Vitamin D Status and Cardiovascular Risk Factors in Patients with Type 2 Diabetes Mellitus: A Cross-Sectional Study in a Tertiary-Level Hospital in Antananarivo, Madagascar.

Background: Diabetes mellitus is already a major cardiovascular risk factor (CRF). Hypovitaminosis D is common in patients with type 2 diabetes mellitus (T2DM). It also increases the cardiovascular risk of these subjects. Objective: To determine the vitamin D status of Malagasy with T2DM seen at the Soavinandriana Hospital Center, and the association between hypovitaminosis D and CRF. Methods: This was a cross-sectional study, carried out over a period of 2 years. Assayed by the chemiluminescence technique, vitamin D was "normal", "insufficient" and "deficient" if the 25-hydroxyvitamin D plasma was ≥30 ng/mL, 20-29 ng/mL and ≤19 ng/mL, respectively. Hypovitaminosis D was the set of vitamin D insufficiency and deficiency. Results: Among the 318 T2DM, the prevalence of hypovitaminosis D was 66.0% (45.2% insufficiency and 20.8% deficiency). Their factors associated were age ≥70 years (OR = 2.15 [1.26-3.66]), glycated haemoglobin ≥7% (4.97 [2.97-8.39]), and retinopathy (OR = 4.15 [1.85-9.32]). After adjustment for age, Hb A1c ≥7% and retinopathy, hypovitaminosis D was associated with hypertension (OR = 8.77 [4.76-16.2]), dyslipidaemia (OR = 8.05 [3.98-14.5]), ex-smoking (OR = 6.07 [2.78-13.3]), microalbuminuria (OR = 2.95 [1.25-6.97]) and carotid atherosclerosis (OR = 2.96 [1.83-4.35]). Conclusion: Hypovitaminosis D was common in T2DM. Its treatment is primarily preventive. It is also important to control associated CRF, diabetes and its complications.

An extensive arterial thrombosis with lower limb ischemia in a COVID-19 patient: A case report.

The coronavirus disease 2019 (COVID-19) pandemic is responsible for huge morbidity and mortality throughout the world. Several serious complications of this disease have been reported. It can cause hypercoagulability, which may lead to venous and arterial thromboembolic diseases. This hypercoagulability state is also associated with high morbidity and mortality. Arterial thrombosis in COVID-19 is poorly described compared to venous thrombosis and pulmonary embolism. We report a case of an extensive arterial thrombosis leading to a limb ischemia with extremely high D-dimer in a COVID-19 patient. A 69-year-old man was hospitalized for febrile dyspnea. He is a hypertensive and diabetic patient. On admission, pulse oxygen saturation was 72% on room air. He had cyanosis of the left foot up to the mid-thigh. The left pedal, posterior tibial, popliteal and femoral pulses were abolished. Chest CT scan was in favor of COVID-19. He has a high D-dimer level of 257,344 ng/mL. Arterial Echo-Doppler found an extensive intraluminal thrombus along the arterial axes of the left lower limb, completely obstructing them, starting from the primitive iliac artery just after its bifurcation with the aorta, and extending distally (external iliac; common femoral; superficial femoral; popliteal; anterior tibial; posterior tibial; fibular and pedal). The patient was diagnosed with COVID-19 critical form, associated with ischemia of the left lower limb secondary to an extensive arterial thrombosis. He was receiving anticoagulation, and underwent surgical amputation of the ischemic limb. The patient survived the event; however, he was on long-term oxygen therapy at home. Arterial thrombosis may occur during COVID-19 and may be responsible for peripheral or central ischemia aggravating morbidity and mortality. The occurrence of these events is related to the D-dimer value. Anticoagulation is an important part of the management of COVID-19, especially in severe forms in order to limit the occurrence of these thromboembolic diseases.

Prevalence and factors associated with carotid atherosclerosis in a Malagasy population with Type 2 diabetes mellitus: A cross-sectional retrospective study.

AIM: Our study aims to determine the prevalence and factors associated with carotid atherosclerosis in Malagasy Type 2 diabetes mellitus (T2DM). METHODS: This was a cross-sectional retrospective study, carried out over a period of 30 months. The diagnosis of carotid atherosclerosis is established by the presence of a carotid plaque increased carotid intima-media thickness ≥1.1 mm on Doppler ultrasound. RESULTS: We included 132 T2DM. The prevalence of carotid atherosclerosis was 63.6% (38.6% carotid plaque and 25% intima-media thickening). After univariate analysis, the factors associated with carotid atherosclerosis were age ≥70 years (3.28 [1.18-10, 62]), previous intake of oral antidiabetics (0.33 [0.14-0.73]), insulin (0.28 [0.11-0.66]) and angiotensin receptor blocker (0.45 [0.20-0.98]), and current smoking (5.93 [1.64-32.6]). After adjustment for age and gender, previous intake of oral antidiabetics (0.29 [0.13-0.64]), insulin (0.27 [0.12-0.61]) and angiotensin receptor blocker (0.40 [0.19-0.86]), and current smoking (5.98 [1.61-22.1]) were associated with carotid atherosclerosis. CONCLUSION: Smoking cessation, education on therapeutic compliance and comprehensive management of all cardiovascular risk factors and T2DM are therefore essential in order to reduce the occurrence of carotid atherosclerosis.

Urinary tract infection in diabetics hospitalized in Befelatanana Hospital, Antananarivo: Epidemiological, clinical, biological profiles and risk factors for multidrug-resistant bacterial infection.

Key Clinical Message: The main type of urinary tract infection in hospitalized diabetics in Antananarivo is acute pyelonephritis; Escherichia coli is the most isolated uropathogen; imipenem, amikacin, fosfomycin and ceftriaxone are the major antibiotics for which Escherichia coli retain good sensitivity; Type 2 diabetes is predictive factor for infection by multidrug resistant bacteria. Abstract: This study aimed to describe the epidemiological-clinical profiles of diabetics hospitalized for bacterial urinary tract infections in the Endocrinology Department of Befelatanana Hospital, to identify the main bacteria responsible, their antibiotic sensitivity profile and the factors associated with multidrug-resistant bacterial infection. A cross-sectional study was conducted between March 2017 and March 2020 involving all diabetics hospitalized for documented community-acquired bacterial urinary tract infection during this period. The hospital prevalence of urinary tract infections was 4.64%. The mean age of the patients was 59.06 ± 14.26 years and the sex ratio was 0.15. The main sign was fever (55.76%). The main clinical form was uncomplicated acute pyelonephritis (38.46%). Fifty-seven bacterial uropathogens were isolated. The most frequent was Escherichia coli (77.19%). Escherichia coli was sensitive to ertapenem and nitrofurantoin in 100% of cases, to Amikacin in 97.5% of cases, to Fosfomycin in 94.4% of cases and to Ceftriaxone in 80.65% of cases. Thirteen patients were infected with multidrug-resistant bacteria, all of them are extended-spectrum beta-lactamase-producing Enterobacteriaceae. Only the type of diabetes was associated with multidrug-resistant bacteria infection. The epidemiological-clinical and biological characteristics of urinary tract infections in our diabetics are similar to those reported in the literature. Compliance with the rules of proper antibiotic use is imperative to limit the emergence and spread of multidrug-resistant bacteria.

A retrospective cohort analysis of people living with HIV/AIDS enrolled in HIV care at a reference center in Antananarivo, Madagascar.

Background: The impact of the "Treat all" policy on the individual and in terms of public health is closely related to early diagnosis and retention in care. Patient-level data are scarce in Madagascar. In this study, we aimed to describe the profile of a cohort of newly diagnosed people living with HIV/AIDS (PLHIV), identify their outcomes, and assess factors associated with attrition from care and advanced HIV disease (AHD) at presentation. Methods: We conducted a retrospective cohort study of PLHIV aged ≥15 years newly diagnosed at the University Hospital Joseph Raseta Befelatanana Antananarivo from 1 January 2010 to 31 December 2016. Results: A total of 490 PLHIV were included in the cohort analysis. In total, 67.1% were male. The median age (interquartile range) at enrollment in care was 29 years (24-38). Overall, 36.1% of PLHIV were diagnosed with AHD at baseline. The proportion of patients with WHO stage IV at baseline increased significantly from 3.3% in 2010 to 31% in 2016 (p = 0.001 for trend). The probability of retention in care after the diagnosis at 12 months, 24 months, and 36 months was 71.8%, 65.5%, and 61.3%, respectively. Age ≥ 40 years (aHR: 1.55; 95% CI: 1.05-2.29; p = 0.026), low level of education (aHR:1.62; 95% CI: 1.11-2.36; p = 0,013), unspecified level of education (aHR:2.18; 95% CI: 1.37-3.47; p = 0.001) and unemployment (aHR:1.52; 95% CI: 1.07-2.16; p = 0.019) were independently associated with attrition from care. Factors associated with AHD at baseline were age ≥ 40 (aOR: 2.77; 95% CI: 1.38-5.57, p = 0.004), unspecified level of education (aOR: 3.80; 95% CI: 1.58-9.16, p = 0.003) and presence of clinical symptoms at baseline (aOR: 23.81; 95% CI: 10.7-52.98; p < 0.001). Sex workers were independently less likely to have an AHD at presentation (aOR: 0.23; 95% CI: 0.05-0.96, p = 0.044). Conclusion: Sociodemographic determinants influenced retention in care more than clinical factors. The presence of clinical symptoms and sociodemographic determinants were the main factors associated with AHD at baseline.

[Epidemiologic-clinical, biological and radiological features of pulmonary tuberculosis in patients with diabetes in Antananarivo, Madagascar]. / Particularités épidémio-cliniques, biologiques et radiologiques de la tuberculose pulmonaire chez les diabétiques à Antananarivo, Madagascar.

Pulmonary tuberculosis is frequently associated with diabetes mellitus and, sometimes, it may present with atypical signs. The purpose of this study is to identify the epidemiological, clinical, biological and radiological features of pulmonary tuberculosis in patients with diabetes versus patients without diabetes in order to improve treatment. We conducted a retrospective, cross-sectional descriptive and analytical study in the Department of Endocrinology and Pneumology at the Joseph Raseta Befelatanana University Hospital Center and in the Department of Respiratory Diseases at the Soavinandriana Hospital Center in Antananarivo, Madagascar. It involved patients diagnosed with pulmonary tuberculosis who presented a positive bacilloscopy exam from January 2018 to January 2020 (25 months). In our study, the overall prevalence of diabetes among TB patients was 20.31 %. Older age, insidious clinical course, severe biologic inflammatory syndrome, fewer caves but more systematized opacities and diffuse radiological lesions in the basal zone (more commonly unilateral right lesions) were mainly detected in patients with diabetes compared to patients without diabetes. Knowledge of signs of pulmonary TB in patients with diabetes can help health care workers to make a diagnosis, even in patients with atypical signs. Moreover, as the majority of pulmonary tuberculosis occur in patients with unstable diabetes, a good glycemic balance can certainly reduce its incidence.

[Characteristics of chest pain in acute coronary syndromes seen in the cardiology department of Befelatanana (Madagascar)]. / Caractéristiques des douleurs thoraciques au cours des syndromes coronariens aigus vus au service de cardiologie de Befelatanana (Madagascar).

INTRODUCTION: Chest pain is one of the different elements of orientation for the diagnosis of acute coronary syndrome. Sometimes its clinical presentation is misleading. The objective of this study was to describe the characteristics of chest pain during an acute coronary syndrome in the cardiology department of the Joseph Raseta Befelatanana University Hospital Center, Antananarivo, Madagascar. METHODS: We carried out a cross-sectional, descriptive study of 10 months from January 2019 to October 2019. All patients diagnosed with acute coronary syndrome during this period were included. RESULTS: Sixty-five cases were included. A "typical chest pain" was only encountered in 7.7% of cases. Advanced age (p = 0.04) and sedentary lifestyle (p = 0.03) were associated with the occurrence of silent myocardial ischemia, and. hypertension with a prolonged duration (≥15 minutes) of chest pain (p = 0.03). Dyslipidemia was associated with atypical irradiation of chest pain (p = 0.003). Alcoholism had an impact on pain triggered by effort (p = 0.01) and relieved by rest (p = 0.04). CONCLUSION: The current symptomatology of acute coronary syndrome is increasingly atypical. Knowledge of the factors that can influence the different characteristics of chest pain could serve as a benchmark in clinical practice in our population.

Clinical and epidemiological features discriminating confirmed COVID-19 patients from SARS-CoV-2 negative patients at screening centres in Madagascar.

Early and fast detection of COVID-19 patients help limit the transmission and wide spread of the virus in the community and will have impact on mortality by reducing the incidence of infection among vulnerable people. Therefore, community-based screening is critical. We aimed to identify clinical signs and symptoms and epidemiological features that could help discriminate confirmed cases of COVID-19 from SARS-CoV-2 negative patients. We found that age (aOR:1.02, 95%CI:1.02-1.03, p < 0.001), symptoms onset between 3 and 14 days (aOR:1.35, 95%CI:1.09)1.68, p = 0.006), fever or history of fever (aOR:1.75, 95%CI:1.42-2.14, p < 0.001), cough (aOR:1.68, 95%CI:1.31-2.04), sore throat (aOR:0.65, 95%CI:0.49-0.85, p = 0.002), ageusia (aOR:2.24, 95%CI:1.42-3.54, p = 0.001), anosmia (aOR:6.04, 95%CI:4.19-8.69, p < 0.001), chest pain (aOR:0.63, 95%CI:0.47-0.85, p = 0.003), myalgia and/or arthralgia (aOR:1.64, 95%CI:1.31-2.04, p < 0.001), household cluster (aOR:1.49, 95%CI:1.17-1.91, p = 0.001) and evidence of confirmed cases in the neighbourhood (aOR:1.92, 95%CI:1.56-2.37, p < 0.001) could help discriminate COVID-19 patients from SARS-CoV-2 negative. A screening score derived from multivariate logistic regression was developed to assess the probability of COVID-19 in patients. We suggest that a patient with a score ≥14 should undergo SARS-CoV-2 PCR testing. A patient with a score ≥30 should be considered at high risk of COVID-19 and should undergo testing but also needs prompt isolation and contact tracing.

Knowledge, attitudes, perception and practices regarding antiretroviral therapy among HIV-infected adults in Antananarivo, Madagascar: a cross-sectional survey.

BACKGROUND: Adherence to antiretroviral therapy (ART) may be influenced by knowledge, perception and perception regarding ART. The purpose of this study was to assess knowledge, attitude/perception and practice regarding ART among people living with HIV/AIDS (PLHIV). METHODS: We conducted a cross-sectional survey to assess knowledge, attitudes, perception and practices ART in PLHIV. The survey was suggested to all PLHIV of at least 18 years old and who were on ART for at least 1 month. PLHIV who were unable to answer questions correctly and those who did not complete the survey for any reason were excluded. RESULTS: During the study period, 234 PLHIV were included. Participants were mostly men (75.2%). The median age was 33 years (IQR: 27-41). The median time since HIV diagnosis was 25 months (IQR: 9-56) and the median duration of ART was 18 months (IQR: 8-48). 87.6% had an overall good knowledge of ART. However, only 3.2% knew the name of their ART, 31.2% were aware that ART should be taken at a fixed time and 17.1% knew how to take ART in relation to food intake. 75.6% of participants had an overall positive attitude/perception of ART. However, 10.7% were convinced that other methods were more effective than ART for treating HIV and 42.7% thought that taking ART was shameful. The assessment of practices showed that in case of missed dose, 48.3% of participants routinely skipped this dose instead of trying to take it as soon as possible. In multivariate analysis, good knowledge of ART was independently associated with high level of education (aOR: 4.7, IC95%: 1.6-13.7, p = 0.004) and disclosure of HIV status (aOR: 2.7, IC95%: 1.1-6.6, p = 0.029). CONCLUSIONS: This study showed an overall good knowledge and a predominantly positive attitude/perception of ART. However, accurate knowledge of ART intake was insufficient and the stigma associated with taking ART remained very present. Furthermore, very heterogeneous practices may reflect lack of instruction given by the physician regarding ART intake.

Hospitalization of HIV positive patients in a referral tertiary care hospital in Antananarivo Madagascar, 2010-2016: Trends, causes and outcome.

BACKGROUND: During the last few years, significant efforts have been made to improve access to antiretroviral therapy which led to dramatic reduction in AIDS-related events and mortality in HIV positive patients at the global level. However, current data in Africa suggested modest impact of widespread antiretroviral therapy scale-up especially regarding HIV-related hospitalization. In this study, we aimed to describe causes of hospitalization and factors associated with AIDS-defining events and inpatient mortality. MATERIALS AND METHODS: A retrospective study was performed on medical records of HIV positive patients admitted for at least 24 hours in the Infectious Diseases Unit of the University Hospital Joseph Raseta Befelatanana Antananarivo. Cause of hospitalization was considered as the main diagnosis related to the symptoms at admission. Diagnostic criteria were based on criteria described in WHO guidelines. AIDS-defining events were defined as diseases corresponding to WHO stage 4 or category C of CDC classification. RESULTS: From 2010 to 2016, 236 hospital admissions were included. AIDS-defining events were the most frequent cause of hospitalization (61.9%) with an increasing trend during the study period. Tuberculosis (28.4%), pneumocystis pneumonia (11.4%), cerebral toxoplasmosis (7.2%) and cryptococcosis (5.5%) were the most frequent AIDS-defining events. Tuberculosis was also the most frequent cause of overall hospitalization. In multivariate analysis, recent HIV diagnosis (aOR = 2.0, 95% CI: 1.0-3.9), CD4<200 cells/µl (aOR = 4.0, 95%CI: 1.9-8.1), persistent fever (aOR = 4.4, 95%CI: 2.1-9.0), duration of symptoms≥ 6 weeks (aOR = 2.6, 95%CI: 1.2-5.4) were associated with AIDS-defining events. Overall inpatient mortality was 19.5%. Age≥55 years (aOR = 4.9, 95%CI: 1.5-16.6), neurological signs (aOR = 3.2, 95%CI: 1.5-6.9) and AIDS-defining events (aOR = 2.9, 95%CI: 1.2--7.2) were associated with inpatient mortality. CONCLUSIONS: AIDS-defining events were the most frequent cause of hospitalization during the study period. Factors associated with AIDS-defining events mostly reflected delay in HIV diagnosis. Factors associated with mortality were advanced age, neurological signs and AIDS-defining events.

Clinical Features and Outcome in Adult Cases of Tuberculous Meningitis in Tertiary Care Hospital in Antananarivo, Madagascar.

Purpose. We aimed to describe and to assess prognosis factors in tuberculous meningitis in adult patients. Methods. We performed a retrospective study of case records of adult patients. Patients classified as definite, probable, or possible tuberculous meningitis according to standardized definition criteria were included and assessed in the study. Results. Seventy-five patients were included in the study. Tuberculous meningitis was classified as definite in 8 (10.7%), probable in 44 (58.7%), and possible in 23 patients (30.6%). HIV was found in 3% of patients. Patients were in advanced stages at admission in 82.7%. Median duration of symptoms prior to admission was 3 weeks (IQR: 2-5). Median time to diagnosis following admission was 5 days (IQR: 3-8). Median CSF WCC was 75 per mm3 with lymphocytic predominance in 38 cases (52.8%). Median CSF glucose level was 1.48 mmol/L and median CSF protein level was 1 g/L. Mortality rate was 28%. Age ≥ 35 years (aOR: 4.06; 95% CI: 1.16-14.26) and coma (aOR: 12.98; 95% CI: 1.13-149.16) predicted inpatient mortality. Conclusion. Most of the patients experienced more than 3 weeks of diagnostic delay prior to admission. Mortality was high and occurred early after admission. Age and coma were identified as independent prognosis factors.