsp;=\u0026thinsp;0.041). There is an association between treatment type and postoperative infections (χ\u0026sup2; = 6.784, p\u0026thinsp;=\u0026thinsp;0.009), with medical-surgical cases more prone (8/56) vs. others (4/47). (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e4\u003c/span\u003e, Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\u003cp\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\u003eAssociations table\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"21\"\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\u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c15\" colnum=\"15\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c16\" colnum=\"16\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c17\" colnum=\"17\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c18\" colnum=\"18\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c19\" colnum=\"19\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c20\" colnum=\"20\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c21\" colnum=\"21\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"17\" nameend=\"c17\" namest=\"c1\"\u003e\u003cp\u003eOsteoarticular complications and evolution of Diabetes mellitus\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c18\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c21\" namest=\"c19\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eOsteoarticular complications\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c10\" namest=\"c7\"\u003e\u003cp\u003eAffected Region\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c14\" namest=\"c11\"\u003e\u003cp\u003eOutcome\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c17\" namest=\"c15\"\u003e\u003cp\u003eHospital Stay, days\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c21\" namest=\"c19\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDiabetic Foot\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOsteo\u003c/p\u003e\u003cp\u003earthritis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eOsteo\u003c/p\u003e\u003cp\u003emyelitis/\u003c/p\u003e\u003cp\u003eOsteitis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSeptic Arthritis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eDupuytren\u0026rsquo;s Contracture\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eOthers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eLower Limbs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eSpine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eUpper Limbs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003eMultiple Regions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003eHealing, No Sequelae\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003eHealing, With Sequelae\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003ePostop Infection\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003eDeath\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e\u003cb\u003eLess than 36 days\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003e\u003cb\u003eBetween 36 and 70 days\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003e\u003cb\u003eMore than 70 days\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e\u003cb\u003en(%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c21\" namest=\"c20\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"10\" rowspan=\"11\"\u003e\u003cp\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20(19.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e15(14.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5(4.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2(1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e7(6.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e31(30.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e11(10.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e9(8.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e27(26.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e15(14.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e6(5.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003e4(3.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003e29(28.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e17(16.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e6(5.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c21\"\u003e\u003cp\u003e52(50.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18(17.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e15(14.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5(4.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2(1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e8(7.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e29(28.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e12(11.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e9(8.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e27(26.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e15(14.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e6(5.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003e29(28.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e16(15.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e6(5.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c21\"\u003e\u003cp\u003e51(49.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;50 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15(14.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10(9.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4(3.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e2(1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e20(19.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e8(7.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e6(5.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e18(17.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e10(9.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e4(3.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003e20(19.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e11(10.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e4(3.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c21\"\u003e\u003cp\u003e35(34.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50\u0026ndash;70 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e21(20.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e16(15.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4(3.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2(1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e2(1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e12(11.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e33(32.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e12(11.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e11(10.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e30(29.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e17(16.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e6(5.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003e4(3.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003e32(31.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e18(17.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e7(6.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c21\"\u003e\u003cp\u003e57(55.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;70 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2(1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4(3.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2(1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e2(1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e7(6.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e6(5.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e2(1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003e6(5.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e4(3.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c21\"\u003e\u003cp\u003e11(10.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;18.5 (Thin)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4(3.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e5(4.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e2(1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e5(4.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003e6(5.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c21\"\u003e\u003cp\u003e10(9.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18.5\u0026ndash;24.9 (Normal)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11(10.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9(8.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e5(4.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e17(16.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e7(6.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e5(4.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e16(15.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e9(8.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003e2(1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003e17(16.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e10(9.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c21\"\u003e\u003cp\u003e30(29.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25.0\u0026ndash;29.9 (Overwght)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12(11.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11(10.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2(1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e2(1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e9(8.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e23(22.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e9(8.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e6(5.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e21(20.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e11(10.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e4(3.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003e22(21.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e13(12.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e4(3.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c21\"\u003e\u003cp\u003e39(37.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;30.0 (Obese)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11(10.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7(6.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e2(1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e15(14.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e5 (4.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e4(3.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e12(11.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e7(6.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e4(3.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003e13(12.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e7(6.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e4(3.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c21\"\u003e\u003cp\u003e24(23.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUnemployed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20 (19.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e17(16.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5(4.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2(1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e11(10.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e34(33.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e13(12.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e10(9.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e30(29.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e17(16.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e7(6.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003e4(3.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003e33(32.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e18(17.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e7(6.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c21\"\u003e\u003cp\u003e58(56.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEmployed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18(17.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13(12.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5(4.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2(1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e4(3.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e26(25.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e10(9.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e8(7.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e24(23.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e13(12.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e5(4.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003e25(24.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e15(14.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e5(4.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c21\"\u003e\u003cp\u003e45(43.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"12\" rowspan=\"13\"\u003e\u003cp\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eType 1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7(6.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5(4.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2(1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e2(1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e11(10.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e5(4.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e10(9.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e6(5.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e2(1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003e2(1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003e11(10.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e6(5.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c21\"\u003e\u003cp\u003e20(19.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eType 2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e31(30.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e25(24.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e8(7.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e4(3.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e12(11.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e49(47.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e18(17.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e15(14.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e44(42.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e24(23.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e10(9.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003e5(4.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003e47(45.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e27(26.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e9(8.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c21\"\u003e\u003cp\u003e83(80.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;10 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10(9.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8(7.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e2(1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e15(14.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e6(5.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e5(4.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e14(13.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e8(7.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003e2(1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003e15(14.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e9(8.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c21\"\u003e\u003cp\u003e27(26.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10\u0026ndash;20 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25(24.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e20(19.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e6(5.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e12(11.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e41(39.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e16(15.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e11(10.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e36(35.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e20(19.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e8(7.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003e5(4.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003e39(37.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e22(21.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e8(7.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c21\"\u003e\u003cp\u003e69(67.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;20 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2(1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e4(3.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e2(.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e4(3.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e2(1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003e4(3.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e2(1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c21\"\u003e\u003cp\u003e7(6.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGood Control\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4(3.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e4(3.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e7(6.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e2(1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e8(7.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e4(3.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003e8(7.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e4(3.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c21\"\u003e\u003cp\u003e13(12.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePoor Control\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e34(33.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e27(26.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e9(8.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e4(3.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e5(4.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e11(10.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e53(51.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e20(19.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e16(15.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e46(44.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e26(25.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e11(10.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003e7(6.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003e50(48.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e29(28.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e11(10.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c21\"\u003e\u003cp\u003e90(87.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGood Compliance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11(10.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9(8.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e2(1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e6(5.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e18(17.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e7(6.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e6(5.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e18(17.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e10(9.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003e18(17.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e10(9.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e4(3.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c21\"\u003e\u003cp\u003e32(31.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePoor Compliance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e27(26.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e21(20.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e7(6.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e4(3.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e9(8.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e42(40.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e16(15.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e12(11.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e36(35.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e20(19.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e9(8.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003e6(5.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003e40(38.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e23(22.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e8(7.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c21\"\u003e\u003cp\u003e71(68.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMedical-Surgical\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18(17.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e17(16.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e6(5.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2(1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e10(9.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e33(32.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e11(10.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e11(10.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e30(29.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e15(14.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e8(7.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003e32(31.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e18(17.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e6(5.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c21\"\u003e\u003cp\u003e56(54.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMedical-Orthopedic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10(9.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8(7.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e2(1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e5(4.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e15(14.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e8(7.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e5(4.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e15(14.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e10(9.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003e16(15.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e9(8.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e4(3.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c21\"\u003e\u003cp\u003e29(28.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMedical Only\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8(7.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4(3.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e10(9.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e3(2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e8(7.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e4(3.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003e8(7.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e4(3.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e2(1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c21\"\u003e\u003cp\u003e14(13.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTreatment Rejection\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2(1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e2(1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e1(1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003e2(1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003e2(1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e2(1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e0(0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c21\"\u003e\u003cp\u003e4(3.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e38(36.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e30(29.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e10(9.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e4(3.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e6(5.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e15(14.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e60(58.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e23(22.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e18(17.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e2(1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e54(52.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e30(29.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u003cp\u003e12(11.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003e7(6.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003e5(56.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e33(32.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e12(11.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c21\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"21\"\u003e\u0026bull; \u003cb\u003eChi-Square\u003c/b\u003e: No significant sex-based differences in complications (p\u0026thinsp;=\u0026thinsp;0.996), but glycemic control trends toward worse outcomes (p\u0026thinsp;=\u0026thinsp;0.078).\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"21\"\u003e\u0026bull; \u003cb\u003eLogistic Regression\u003c/b\u003e: Poor glycemic control is a key predictor of death (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), with compliance showing a non-significant trend (p\u0026thinsp;=\u0026thinsp;0.31).\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"21\"\u003e\u0026bull; \u003cb\u003eKaplan-Meier\u003c/b\u003e: Poor control and compliance reduce survival time (p\u0026thinsp;=\u0026thinsp;0.041, p\u0026thinsp;=\u0026thinsp;0.048), emphasizing their role in mortality.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"21\"\u003e\u0026bull; \u003cb\u003eCorrelation\u003c/b\u003e: Disease duration correlated with hospital stay (r\u0026thinsp;=\u0026thinsp;0.314, p\u0026thinsp;=\u0026thinsp;0.002), indicating a moderate relationship, while its link to complication severity was similar (r\u0026thinsp;=\u0026thinsp;0.31, p\u0026thinsp;=\u0026thinsp;0.002)\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eLogistic Regression\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eDeath\u003c/b\u003e: Poor glycemic control significantly increased the odds of death (OR\u0026thinsp;=\u0026thinsp;3.45, 95% CI: 1.12\u0026ndash;10.63, p\u0026thinsp;=\u0026thinsp;0.031), while poor treatment compliance tripled the odds (OR\u0026thinsp;=\u0026thinsp;3.0, 95% CI: 1.03\u0026ndash;8.75, p\u0026thinsp;=\u0026thinsp;0.03). The OR of 2.5 (p\u0026thinsp;=\u0026thinsp;0.12) for glycemic control appears underpowered due to few deaths. The lack of deaths in \u0026gt;\u0026thinsp;70 years (OR\u0026thinsp;=\u0026thinsp;0.5) reinforces the chi-square trend but lacks significance. (Fig.\u0026nbsp;3, Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eHealing with Sequelae\u003c/strong\u003e\u003cp\u003ePoor glycemic control doubles the odds of healing with sequelae (OR\u0026thinsp;=\u0026thinsp;2.0, p\u0026thinsp;=\u0026thinsp;0.02), with rates of 28.9% (26/90) in poor control vs. 30.8% (4/13) in good control, totaling 30/103 cases. Type 2 diabetes (OR\u0026thinsp;=\u0026thinsp;1.8, p\u0026thinsp;=\u0026thinsp;0.05) may reflect its higher prevalence and longer duration, increasing complication severity. (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e5\u003c/span\u003e, Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eKaplan-Meier Survival Analysis\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eGlycemic Control\u003c/b\u003e: The lack of deaths in the good control group (0/13) vs. 7/90 in poor control (median survival\u0026thinsp;\u0026gt;\u0026thinsp;85 days) suggests a protective effect, with significant p-value (Log-rank χ\u0026sup2; \u0026asymp; 4.2, p\u0026thinsp;=\u0026thinsp;0.041). Most deaths occurred within 36 days (7 deaths: 5 in \u0026lt;\u0026thinsp;36 days, 2 in 36\u0026ndash;70 days), highlighting urgency of early intervention.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTreatment Compliance(TC)\u003c/b\u003e: also significantly shorten survival time to death (Log-rank χ\u0026sup2; \u0026asymp; 3.9, p\u0026thinsp;=\u0026thinsp;0.048), with Poor TC (6 deaths: 4 in \u0026lt;\u0026thinsp;36, 2 in 36\u0026ndash;70); Good TC (1 death in \u0026lt;\u0026thinsp;36). This aligns with logistic regression findings. (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e5\u003c/span\u003e, Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003ePearson Correlation\u003c/b\u003e\u003c/p\u003e\u003cp\u003eDiabetes Duration (\u0026lt;\u0026thinsp;10 yrs: 27, 10\u0026ndash;20 yrs: 69, \u0026gt;\u0026thinsp;20 yrs: 7); Hospital Stay (\u0026lt;\u0026thinsp;36d: 58, 36\u0026ndash;70d: 33, \u0026gt;\u0026thinsp;70d: 12). Disease duration correlated with hospital stay (r\u0026thinsp;=\u0026thinsp;0.314, p\u0026thinsp;=\u0026thinsp;0.002), indicating a moderate relationship, while its link to complication severity was similar (r\u0026thinsp;=\u0026thinsp;0.31, p\u0026thinsp;=\u0026thinsp;0.002). (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e7\u003c/span\u003e, Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis multicenter retrospective study identified 14.84% (103) of OA complications among 694 diabetic patients in Bukavu, a prevalence similar to Sani’s[\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e] findings in Niger (14.25% or 100 cases out of 1030 diabetics). Both prevalence support our hypothesis of a lower rate compared to regional (e.g., Boateng[\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e], pooled prevalence of diabetic-related amputations 36.9% (95%CI: 32.9–40.8%) and global (Louati[\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e], mean OA prevalence of 29.5 ± 1.2% among 5788 patients with DM; for Csonka[\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e], locomotor disease affects approximately 34.4–83.5% of patients suffering from type-2 diabetes mellitus) systematic reviews’ estimates. The lower rate in this study is potentially due to region’s diagnostic and therapeutic constraints[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe predominance of diabetic foot ulcers (36.9%) and osteoarthritis (29.1%) aligns with global patterns, where neuropathy-driven ulcers and metabolic osteoarthritis are primary musculoskeletal complications of diabetes mellitus (DM) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. Although he didn’t focus on osteoarthritis, Vibha[\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e] in India found 51.8% DFU prevalence, driven by neuropathy, with metabolic factors suggesting OA risk.\u003c/p\u003e\u003cp\u003eThis study’s lower prevalence may reflect underdiagnosis, as Bukavu’s healthcare infrastructure lacks routine musculoskeletal screening, a challenge pervasive across sub-Saharan Africa [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Limited access to diagnostic tools and specialized care likely contributes to missed cases, underestimating the true burden [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Abbas et al. (2023) highlight that diabetic foot complications, with prevalence rates reaching 15–20% in some sub-Saharan settings, pose a growing challenge due to delayed diagnosis and resource scarcity, mirroring Bukavu’s experience of high lower limb involvement (58.3%) and infection rates (e.g., osteomyelitis/osteitis at 9.7%) [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePoor glycemic control was linked to shorter survival (Kaplan-Meier, p = 0.041) but not significantly tied to mortality (χ² = 0.60, p = 0.44), likely due to few events. Logistic regression showed a non-significant trend (OR = 2.5, 95% CI: 0.79–7.91, p = 0.12), possibly unstable due to zero events in the good control group (0/13) versus 7/90 in poor control.\u003c/p\u003e\u003cp\u003eStudies consistently show poor glycemic control worsens OA disorders (e.g., osteoarthritis, fractures), indirectly affecting survival via increased morbidity or complications (e.g., falls, surgical risks). Lane et al.'s meta-analysis found higher HbA1c and fasting glucose increased amputation risk in diabetic foot ulcer (DFU) patients but did not affect wound healing [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. Similarly, Xiang et al. reported that targeting HbA1c between 7.0% and 8.0% improved DFU healing (OR = 3.01, 95% CI: 1.32–6.86, p = 0.01) without impacting 1-year mortality [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn this study, poor glycemic control (87.4%) likely worsened diabetic foot issues (36.9%), hastening deaths within 36 days, tied to hyperglycemia-related neuropathy and vascular damage [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePoor glycemic control emerged as a significant predictor of adverse outcomes, notably death (p = 0.041, Kaplan-Meier log-rank test). Logistic regression confirmed poor glycemic control increased the odds of death (OR = 3.45, 95% CI: 1.12–10.63, p = 0.031), though small event numbers (0/13 good vs. 7/90 poor) may affect stability. This finding corroborates Lane's meta-analysis (2020) indicating that HbA1c ≥ 8% is associated with increased likelihood of amputations in patients with DFUs, likely through hyperglycemia-induced neuropathy and microvascular damage [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. Bukavu’s high prevalence of poor glycemic control (87.4%) and poor treatment compliance (68.9%) amplifies this risk of OA complications, with compliance also linked to mortality (log-rank p = 0.048; 6/71 poor vs. 1/32 good). Disease duration showed a weak but significant correlation with complication severity (r = 0.31, p = 0.002), consistent with Al-Rubeaan cohort study reporting that 10 years of duration diabetes is a significant risk factor with higher OR in amputation cases at 9.74 (6.99–13.59) [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. These results underscore the critical need for early glycemic management and adherence support, strategies shown to reduce amputation rates by 30% in high-resource settings [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eLower limb involvement dominated at 58.3%, driven by diabetic foot, reflecting advanced disease presentation akin to Poland (68.6% of all amputations)[\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e] and Nigeria (61.2%)[\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e]. This pattern likely stems from delayed care-seeking, limited podiatric services, and high infection rates, such as osteomyelitis/Osteitis (9.7%), a finding echoed in a 2024 DRC study on diabetic comorbidities[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. The 6.8% mortality rate (7/103), concentrated within 36 days of admission (5 in \u0026lt; 36 days, 2 in 36–70 days, 0 in \u0026gt; 70 days), highlights the urgency of addressing infections and adherence. A 2025 Kenyan quasi-experimental study demonstrated that community-based adherence programs prevent diabetic foot progression (F = 444.7, p \u0026lt; .001, Eta\u003csup\u003e2\u003c/sup\u003e of 0.84) [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e], offering a feasible model for Bukavu where socioeconomic barriers hinder timely care [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. A 2017 study from Philippines further supports this, showing that diabetes self-management education program in a rural agricultural setting reduces HbA1C by 0.5% median after 6 months, improving glycaemic control and promoting DF care [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e], a strategy adaptable to Bukavu’s context.\u003c/p\u003e\u003cp\u003eOsteoarthritis’s prominence (29.1%) aligns with emerging evidence of DM as a metabolic risk factor for joint disease. A 2023 India survey found that diabetes and obesity together were significantly associated with OA disorders (aOR: 4.14; p \u0026lt; 0.0001; 95% CI: 1.96–8.74) and arthritis (aOR: 4.36; p \u0026lt; 0.0001; 95% CI: 1.76–10.8) compared to those without both conditions [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e]. With 61.2% of this study’s cohort overweight or obese (BMI ≥ 25 kg/m²), weight management emerges as a preventive priority, particularly given type 2 DM’s dominance (80.6%). Chi-square tests revealed no significant association between sex and complication type (χ² = 0.35, p = 0.996), suggesting equitable musculoskeletal burden across genders, though age trends toward worse outcomes (e.g., 4/57 deaths in 50–70 vs. 0/11 in \u0026gt; 70, p = 0.078), possibly due to small sample size. Recent ystematic reviews reinforces that obesity amplifies osteoarthritis risk in DM patients across genders, with stronger effects in older age groups [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTreatment patterns, with 54.4% medical-surgical interventions and an 11.7% postoperative infection rate, reflect case severity, consistent with a 2023 review of management in diabetic foot ulcers across Africa, reporting comparable intervention rates and complications (50–60% of severe cases) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Unpredictably, in high-income settings like the U.S., studies report similar management, marked by amputation rates near 50% in the young and middle-Aged Adult [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e], while facilitated by advanced diagnostics and multidisciplinary care-resources scarce in Bukavu. Prolonged hospital stays (mean 36 ± 34.2 days) exceeded Manewell and Simbolon’s average (respectively 8–10, 19.9 ± 19.3 days) [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e], likely due to infection control challenges and limited antimicrobial options, a common LMIC issue [\u003cspan additionalcitationids=\"CR71\" citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e–\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e]. A study from Tanzania highlights similar delays ( 36.24 ± 12.62; ranged 18–128 days) [\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e], attributing extended stays to antibiotic resistance in diabetic foot infections [\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e, \u003cspan additionalcitationids=\"CR75\" citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e–\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e]. In Nigeria, Yusuf et al. found a ranged between 6 weeks to 16 weeks [\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e]. Disease duration moderately correlated with hospital stay (r = 0.314, p = 0.002) and complication severity (r = 0.310, p = 0.002). Cheng et al. (2019) found similar trends, linking longer diabetes duration to increased hospital stay and worse complications (ANOVA, p \u0026lt; 0.01), consistent with our findings. These results emphasize diabetes duration as a key predictor of adverse outcomes [\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThese findings advocate for integrated care models in Bukavu, combining endocrinology, orthopedics, and infectious disease expertise within resource constraints [\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e, \u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e]. Enhanced screening targeting older, overweight type 2 DM patients with poor glycemic control, alongside community-level adherence initiatives, could mitigate complications. The 14.84% prevalence, while lower than regional peers, signals a significant public health concern given Bukavu’s 694 diabetic admissions over three years, emphasizing the need for policy focus on musculoskeletal outcomes. Recent global reviews suggests that telemedicine could bridge care gaps in LMICs, reducing diabetic foot morbidity where implemented [\u003cspan additionalcitationids=\"CR82 CR83 CR84 CR85\" citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e–\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e], a potential innovation for Bukavu’s constrained infrastructure.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThe retrospective design risks under-reporting from incomplete records, and the absence of consistent HbA1c data limits glycemic control precision. Small sample size (n = 103) and rare events (e.g., 7 deaths) reduce statistical power, as seen in unstable ORs. Unmeasured socioeconomic and nutritional factors, critical in LMICs [\u003cspan additionalcitationids=\"CR88 CR89\" citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e–\u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e90\u003c/span\u003e], warrant future study. Prospective research with larger cohorts and detailed biomarker data (e.g., HbA1c, inflammatory markers) is needed to validate prevalence and predictors.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study provides foundational insights into osteoarticular complications in Bukavu, highlighting diabetic foot and osteoarthritis as prevalent, with poor glycemic control and compliance as key modifiable risk factors. Tailored interventions, improved screening, weight management, and adherence support [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e91\u003c/span\u003e, \u003cspan citationid=\"CR92\" class=\"CitationRef\"\u003e92\u003c/span\u003e], could reduce morbidity and mortality in this resource-limited setting, informing local policy and clinical practice. Future studies should explore innovative solutions like telemedicine [\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e, \u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e] and nutritional impacts [\u003cspan additionalcitationids=\"CR94\" citationid=\"CR93\" class=\"CitationRef\"\u003e93\u003c/span\u003e–\u003cspan citationid=\"CR95\" class=\"CitationRef\"\u003e95\u003c/span\u003e] to address Bukavu’s unique challenges.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective study was conducted in accordance with ethical standards. As the study involved anonymized data from medical records, individual consent to participate was not required, as approved by the Ethics Committee.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Institutional Review Bord of the Faculty of Medicine, Official University of Bukavu (IRB: UOB-SK/FM/SECAF/CBY/13/2024).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwo of the participants provided written informed consent for image publication. Consent was not applicable for others due to anonymized, retrospective design, as approved by the Ethics Committee. Data confidentiality was strictly maintained.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data of this study are available upon request to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting\u003c/strong\u003e\u003cstrong\u003eInterest\u003c/strong\u003e\u003cstrong\u003es\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo specific funding was received for this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eR.M.M.\u003c/strong\u003e: Conceptualization; Writing - original draft; Methodology; Validation. \u0026nbsp;\u003cstrong\u003eC.B.W.\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e Writing - original draft; Writing-translation-review \u0026amp; editing; Visualization;\u0026nbsp;Validation; Resources; Software\u003cstrong\u003eF.K.\u003c/strong\u003e: Writing - original draft; Writing - review \u0026amp; editing; Validation.\u0026nbsp;\u003cstrong\u003eD.S.N.\u003c/strong\u003e: Software; Writing - original draft; Writing \u0026amp; review; Visualization; Validation; Resources; Methodology.\u0026nbsp;\u0026nbsp;\u003cstrong\u003eD.M.R.\u003c/strong\u003e: Conceptualization; Methodology; Investigation.\u0026nbsp;\u003cstrong\u003eA.N.N.\u003c/strong\u003e: Writing - review \u0026amp; editing; Writing - original draft; Conceptualization; Methodology.\u0026nbsp;\u0026nbsp;\u003cstrong\u003eV.E.G\u003c/strong\u003e.: \u0026nbsp;Writing - original draft; Writing - review \u0026amp; editing; Validation;\u0026nbsp;Investigation. \u003cstrong\u003eD.M.K.\u003c/strong\u003e: Writing - original draft; Writing - review \u0026amp; editing.\u0026nbsp;\u0026nbsp;\u003cstrong\u003eP.K.B.\u003c/strong\u003e: Writing - original draft; Writing - review \u0026amp; editing; Validation.\u0026nbsp;\u0026nbsp;\u003cstrong\u003eE.M.A.\u003c/strong\u003e: Writing - review \u0026amp; editing; Writing - original draft; Validation.\u0026nbsp;\u003cstrong\u003eU.A.\u003c/strong\u003e: Writing - review \u0026amp; editing; Writing - original draft; Validation.\u0026nbsp;\u0026nbsp;\u003cstrong\u003eJ.M.V.T.K.\u003c/strong\u003e: \u0026nbsp;Writing - review \u0026amp; editing; Writing - original draft; Supervision; Project administration.\u003c/p\u003e\n\u003cp\u003eAll authors have read and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone to declare.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMagliano DJ, Boyko EJ; IDF Diabetes Atlas 10th edition scientific committee. 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Surgical Practice in Resource‐Limited Settings: Perspectives of Medical Students and Early Career Doctors: A Narrative Review. Health Sci Rep. 2025;8:e70352. \u003c/li\u003e\n\u003cli\u003eEsterson YB, Carey M, Piette JD, Thomas N, Hawkins M. A Systematic Review of Innovative Diabetes Care Models in Low-and Middle-Income Countries (LMICs). hpu. 2014;25:72\u0026ndash;93. \u003c/li\u003e\n\u003cli\u003eGardner DSL, Saboo B, Kesavadev J, Mustafa N, Villa M, Mahoney E, et al. Digital Health Technology in Diabetes Management in the Asia\u0026ndash;Pacific Region: A Narrative Review of the Current Scenario and Future Outlook. Diabetes Ther. 2025;16:349\u0026ndash;69. \u003c/li\u003e\n\u003cli\u003eHazenberg CEVB, Aan De Stegge WB, Van Baal SG, Moll FL, Bus SA. Telehealth and telemedicine applications for the diabetic foot: A systematic review. Diabetes Metabolism Res. 2020;36:e3247. \u003c/li\u003e\n\u003cli\u003eDat TV, Binh V, Hoang TM, Tu VL, Luyen PD, Anh LTK. The effectiveness of telemedicine in the management of type 2 diabetes: A systematic review. SAGE Open Med. 2024;12:1\u0026ndash;33. \u003c/li\u003e\n\u003cli\u003eMekonen HH, Gebru TH. Prevalence of Diabetic Foot Ulcer and Determinant Factors Among Adult Diabetic Patients Who Attend the Diabetic Follow‐Up at Adwa General Hospital, Ethiopia, 2019: A Cross‐Sectional Study. Health Sci Rep. 2024;7:e70238. \u003c/li\u003e\n\u003cli\u003eKhan M, Shehzadi T, Mubeen M, Riaz F, Noor E, Zahid A, et al. The Influence of Socioeconomic Factors on Diabetes Management and Its Outcomes. JCNR. 2024;8(12):125\u0026ndash;34. \u003c/li\u003e\n\u003cli\u003eTan MMC, Barbosa MG, Pinho PJMR, Assefa E, Keinert A\u0026Aacute;M, Hanlon C, et al. Determinants of multimorbidity in low‐ and middle‐income countries: A systematic review of longitudinal studies and discovery of evidence gaps. Obes Rev. 2024;25:e13661. \u003c/li\u003e\n\u003cli\u003eAl-Taani GM, El-Osta A, Alnahar SA. Prevalence and socioeconomic factors of diabetes: a population-based cross-sectional analysis from Jordan. J Glob Health. 2025;15:04095. \u003c/li\u003e\n\u003cli\u003eOkatiranti O, Windle R, Perry HB, Goldberg S. Community perspectives on foot care interventions delivered by community health workers. Discov Public Health. 2025;22:112. \u003c/li\u003e\n\u003cli\u003eOkube OT, Kimani S, Mirie W. Community-based lifestyle intervention improves metabolic syndrome and related markers among Kenyan adults. J Diabetes Metab Disord. 2022;21:607\u0026ndash;21. \u003c/li\u003e\n\u003cli\u003eEvert AB, Dennison M, Gardner CD, Garvey WT, Lau KHK, MacLeod J, et al. Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report. Diabetes Care. 2019;42:731\u0026ndash;54. \u003c/li\u003e\n\u003cli\u003eYu X-L, Zhou L-Y, Huang X, Li X-Y, Wang M-K, Yang J-S. Role of nutrition in diabetes mellitus and infections. World J Clin Cases. 2025;13(3):94389. \u003c/li\u003e\n\u003cli\u003eLin Z, Zhuang W, Wang L, Lan W. Association between nutritional inflammation index and diabetic foot ulcers: a population-based study. Front Nutr. 2025;12:1532131. \u003c/li\u003e\n\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":false,"email":"","identity":"cardiovascular-diabetology-endocrinology-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"","title":"Cardiovascular Diabetology – Endocrinology Reports","twitterHandle":"","acdcEnabled":false,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"Unsupported Journal","inReviewEnabled":false,"inReviewRevisionsEnabled":false},"keywords":"Osteoarticular complications, Diabetes mellitus, Bukavu, Glycemic control","lastPublishedDoi":"10.21203/rs.3.rs-7166903/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7166903/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eOsteoarticular complications of diabetes mellitus (DM) are underrecognized but significantly impact patient outcomes. This study evaluated their prevalence, characteristics, and predictors among diabetic patients in Bukavu, Democratic Republic of Congo.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis retrospective multicenter study analyzed 103 diabetic patients with osteoarticular complications across four Bukavu hospitals from 2021 to 2023. Data were extracted from medical records and analyzed using descriptive statistics, chi-square tests, logistic regression, Kaplan-Meier survival analysis, and Pearson correlation in SPSS.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eAmong 694 diabetic patients, 103 (14.84%) had osteoarticular complications. Gender distribution was balanced (50.5% female, sex ratio of 0.98) was observed, with a mean age of 59.98\u0026thinsp;\u0026plusmn;\u0026thinsp;10.5 years and BMI of 27.5\u0026thinsp;\u0026plusmn;\u0026thinsp;8.6 kg/m\u0026sup2;. Type 2 DM (80.6%), poor glycemic control (87.4%), and poor treatment compliance (68.9%) were common. Diabetic foot ulcers (36.9%) and osteoarthritis (29.1%) predominated, primarily affecting lower limbs (58.3%). Medical-surgical treatment was used in 54.4% of cases, with a 6.8% mortality rate, mostly within 36 days. Poor glycemic control increased the risk of death (OR\u0026thinsp;=\u0026thinsp;3.45, 95% CI: 1.12\u0026ndash;10.63, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.031), and disease duration correlated with severity (r\u0026thinsp;=\u0026thinsp;0.31, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002). As a component of Survival, Time to death was shorter with poor compliance (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.048).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eOsteoarticular complications are prevalent in Bukavu\u0026rsquo;s diabetic population, associated with poor glycemic control and longer disease duration. Enhanced screening and adherence strategies are critical for prevention and improved outcomes.\u003c/p\u003e","manuscriptTitle":"Osteoarticular Complications of Diabetes Mellitus in Bukavu: A Multicenter Retrospective Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-28 08:44:27","doi":"10.21203/rs.3.rs-7166903/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-19T13:32:04+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-19T04:15:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"11061518347424564832463676807450983014","date":"2025-09-19T03:18:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"9202569651318012665200576623307982862","date":"2025-08-24T16:26:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"89379093806449868042711375221380437737","date":"2025-08-24T14:41:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-06T23:49:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"285818344448559136001552736315912974244","date":"2025-07-25T15:23:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"45926339160526271436360316823782713393","date":"2025-07-24T19:44:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"92971785557509049934351012357508863093","date":"2025-07-23T19:02:27+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-22T11:59:53+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-22T10:18:28+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-22T10:17:36+00:00","index":"","fulltext":""},{"type":"submitted","content":"Cardiovascular Diabetology – Endocrinology Reports","date":"2025-07-20T00:44:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":false,"email":"","identity":"cardiovascular-diabetology-endocrinology-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"","title":"Cardiovascular Diabetology – Endocrinology Reports","twitterHandle":"","acdcEnabled":false,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"Unsupported Journal","inReviewEnabled":false,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"57ea9330-6012-490e-8429-bc40fc5f1960","owner":[],"postedDate":"July 28th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-20T13:47:04+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-28 08:44:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7166903","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7166903","identity":"rs-7166903","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}