Process and outcome measures of quality of care at the diabetes outpatient clinic, University College Hospital, Ibadan.

OBJECTIVE: The study aims to assess the quality of care provided at a diabetes outpatient clinic of a tertiary hospital in Nigeria using quality indicators approved by the National Diabetes Quality Improvement Alliance (NDQIA). MATERIALS AND METHODS: The medical records of patients who had visited the clinic at least two times within a 12 months period preceding the index visit were reviewed during a 5 month period. Process measure indicators, approved by the NDQIA (evaluating the functioning of the clinic) and outcome measures, published by the American Diabetes Association, (evaluating the health status of the attending patients) were retrieved from the medical records. RESULTS: The 332 records reviewed showed that the most consistently performed process measures were blood pressure and weight measurement (>90%). Foot examination was done infrequently (10.5%). Less than 50% had at least an annual low-density lipoprotein cholesterol (LDL-C) and hemoglobin A1c testing done. The mean (standard deviation) HbA1C (%), LDL-C (mg/dL) systolic blood pressure (SBP) (mmHg), and diastolic blood pressure (DBP) (mmHg) were 7.6 (2.0), 107.3 (31.5), 134.3 (20.8), 79.5 (11.0), respectively. HbA1C >8.0%, LDL-C >130 mg/dL, SBP >130 mmHg, and DBP >90 mmHg) were observed in 34.8%, 21.1%, 40.4%, and 23.8%, respectively. CONCLUSION: Although the organization of the outpatient services allowed for good performance with regards to "free" services such as blood pressure and weight measurement, it performed suboptimally for foot examinations. Performance indicators that required payment were consistently underperformed. Regular assessment of the quality of care may help in the identification of opportunities for improvement in the organization and delivery of care.

THE metabolic syndrome and accurate cardiovascular risk prediction in persons with type 2 diabetes mellitus.

BACKGROUND: Persons with type 2 DM have a cardiovascular risk 2-4 times that of the normal population. Co-occurrence of metabolic syndrome (MS) with type 2 DM is associated with an increased risk of development of cardiovascular disease. The aim of this study was to determine the prevalence of the MS in patients with type 2 diabetes mellitus and to compare absolute cardiovascular risk in type 2 DM Patients with MS with those without MS. METHODS: Anthropometric measurements and Blood Pressure of 340 eligible patients with type 2 DM recruited into the study were taken. Participants' FPG, FLP and glycated haemoglobin were also estimated. Cardiovascular risk score was calculated using the United Kingdom Prospective Diabetes Study (UKPDS) risk engine. Diagnosis of the MS was the International Diabetes Federation Criteria (IDF). RESULTS: Over 66% participants had MS. The absolute cardiovascular risk score was found to be similar in persons with type 2 DM whether they fulfilled the criteria for diagnosis metabolic syndrome or not. CONCLUSION: The absolute cardiovascular risk score was similar in type 2 DM patients with or without the metabolic syndrome.

Dealing with diabetes-specific emotional distress: A cross-sectional survey of physical activity option.

BACKGROUND: Diabetes-specific emotional distress is common among people with type 2 diabetes due to the complexities associated with care and maintenance of wellness among the patients. Unlike the focus on glycaemic control, literature appears unavailable about how physical activity may help in the control of diabetes-specific emotional distress. This study was conducted to investigate the link between diabetes- specific emotional distress and physical activity. METHODOLOGY: Type 2 diabetes patients (n = 206) were enrolled into this study from two major health care facilities in Ibadan, Southwestern Nigeria. Physical activity was assessed using the International Physical Activity Questionnaire while diabetes-specific emotional distress was assessed using the Problem Areas in Diabetes Questionnaire. Data were analysed using descriptive and inferential statistics at ± 0.05. RESULTS: The participants' mean age was 58.6 12.7 years with 109 (52.9%) reporting low physical activity levels and 182 (88.3%) reporting varying degrees of diabetes- specific emotional distress. Compared to participants with low physical activity, those who reported moderate-to- vigorous physical activity reported a reduced risk of diabetes-specific emotional distress (OR = 0.53; 95% CI = 0.26-0.82). Age, sex and level of education were not associated with the distress. CONCLUSIONS: A substantial proportion of patients with type 2 diabetes reported low physical activity levels and much more reported diabetes-specific emotional distress. Those who reported moderate-to-vigorous physical activity reported a significantly lower risk of diabetes-specific emotional distress. Reduction in. the risk of diabetes-specific emotional distress may be yet another strong point in advocacy for physical activity among patients with type 2 diabetes.

Type 1 diabetes mellitus and Graves' disease in Down's syndrome--a rare combination.

BACKGROUND: Autoimmune diseases including thyroid. disorders, type 1 diabetes and celiac disease are commoner in persons with Down's syndrome compared with the general population. Coexistent type 1 diabetes and hyperthyroidism in Down's syndrome is however not commonly reported in literature. OBJECTIVE: To report a case of a lady presenting with Graves' disease and type 1 diabetes at the same time. CLINICAL PRESENTATION: We report the case of a 22- year-old lady with Down's syndrome who presented with weight loss, polyuria and polydipsia. Physical examination revealed typical dysmorphicfacies of Down's syndrome and a goitre. Laboratory data revealed hyperglycaemia (random plasma glucose-331 mg/dl). She also had biochemical evidence in keeping with hyperthyroidism and markedly elevated thyroid peroxidase antibodies (>1087.0 IU/ml). She improved after rehydration, insulin therapy and antithyroid drugs. CONCLUSION: Coexisting autoimmune diseases may present in patients with Down's syndrome. We advocate for routine screening for diabetes and thyroid dysfunction in ersons with Down's syndrome.

Effectiveness of a structured checklist of risk factors in identifying pregnant women at risk of gestational diabetes mellitus: a cross-sectional study.

BACKGROUND: Gestational diabetes mellitus (GDM) is associated with increased risk of mortality and morbidity for pregnant women and newborns. Identifying pregnant women with risk factors for GDM based on the clinical suspicion is a popular approach. However, the effectiveness of the use of a structured checklist of risk factors is yet to be evaluated. This study assessed the effectiveness of a structured checklist of risk factors in identifying pregnant women at risk of GDM at the University College Hospital, Ibadan. MATERIALS AND METHODS: It was a comparative cross-sectional study implemented in two phases. The first phase (Group A) of the study was a prospective study that involved 530 pregnant women who presented at the booking clinic. A structured checklist containing risk factors was used to identify women at the risk of GDM. The second phase (Group B) was a retrospective study of 530 pregnant women managed 2 years previously who were selected by systematic random technique. RESULTS: The mean age, gestational age at booking, gestational age at delivery and birth weight were 30.2 ± 5.2 years, 21 ± 10.8 weeks, 38.7 ± 2.7 weeks and 3.1 ± 0.7 kg respectively. The prevalence of GDM in Group A and B were 4.9% and 1.6% respectively ( P < 0.05). There was about three fold increase in identification of women at risk of GDM by use of a checklist. CONCLUSION: Identification of women at risk of GDM was approximately 3-4 fold higher with the use of checklist of risk factors. Exhaustive clinical identification with a checklist of risk factors for GDM should be encouraged.

Insulin resistance in Nigerians with essential hypertension.

BACKGROUND: Reports on the association between hypertension and insulin resistance have been inconsistent even though most studies show a definite association. It is also not certain if the association between insulin resistance and hypertension applies to all populations. OBJECTIVE: To determine the prevalence of insulin resistance in hypertensive Nigerians and to examine the association of insulin resistance with hypertension and some anthropometric indices. METHODS: Thirty five adults with essential hypertension and thirty five normotensives were studied. Anthropometric parameters, blood pressure, fasting glucose and insulin were measured. Homeostasis model assessment (HOMA) was used to determine insulin resistance (IR). RESULTS: The hypertensive subjects had significantly higher fasting insulin and HOMA-IR compared with normotensives (p = 0.02 and 0.04) respectively. There were significant correlations between HOMA-IR, BMI, waist and hip circumference in subjects with hypertension. At multiple linear regression, hypertension and body mass index were found to be the only significant predictors of insulin resistance. CONCLUSION: The hypertensives we studied had a higher occurrence of insulin resistance compared to the normotensives. This makes it necessary for persons with hypertensive to have regular screening for diabetes and other categories of glucose intolerance as the increased insulin increases their risk of developing type 2 diabetes mellitus.

Subclinical hypothyroidism unmasked by preeclampsia and ascites.

Subclinical hypothyroidism is an asymptomatic endocrine disorder while hypothyroidism, on the other hand, can present with a wide range of clinical features which may be nonspecific. We describe a case of subclinical hypothyroidism in a 39-year-old pregnant woman presenting with preeclampsia and ascites. Ascitic fluid was found to be exudative as typically found in persons with hypothyroidism presenting with ascites. Treatment with levothyroxine resulted in complete resolution of ascites. The possibility of subclinical and clinical hypothyroidism should be borne in mind when persons with refractory exudative ascites of unknown origin are being investigated. Also, pregnant women with severe preeclampsia will benefit from screening for subclinical and clinical hypothyroidism.

Ultrasound prevalence of gallstone disease in diabetic patients at Ibadan, Nigeria.

BACKGROUND: Gallstones (GS) in the gallbladder (GB) can be responsible for a whole spectrum of disease entities which may lead to a surgical emergency with high mortality. Diabetes mellitus (DM) is a debilitating disease that affects all systems in the body, and literature documents a higher incidence of gallstone disease (GSD) and its complications in diabetics than in the non-diabetic population. Most local studies on the association between GS formation and DM have focused on type 2 diabetics. This study was therefore designed to determine the prevalence of GS in both type 1 and type 2 DM and elucidate the demographic and social factors associated with formation of GS in diabetic patients. MATERIALS AND METHODS: Four hundred diabetic patients aged between 15 and 82 years had abdominal ultrasound to diagnose or exclude the presence of GS. RESULTS: GS was found in 70 (17.5%) of the 400 patients. Positive cases had a male to female ratio of 3:4 and 59 (51.92%) were above the age of 40 years with type 2 DM. Body mass index (BMI) greater than 25 kg/m 2 was seen in 56 (48.3%) patients; smoking and alcohol intake were insignificantly implicated. Jaundice was recorded in 8 (11.4%) while abdominal pain was in 24 (34.3%) patients, and 52 (74.3%) patients of those with GSD had had diabetes for more than 4 years. CONCLUSION: GSD in DM is influenced significantly by age, BMI, and duration of the disease, while gender, social factors, and parity do not influence as strong associated factors.

Undiagnosed diabetes and prediabetes in hypertensive and normotensive adults at the university college hospital, Ibadan, Nigeria.

BACKGROUND: Essential hypertension is associated with an increased incidence of glucose intolerance (prediabetes and type 2 diabetes mellitus) but many persons with glucose intolerance remain undiagnosed for many years. AIMS: To determine the frequency of undiagnosed diabetes and prediabetes in a group of hypertensives and normotensives. METHODS: Anthropometry, blood pressure and standard oral glucose tolerance test (OGTT) were done in adult participants (hypertensive and normotensive controls) newly presenting to a General Outpatient Clinic of the University College Hospital, Ibadan. RESULTS: Using the OGTT, the frequency of undiagnosed diabetes was 10.4% and 4.3% in hypertensives and normotensives respectively (p = 0.031) but was 5.2% and 2.6% in hypertensives and normotensives respectively using fasting plasma glucose (FPG) alone (p=0.308).Using the OGTT, impaired glucose tolerance (IGT) was diagnosed in 32.2% of hypertensives compared to 14.8% of normotensives (p = 0.002) while impaired fasting glucose (IFG) was diagnosed in 5.2% of hypertensive and 2.6% of the normotensives (p = 0.288). After adjusting for hypertension, age, level of education, body mass index and waist circumference, hypertensives and persons with a higher waist circumference had statistically significantly increased odds of having glucose intolerance: hypertension (OR 2.915; 95% CI 1.526-5.556) and waist circumference (OR 1.050; 95% CI 1.010-1.090). CONCLUSION: Diabetes and prediabetes are commoner in hypertensive persons and such persons require close and frequent monitoring for the development of this disease. Screening with both fasting plasma glucose and post glucose load plasma glucose (OGTT) identifies more persons with glucose intolerance than fasting plasma glucose alone.

Ultrasound Prevalence of Gallstone Disease in Diabetic Patients at Ibadan; Nigeria

Background: Gallstones (GS) in the gallbladder (GB) can be responsible for a whole spectrum of disease entities which may lead to a surgical emergency with high mortality. Diabetes mellitus (DM) is a debilitating disease that affects all systems in the body; and literature documents a higher incidence of gallstone disease (GSD) and its complications in diabetics than in the non-diabetic population. Most local studies on the association between GS formation and DM have focused on type 2 diabetics. This study was therefore designed to determine the prevalence of GS in both type 1 and type 2 DM and elucidate the demographic and social factors associated with formation of GS in diabetic patients. Materials and Methods: Four hundred diabetic patients aged between 15 and 82 years had abdominal ultrasound to diagnose or exclude the presence of GS. Results: GS was found in 70 (17.5) of the 400 patients. Positive cases had a male to female ratio of 3:4 and 59 (51.92) were above the age of 40 years with type 2 DM. Body mass index (BMI) greater than 25 kg/m 2 was seen in 56 (48.3) patients; smoking and alcohol intake were insignificantly implicated. Jaundice was recorded in 8 (11.4) while abdominal pain was in 24 (34.3) patients; and 52 (74.3) patients of those with GSD had had diabetes for more than 4 years. Conclusion: GSD in DM is influenced significantly by age; BMI; and duration of the disease; while gender; social factors; and parity do not influence as strong associated factors

Frequent occurrence of high gamma-glutamyl transferase and alanine amino transferase among Nigerian patients with type 2 diabetes.

Liver function tests (LFTs) are commonly deranged in diabetic patients. There is, however, paucity of local data on actual prevalence and pattern of LFTs abnormality among diabetic patients. A case-control study was carried out to study the pattern of LFTs abnormality among patients with type 2 diabetes (DM). Ninety consecutive patients with type 2 diabetes attending Medical Outpatient Clinic of the University College Hospital, Ibadan, and 90 nondiabetic controls with comparable age and sex were recruited into the study. Serum albumin, alanine amino transferase (ALT) and Gamma glutamyl transpeptidase (GGT) were tested in all subjects. Data were analyzed using Student's t-test, chi-square test and Mann-Whitney U. Among the diabetic patients, 70% had at least one deranged LFTs. The ALT and GGT values were significantly higher (52.9 IU/L and 24.3 U/L respectively) in the diabetic group compared to the controls (34.4 IU/L and 9.2 U/L respectively). Also, the most predominant LFT abnormality in diabetic group was isolated elevation of GGT. This study has confirmed the reported common derangement of LFTs in patients with type 2 DM. In addition, isolated elevation of GGT and ALT are common in Nigerian type 2 diabetic patients. There is need for further study to determine the significance of high GGT and ALT in Nigerian type 2 diabetic population.

An unusual case of total maxillary sequestration in a diabetic patient.

Osteomyelitis of the jaw is of relatively low incidence. Maxillary Osteomyelitis is however rare compared with mandibular osteomyelitis. The extensive blood supply and the strut-like bones of the maxilla make it less prone to chronic infections. Systemic conditions that alter the host's resistance such as diabetes mellitus, autoimmune disorders, agranulocytosis, anaemia, especially sickle cell anaemia are predisposing factors for the development of this condition. An unusual case of chronic maxillary osteomyelitis induced by trauma in a diabetic, with subsequent atypical necrotising ulceration of palatal mucosa resulting in total maxillary sequestration is presented.

Perceived family support and blood glucose control in type 2 diabetes

This study aimed to find out if levels of family support are correlated with blood glucose control among Nigerians with type 2 diabetes. One hundred and fifty (150) patients attending the diabetes clinic of the University College Hospital, Ibadan, were assessed for their perception of family support using a validated family support measure. Fasting plasma glucose was used as the index of glycaemic control, and 39% of subjects were rated as having 'strong' perceived family support, while 31% and 11% were rated wth 'weak' and 'no' perceived family support, respectively. Mean fasting plasma glucose was 7.0±2.5 mmol/L, with lower levels of blood glucose in those who perceived their family as supportive, compared with those who perceived their family as unsupportive. Positive family support was found to correlate positively with blood glucose control

Diabetes care in Nigeria: time for a paradigm shift.

Diabetes mellitus is becoming a major public health problem in Africa and its burden is expected to increase. Persons with diabetes mellitus require continuing medical care and self-management education to prevent complications. In both developed and some resource-poor countries, the management of persons with diabetes has been undergoing rapid changes in order to improve standards of care, through restructuring of clinics or through the establishment of diabetes centres with a multidisciplinary team approach to care. There has been a progressive increase in the prevalence of diabetes mellitus in Nigeria and the burden is expected to increase even further. In view of the looming burden of diabetes in Nigeria, there is an urgent need to examine existing healthcare structures, revise the delivery process of healthcare programmes for persons with diabetes and effectively implement a process that facilitates accessibility to such programmes. Well-structured community-based care, appropriate to the local situation and resources, would provide for this, making it more accessible and realistic to the needs of persons with diabetes living in urban and rural areas of Nigeria. Various models have been adopted for the delivery of diabetes care. This article aims to highlight some of these various models of diabetes care. It concludes with a proposed model for the care of persons with diabetes mellitus in Nigeria.

Microalbuminuria and clinical correlates in black African patients with type 2 diabetes.

BACKGROUND: Diabetes mellitus is a major cause of morbidity and mortality as a result of its complications. Long-term complications of diabetes mellitus have been linked to poor glycemic control. Diabetic nephropathy is the leading cause of end stage renal disease in the developed world and third leading cause in Nigeria. Various independent risk factors have been identified as predictors of diabetic nephropathy. One of such factors is urinary albumin excretion. OBJECTIVE: This study set out to determine the prevalence of microalbuminuria (MA), glycemic control and the relationship between urinary albumin excretion (UAE) and other known predictors of diabetic nephropathy in type 2 diabetic patients with disease duration greater than 5 years. STUDY DESIGN: Fifty non-proteinuric patients were selected consecutively for this cross-sectional study. Urinary albumin concentration was determined in a timed overnight urine sample by immunoturbidimetry and glycated haemoglobin was determined using boronate affinity method. Comparison was made between the patients with microalbuminuria and those with normal albumin excretion and the most likely predictors of urinary albumin excretion were determined. RESULTS: Fifty-two percent of the patients studied had good glycaemic control (HbA1c < 7%) while 83% had microalbuminuria (UAE 20-200 mg/min). There was no significant correlation between the UAE and the HbA1c. UAE however correlated significantly with the age and diastolic blood pressure (DBP) of the patients. CONCLUSION: Almost half of the patient population had suboptimal glycemic control. There was a high prevalence of microalbuminuria amongst the patients studied. Significant predictors of UAE in this study were the age of the patients and DBP but not HbA1c.

Unusual presentation of thyrotoxicosis--a case report and review of literature.

BACKGROUND: The majority of patients with thyrotoxicosis are readily diagnosed clinically. It must be accepted however that not every patient presents with the characteristic picture. Thyrotoxicosis occasionally presents in an unknown or atypical fashion in which the diagnosis may not be obvious. CASE REPORT: A 45-year-old woman presented with choreoathetoid movements of the right upper limb, persistent vomiting and generalized body weakness. Over the next few weeks, the clinical picture slowly evolved to give the characteristic symptoms and signs of thyrotoxicosis, which were not evident at presentation. Thyroid function tests revealed elevated serum thyroxine and triiodothyronine as well as low thyroid stimulating hormone concentrations, confirming the diagnosis of thyrotoxicosis. CONCLUSION: This case illustrates unusual initial presenting features of thyrotoxicosis, which long preceded the development of the characteristic and more common manifestations. This led to a delay in the diagnosis. Awareness of these atypical presentations will further assist the physician to make a timely and cost effective diagnosis of this condition.

Glucose and insulin responses in offspring of Nigerian Type 2 diabetics.

Type 2 diabetes mellitus has a strong genetic basis by a concordance rate ranging between 60 and 90% in monozygotic twins. Glucose and insulin responses to an oral glucose load were measured in 52 offspring of Nigerian Type 2 diabetics and 50 control subjects selected to achieve a similar distribution of age and gender. All subject studied were glucose tolerant. In comparison with control subjects, offspring of Type 2 diabetics had a significantly higher mean (SD) (i) fasting plasma glucose level [69.2 (13.0) mg/dl vs. 62.2 (7.6) mg/dl; P = 0.0012] (ii) fasting plasma insulin level [26.6 (15.4) microIU/ml vs 14.8 (6.8) microIU/ml; P < 0.0001] (iii) 2 hours post glucose load plasma insulin level [59.8 (33.9) microIU/ml vs. 40.9 (24.2) microIU/ml; P = 0.0028]. The mean (SD) 2-hour post glucose load plasma glucose level did not differ significantly between both groups of subjects [92.8 (23.8) mg/dl vs. 85.5 (21.3) mg/dl; P = 0.11]. Further multiple regressional analysis showed that the differences in fasting plasma insulin and 2-hour post glucose load insulin observed were only accounted for by the presence of a parental history of diabetes and were not influenced significantly by BMI, waist and hip circumferences. This study shows that offspring of Nigerian Type 2 diabetics have hyperinsulinaemia, despite being glucose tolerant and this supports the insulin-resistance hypothesis for Type 2 DM. This implies that they are at a greater risk for developing diabetes mellitus and are therefore an important group for the primary prevention of Type 2 DM.