Establishing Reference Intervals for Serum and Salivary Cortisol in a Selected Population in Kano, Nigeria.

OBJECTIVE: Serum cortisol has long been used in the assessment of disorders of the hypothalamic-pituitary-adrenal axis. The reference interval for cortisol in both serum and saliva depends on the analytical methodology and the population studied; hence, a locally derived population-based reference interval is recommended. To our knowledge, there are no studies on reference interval determination in the study area, raising concerns about the use of reference intervals established in European and North American populations. This work aimed to establish reference intervals for baseline serum and salivary cortisol levels among healthy adults in Kano, Nigeria, using methods available in our laboratory. METHODS: A cross-section of 148 apparently healthy reference individuals aged 16 to 67 years were recruited from a local community in Kano, Nigeria, using a systematic sampling technique. Baseline serum cortisol was analyzed using highly sensitive and specific electrochemiluminescence quantitative measurements on an automated immunology analyzer. Salivary cortisol levels were measured using Salimetrics' competitive enzyme-linked immunosorbent assay test kits. Parametric methods with a 95% confidence interval were used to calculate reference intervals. RESULTS: The reference intervals for cortisol in serum and saliva were 72.0 nmo/L to 554.0 nmol/L and 0.40 nmol/L to 18.0 nmol/L, respectively. There was a weak positive correlation between serum and salivary cortisol values, but this association was not statistically significant. CONCLUSION: The development of locally derived adult reference intervals can improve the diagnostic utility of serum and salivary cortisol assessment and strengthen the reliability of adrenal insufficiency diagnoses in our population.

Doppler Sonographic Characteristics and Clinical Outcomes of Diabetic Foot Syndrome: A 5-Year Audit from a Tertiary Hospital in Northern Nigeria.

Background: Diabetes foot syndrome is one of the common complications of diabetes. Detailed information on the clinical and vascular characteristics of patients with diabetic foot disease in relation to the outcome of the care provided to these patients will be useful to policymakers and clinicians in early detection and timely interventions for the prevention of disabling complications. Materials and Methods: This is a review of patients with diabetic foot managed in Aminu Kano Teaching Hospital over 5 years (January 2017-May 2022). The sociodemographic characteristics, Wagner classification of the foot, Doppler sonographic characteristics and clinical outcomes, etc., were reviewed. Results: A total of 51 patients were reviewed. Males and females accounted for 56.8% and 43.1%, respectively. Twenty-five patients had Wagner grade 4 ulcers, and fewer patients had Wagner grade 1 and 5-foot ulcers. The mean ± standard deviation Doppler arterial intimal media thickness was 1.53 ± 0.33 (range 0.90-2.40 mm). The majority of DFS patients had Doppler sonographic lesions on the right lower limb 28 (54.9%) only, and 11 (21.6%) of the lesions were bilateral. The posterior tibial artery 11 (21.6%) was the most involved arterial segment with plaques, followed by a combination of popliteal and tibial arterial 10 (19.6%) segments. At 6 months, 45.2% had limb amputation, 17.6% healed ulcers, 17.6% delayed wound healing, and 9.8% died. Conclusion: There is an unacceptably high prevalence of poor treatment outcomes, thus, contributing to a huge burden of care to patients living with diabetes. There is a strong association between severe arterial stenosis detected by Doppler ultrasound and higher rates of amputations.

The role of medical-grade maggots in facilitating healing of diabetic foot ulcers in Kano, northern Nigeria: a case series.

OBJECTIVE: Approximately 13% of people living with diabetes develop one or more ulcers during the course of the disease, and diabetic foot ulcer (DFU) is responsible for >60% of lower limb amputations worldwide. This case series aimed to demonstrate the effectiveness of medical-grade maggots on DFUs in promoting wound healing and reducing related hospital stays in northern Nigeria. METHOD: Maggot debridement therapy (MDT) was applied to the DFUs of patients who consented to this treatment between January-August 2021 at the Orthopaedic Unit of the Aminu Kano Teaching Hospital (AKTH), Kano, Nigeria. Sterile first instar larvae of Lucilia sericata were obtained indigenously and applied using the confinement (free-range) method under aseptic procedure. RESULTS: A total of 15 patients with DFUs of Wagner classification grades III (33.3%) and IV (66.7%), were seen and documented. The patients included 10 (66.7%) females and five (33.3%) males, giving a female:male ratio of 2:1. The mean age (±standard deviation) of the respondents was 51.6±10.8 years. The surface area of the wounds ranged from 24-140cm2, with a median value of 75cm2. Among the patients, 60% had two cycles of MDT, with a median duration of five days. Most of the wounds (53.3%) were debrided within five days; 13.3% (two wounds) took seven days to be fully debrided. A paired sample t-test showed a statistically significant association between wound surface area and therapy duration (t=8.0; p=0.000) and between wound surface area and cycles of therapy (t=8.3; p=0.000). Before maggot application, 14 (93.3%) DFUs were completely (100%) covered with slough and only one (6.7%) was 95% covered with slough. After maggot application, 10 (66.7%) wounds were completely debrided while five (33.3%) wounds required bedside surgical debridement to achieve complete debridement. A paired sample t-test showed statistically significant difference between the pre- and post-MDT slough covering the wounds (t=45.1; p=0.000). CONCLUSION: In this case series, MDT was successfully used in the debridement of DFUs, which facilitated the healing process with an encouraging clinical outcome.

Prevalence and risk factors of diabetes foot ulcers in Kano, northwestern Nigeria.

BACKGROUND: Foot complications account for more hospital admissions than any other diabetes mellitus (DM) complications with adverse outcomes being foot ulcers and amputation. OBJECTIVE: To determine the prevalence and risk factors of diabetic foot ulcers in Kano, Northwestern Nigeria. METHODS: A descriptive cross-sectional study was conducted in the diabetes outpatient clinics and medical and surgical wards of two hospitals in Kano, Nigeria. Data were collected on socio-demographic characteristics, type, and duration of DM. The study subjects were assessed for the presence of and risk factors for foot ulcers. RESULTS: We recruited 394 patients with DM (163 males and 231 females) with a mean (SD) age and duration of DM of 50.8 ± 12.5 years and 7.72 ± 6.65 years respectively. Type 2 DM was present in 95% of the study subjects. Diabetic foot ulcer (DFU) was present in 57 (14.5%) of the patients. Risk factors associated with DFU assessed using univariate analysis were older age, longer duration of DM, presence of peripheral neuropathy (PN), peripheral arterial disease (PAD), diabetic retinopathy, nephropathy, foot deformities, previous DFU, and poor glycemic control. The independent determinants of DFU were previous DFU, foot deformities, retinopathy, PN, PAD, and poor glycemic control. CONCLUSION: DFU can be found in our setting and the predominant risk factors for DFU are common and remain unchanged in our environment. This study, therefore, buttresses the effect of early detection and treatment of DM in preventing the complications that arise from the disease.

Health-related quality of life of persons with diabetic foot ulcers in a cosmopolitan city in northwestern Nigeria.

Background: Diabetic foot ulcer is one of the most serious and disabling complications of diabetes mellitus (DM). It is a major source of morbidity, mortality, and a leading cause of hospitalization. It constitutes a major burden to the patient, family, and health-care system as well as impairs quality of life (QoL). The aim of this study was to determine the QoL of persons with diabetic foot ulcers attending two major hospitals in a cosmopolitan city in northwestern Nigeria. Materials and Methods: We conducted a descriptive cross-sectional study at the diabetes outpatient clinics and wards of two major hospitals in Kano, Northwestern Nigeria. Sociodemographic characteristics, type of DM, duration of DM, and the presence of risk factors for foot ulcers were assessed. The QoL of patients with and without foot ulcer was determined a well-validated questionnaire for chronic diseases, short form 36 (SF 36) health-related QoL questionnaire. Results: We recruited 394 patients with DM (163 males and 231 females) with mean age and duration of DM of 50.8 ± 12.5 years and 7.72 ± 6.65 years, respectively. Ninety-five percent of the study participants had type 2 DM. Foot ulcers were present in 57 (14.5%) study participants. The QoL was generally poor (P < 0.001) in patients with DFU, compared with those without DFU in all domains of the SF 36, that indicated poor QoL in the physical, mental, and emotional well-being of the patients. Conclusion: Diabetic foot ulcers are quite common and impart significantly on the QoL of persons with DM affecting their physical, mental, and emotional well-being. Early detection and management of foot ulcers will reduce the burden of the disease and improve the QoL of affected individuals.

Résumé Contexte: L'ulcère du pied diabétique est l'une des complications les plus graves et les plus invalidantes du diabète sucré (DM). C'est une source majeure de 14 morbidité, mortalité, et l'une des principales causes d'hospitalisation. Il constitue un fardeau majeur pour le patient, la famille et le système de soins de santé, car 15 ans et nuit à la qualité de vie (QoL). Le but de cette étude était de déterminer la qualité de vie des personnes atteintes d'ulcères de pied diabétique fréquentant deux 16 hôpitaux principaux dans une ville cosmopolite du nord-ouest du Nigéria. Matériaux et Méthodes: Nous avons mené une étude transversale descriptive 17 dans les cliniques externes de diabète et les salles de deux grands hôpitaux à Kano, nord-ouest du Nigeria. Des caractéristiques sociodémographiques, le type 18 de DM, la durée de DM, et la présence des facteurs de risque pour des ulcères de pied ont été évalués. La qualité de vie des patients avec et sans ulcère de pied était 19 déterminé un questionnaire bien-validé pour les maladies chroniques, questionnaire court-connexe de qol de la forme 36 (SF 36). Résultats: Nous avons recruté 394 patient avec le DM (163 mâles et 231 femelles) avec l'âge moyen et la durée du DM de 50,8 ± 12,5 ans et 7,72 ± 6,65 ans, respectivement. 20 Quatre-vingt-quinze pour cent des participants à l'étude présentaient un DM de type 2. Des ulcères du pied étaient présents dans 57 (14,5 %) participants à l'étude. Le QoL était généralement pauvre (P < 0,001) dans les patients avec DFU, comparé à ceux sans DFU dans tous les domaines du SF 36, qui a indiqué le QoL pauvre dans le bien-être physique, mental, 22, et émotionnel des patients. Conclusion: Les ulcères diabétiques de pied sont tout à fait communs et transmettent de manière significative sur la QoL de 23 personnes avec le DM affectant leur bien-être physique, mental, et émotionnel. La détection et la prise en charge précoces des ulcères du pied réduiront le fardeau de la maladie et amélioreront la qualité de vie des personnes touchées. Mots-clés: Ulcère du pied diabétique, Qualité de vie liée à la santé, Nord-Ouest du Nigéria, questionnaire abrégé.

Diabetes-related knowledge, attitude, and practice among outpatients of a tertiary hospital in North-western Nigeria.

Introduction: One of the challenges facing the management of diabetes is the misconception and inadequate knowledge about the disease. We assessed the level of diabetes-related knowledge, attitude, and practice (KAP) among patients with diabetes in North-western Nigeria. Materials and Methods: This was a hospital-based cross-sectional study. A total of 400 participants were recruited. A KAP questionnaire was used to assess the KAP of the patients. Glycated hemoglobin was used to measure the level of glucose control of the study participants. Results: The mean age of the patients was 51 years, majority being females 233 (58.3%). The mean knowledge score was 6.2 ± 3.1 points (out of 15), average attitude score was 2.5 ± 1.5 points (out of 5), and the mean practice score was 2.1 ± 1.3 points (out of 6). The level of KAP was found to be directly related to glycemic control (P < 0.01). The level of education (odds ratio [OR]: 5.0 and 95% confidence interval [CI]: 0.196-0.452) and monthly income (OR: 4.4 and 95% CI: 0.123-0.326) were found to be independent predictors of diabetes-related KAP. Conclusion: The study has demonstrated poor diabetes-related KAP. The patient's level of education and income plays a major role in the management of diabetes.

RésuméIntroduction: L'un des défis auxquels est confrontée la gestion du diabète est l'idée fausse et les connaissances insuffisantes sur la maladie. Nous avons évalué le niveau de connaissances, d'attitudes et de pratiques liées au diabète chez les patients atteints de diabète dans le nord-ouest du Nigéria. Matériel et méthodes: Il s'agissait d'une étude transversale en milieu hospitalier. Au total, 400 participants ont été recrutés. Un questionnaire CAP a été utilisé pour évaluer le KAP des patients. L'hémoglobine glyquée a été utilisée pour mesurer le niveau de contrôle du glucose des participants à l'étude. Résultats: L'âge moyen des patients était de 51 ans, la majorité étant des femmes 233 (58,3%). Le score de connaissance moyen était de 6,2 ± 3,1 points (horssur 15), le score d'attitude moyen était de 2,5 ± 1,5 points (sur 5) et le score moyen de pratique était de 2,1 ± 1,3 points (sur 6). Le niveau de KAP s'est avérée être directement liée au contrôle glycémique (P <0,01). Le niveau d'éducation (odds ratio [OR]: 5,0 et intervalle de confiance à 95% [IC]: 0,196 à 0,452) et le revenu mensuel (OR: 4,4 et IC à 95%: 0,123 à 0,326) se sont avérés être des prédicteurs indépendants de la KAP liée au diabète. Conclusion: L'étude a démontré une faible CAP liée au diabète. Le niveau d'éducation et le revenu du patient jouent un rôle majeur dans la gestion du diabète.

Diabetes Mellitus and its Risk Factors Among a Suburban Population of Northwestern Nigerians: A Community-Based Survey.

Background: Diabetes mellitus is a serious public health problem, and its prevalence is increasing globally. However, there are scanty reports of the scope and burden of the disease among suburban populations of Nigeria. This study aims to determine the prevalence of diabetes mellitus and to determine the associated risk factors of the disease among the suburban population of Northern Nigeria. Methodology: A community-based descriptive cross-sectional study was conducted in which 1100 subjects were recruited using a multistage random cluster sampling technique. They were screened for diabetes by fasting plasma glucose (FPG) or casual plasma glucose (CPG) estimation. Individuals with FOG >7mmol//l or CPG >7.8mmol/l abnormal glucose levels had a 75 g oral glucose tolerance test (OGTT) and HbA1c done. The prevalence of diabetes was computed with a 95% confidence interval. Result: The crude prevalence of diabetes from this study is 4.1% (95% CI = 3.3 - 4.9%) and standardized rate of 6.4%. Male gender OR 0.74, (95% CI = 0.569 - 1.982), age >40yrs OR 1.12 (95% CI = 0.851 - 1.463), physical inactivity OR 3.78 (95% CI = 2.881 - 12.726), Hypertension (SBP OR 10.28 (95% CI = 6.319- 29.369), (DBP OR 7.52 (95% CI = 3.928 - 36.914), and family history of DM OR 9.34 (95% CI = 3.890 - 23.481), showed significant independent association with diabetes. Conclusion: The prevalence of diabetes in the suburban population of Northwestern Nigeria is high and the associated risk factors include overweight and obesity, physical inactivity, family history of diabetes and age.

Predictors of intra-hospital mortality in patients with diabetic foot ulcers in Nigeria: data from the MEDFUN study.

BACKGROUND: Diabetic foot ulcers (DFU) are associated with high morbidity and mortality globally. Mortality in patients hospitalized for DFU in Nigeria is unacceptably high. This study was undertaken to determine factors that predict mortality in patients hospitalized for DFU in Nigeria. METHODS: The current study was part of Multi-centre Evaluation of Diabetic Foot Ulcer in Nigeria (MEDFUN), an observational study conducted in six tertiary healthcare institutions across the 6 geopolitical zones of Nigeria. Consecutive type 1 or 2 diabetic patients hospitalized for DFU who consented to participate were recruited and subjected to relevant clinical, biochemical, and radiological assessments and multidisciplinary care until discharge or death. Data for type 1 diabetes mellitus (DM) patients were expunged from current mortality analysis due to their small number. RESULTS: Three hundred and twenty-three type 2 DM subjects with mean age and mean duration of DM of 57.2 ± 11.4 years and 8.7 ± 5.8 years respectively participated in this study. The median duration of ulcers was 39 days with a range of 28 to 54 days and the majority (79.9%) presented with advanced ulcers of at least Wagner grade 3. Mortality of 21.4% was recorded in the study, with the highest mortality observed among subjects with Wagner grade 5. Variables significantly associated with mortality with their respective p values were DM duration more than 120 months (p 0.005), ulcer duration > 1 month (p 0.020), ulcer severity of Wagner grade 3 and above (p 0.001), peripheral arterial disease (p 0.005), proteinuria (p < 0.001), positive blood cultures (p < 0.001), low HDL (p < 0.001), shock at presentation (p < 0.001), cardiac failure (p 0.027), and renal impairment (p < 0.001). On Multivariate regression analysis, presence of bacteraemia (OR 5.053; 95% CI 2.572-9.428) and renal impairment (OR 2.838; 95% CI 1.349-5.971) were significantly predictive of mortality independent of other variables. CONCLUSIONS: This study showed high intra-hospital mortality among patients with DFU, with the majority of deaths occurring among those with advanced ulcers, bacteraemia, cardiac failure, and renal impairment. Prompt attention to these factors might help improve survival from DFU in Nigeria.

Determinants of wound healing in patients hospitalized for diabetic foot ulcer: results from the MEDFUN study.

OBJECTIVE: The high amputation rates from diabetic foot ulcer (DFU) in Nigeria and prolonged hospitalization due to poor wound healing is a source of concern. Furthermore, factors that affect wound healing of DFUs have not yet been well studied in Nigeria, whereas knowing these factors could improve DFU outcomes. Therefore, the objective of this study was to determine the factors that are associated with the wound healing in patients hospitalized for DFU. METHODS: The Multi-Center Evaluation of Diabetic Foot Ulcer in Nigeria (MEDFUN) was an observational study involving 336 diabetic patients hospitalized for DFU and managed by a multi-disciplinary team until discharge or death. Demographic, clinical, and biochemical characteristics were documented. Test statistics used were chi square, t-test, univariate, and multivariate logistic regression. The study endpoints were ulcer healing, LEA, duration of hospitalization, and mortality. Here we present data on wound healing. RESULTS: The mean ± SD age was 55.9±12.5 years. Univariate predictors of wound healing were ulcer duration more than 1 month prior to hospitalization (p<0.001), peripheral arterial disease (PAD) (p<0.001), foot gangrene (p<0.001), Ulcer grade ≥3 (p=0.002), proteinuria (p=0.005), anemia (p=0.009), renal impairment (p=0.021), glycated hemoglobin ≥7% (0.012), and osteomyelitis (p<0.001). On multivariate regression, osteomyelitis was the strongest independent predictor of wound healing after adjusting for all other variables (OR 0.035; 95% CI 0.004-0.332). This was followed by PAD (OR 0.093; 95% CI 0.028-0.311), ulcer duration >1 month (OR 0.109; 95% CI 0.030-0.395), anemia (OR 0.179; 95% CI 0.056-0.571). CONCLUSION: Presence of osteomyelitis, duration of ulcer greater than 1 month, PAD, Wagner grade 3 or higher, proteinuria, presence of gangrene, anemia, renal impairment, and HbA1c ≥7% were the significant predictors of wound healing in patients hospitalized for DFU. Early identification and prompt attention to these factors in a diabetic foot wound might significantly improve healing and reduce adverse outcomes such as amputation and death.

Anemia in patients with diabetic foot ulcer and its impact on disease outcome among Nigerians: Results from the MEDFUN study.

BACKGROUND: Diabetes is a life-long and debilitating disease that is fraught with both acute and chronic complications. Of particular concern to sufferers of the disease is the development of foot problems. These problems range from foot deformities to slowly healing or non-healing ulcers (that may necessitate amputation) and in the worst-case scenario, to death. Identification and prompt treatment of comorbid conditions, such as anemia may improve outcome in patients with diabetic foot ulcers (DFU). We determined the prevalence of anemia in Nigerians with DFU and its impact on disease outcome. METHODS: We prospectively followed 336 patients with diabetes hospitalized for DFU and managed by a multidisciplinary team until discharge or death. Demographic and diabetes-related information and ulcer characteristics were documented. We evaluated each patient for neuropathy, vasculopathy and medical co-morbidities. Relevant laboratory and imaging studies were performed. We present the results of the sub-group analysis of patients with anemia to determine its prevalence and impact on disease outcome in patients with DFU in the MEDFUN study. RESULTS: Anemia was detected in 180(53.6%) subjects with 88(48.9%) of them requiring blood transfusion. Significant demographic and clinical determinants of anemia were ulcer duration more than one month prior to hospitalization (p<0.009), PAD (p<0.001) and presence of gangrene (p<0.001). The comorbid conditions that were significantly associated with anemia included proteinuria (p<0.003), osteomyelitis (p<0.006), moderate (p<0.002) as well as severe (p<0.001) vascular stenosis, history of stroke (p<0.014) and renal impairment (p<0.002). Anemia was significantly associated with poor wound healing (p<0.009), amputation (p<0.036) and risk of death (p<0.034). CONCLUSION: We detected anemia in more than half of our cohort with DFU. We found significant association between anemia and poor wound healing, amputation and mortality among our studied subjects. Future studies should explore whether prompt correction of anemia in subjects hospitalized for DFU would improve outcome.

The prevalence and clinical profile of adrenocortical deficiency among HIV infected persons in Northern Nigeria.

BACKGROUND: Infection with the human immune deficiency virus (HIV) is still a prevalent problem in Africa. OBJECTIVES: The aim of this study was to determine the prevalence of hypocortisolism among patients with HIV and their clinical profile at Aminu Kano Teaching Hospital (AKTH), Kano, Nigeria. METHOD: Three hundred and fifty adult patients with HIV infection were recruited from the HIV clinic of AKTH, Kano. Blood samples for serum electrolytes, and cortisol both before and after the short Synacthen test were taken for estimation. Data were analyzed using the SPSS version 20.0 software. RESULTS: One hundred and eight (30.9%) of participants had low baseline serum cortisol levels, while 57 (16.3%) had a low serum cortisol after short synacthen test. There was no significant relationship between the cortisol levels and clinical features of hypocortisolism, WHO clinical stage of HIV, hypernatremia or HAART regimen. There was a negative correlation between the stimulated serum cortisol and duration of diagnosis of HIV, participants BMI and CD4 counts. CONCLUSION: The biochemical evidence of hypocortisolism was common among patients infected with HIV, associated with a longer duration of HIV infection. However, none of CD4 counts, clinical features or HAART regimen were associated with hypocortisolism.

Predictors of lower extremity amputation in patients with diabetic foot ulcer: findings from MEDFUN, a multi-center observational study.

BACKGROUND: Lower extremity amputation (LEA) is a potential sequelae of diabetic foot ulceration (DFU) and is associated with huge morbidly and mortality. Low and middle income countries are currently at the greatest risk of diabetes-related complications and deaths. We sought to identify demographic, clinical and laboratory variables that significantly predict LEA in patients hospitalized for DFU. METHODS: The Multi-center Evaluation of Diabetic Foot Ulcer in Nigeria (MEDFUN) was an observational study conducted between March 2016 and April 2017 in six tertiary healthcare institutions. We prospectively followed 336 diabetic patients hospitalized for DFU and managed by a multidisciplinary team until discharge or death. Demographic and diabetes-related information and ulcer characteristics were documented. Patients were evaluated for neuropathy, peripheral arterial disease (PAD) and medical co-morbidities while relevant laboratory and imaging tests were performed. The study end-points were ulcer healing, LEA, duration of hospitalization and mortality. Here we present data on amputation. RESULTS: One hundred and nineteen subjects (35.4%) underwent LEA during the follow-up period. Univariate predictors of LEA were ulcer duration more than 1 month prior to hospitalization (P <  0.001), PAD (P <  0.001), Wagner grade ≥ 4 (P <  0.001), wound infection (P 0.041), Proteinuria (P 0.021), leucocytosis (P 0.001) and osteomyelitis (P <  0.001). On multivariate regression, only three variables emerged as significant independent predictors of LEA and these include: ulcer duration more than 1 month (O.R. 10.3, 95% C.I. 4.055-26.132), PAD (O.R. 2.8, 95% C.I. 1.520-5.110) and presence of osteomyelitis (O.R. 5.6, 95% C.I. 2.930-10.776). Age, gender, diabetes type and duration, neuropathy, glycemic control and anemia did not predict LEA in the studied population. CONCLUSION: We identified duration of ulcer greater than 1 month, PAD, Wagner grade 4 or higher, proteinuria, leucocytosis, wound infection and osteomyelitis as the significant predictors of LEA in patients hospitalized for DFU. Prompt attention to these risk factors may reduce amputation rate among these patients.

Burden of diabetic foot ulcer in Nigeria: Current evidence from the multicenter evaluation of diabetic foot ulcer in Nigeria.

BACKGROUND: Nigeria bears the greatest burden of diabetes prevalence in Sub-Saharan Africa. Diabetic foot ulcer (DFU) is a serious and potentially life-threatening complication of diabetes. Significant improvements in diabetic foot incidence and outcomes have been recorded in many Western countries in the past decade. However, the current burden of DFU in Nigeria is largely unknown. AIM: To evaluate the patients' profile, ulcer characteristics, associated co-morbidities and outcome of patients with DFU in Nigeria. METHODS: Multicenter evaluation of diabetic foot ulcer in Nigeria was a one year multicenter observational study of patients hospitalized for DFU in six tertiary health institutions in Nigeria from March 2016 to March 2017. Demographic and diabetes information, ulcer characteristics and associated co-morbidities were assessed. Relevant laboratory and imaging studies were performed. All patients received appropriate multi-disciplinary care and were followed up until discharge or death. Outcome variables of interest were ulcer healing, lower extremity amputation (LEA), duration of hospitalization and mortality. RESULTS: A total of 336 patients (55.1% male) with mean age of 55.9 ± 12.5 years were enrolled into this study. Majority (96.1%) had type 2 diabetes. Only 25.9% of the subjects had prior foot care knowledge. Most of the subjects presented late to the hospital and median (IQR) duration of ulcer at presentation was 39 (28-54) d. Ulcers were already advanced (Wagner grades ≥ 3) in 79.2% of the subjects while 76.8% of the ulcers were infected at the time of admission. The commonest co-morbidities were systemic hypertension, anemia and hyperglycemic emergencies. One hundred and nineteen subjects (35.4%) suffered LEA while 10.4% left against medical advice. The median (IQR) duration of hospitalization was 52.0 (29-66) d with case fatality rate of 20.5%. CONCLUSION: The burden of DFU in Nigeria is very high. The major gaps include low level of foot care knowledge among diabetic patients, overdependence on self-medication and unorthodox medicine following development of foot ulceration, late hospital presentation, and high amputation and mortality rates. Extensive foot care education within the framework of a multi-disciplinary foot care team is highly desirable.

Pattern of Obesity Among Patients with Type 2 Diabetes at a Tertiary Healthcare Center in Northern Nigeria.

PURPOSE: Type 2 diabetes poses a major global health threat both in the developed and developing countries. Factors responsible for the soaring epidemic of T2DM in the developing countries include urbanization, ageing population, physical inactivity and increasing obesity rates. Our aim was to determine the pattern of obesity among patients with T2DM at the Aminu Kano Teaching Hospital (AKTH), Kano, Northwestern Nigeria. PATIENTS AND METHODS: We consecutively recruited 220 patients with type 2 diabetes attending the diabetes clinic of AKTH for the study. Patients with Type 1 diabetes, patients who could not stand or are wheelchair bound and pregnant women were excluded from the study. A pretested questionnaire was used to collect data on socio-demographic characteristics, treatment history for diabetes and history of hypertension from each participant. RESULTS: Of the 220 patients recruited for this study, 97(44.1%) were men, while 123(55.9%) were women. The prevalence of generalized obesity among the study participants was 27.4% (women -30.9% vs men- 22.7%, X2=4.76, p=0.190). Grades I. II and III obesity were found in 17.3%, 5.9% and 3.2% of the study participants, respectively. All the participants with grade III obesity were women. Central obesity defined by WC was detected in 111(50.5%) [20(20.6%) men and 91(73.9%) women, X2=1.93, p=0.001]. Obesity defined by WHR was recorded in 182(82.7%) participants [80(43.9%) men and 102(56.0%) women, X2= 1.97, 0.001]. Using a cut-off of ≥0.5, abnormal WhtR was detected in 179(81.4%) [72(40.2%) men and 107(59.8%) women, X2= 5.82, p=0.01], while using a cut-off of ≥0.6, abnormal WhtR was detected in 84(38.2%) participants [29 (34.5%) men and 55(65.5%) women, X2=6.38, p=0.09]. Hypertension was detected in 103(46.8%) participants, with a higher prevalence among women compared with men [46.3. % vs 47.4%, X2= 1.03 p=0.87]. CONCLUSION: The prevalence of obesity in our cohort of patients with type 2 diabetes was high. The predominant form of obesity was central obesity, which was most prevalent when indexed by WHR. The WhtR was as good as the WHR, but fared better than WC in detecting central obesity in our patients.

Prevalence and Risk Factors for Diabetes Mellitus in Nigeria: A Systematic Review and Meta-Analysis.

INTRODUCTION: There has been no nationwide health (diabetes) survey in Nigeria since 1992, when a diabetes mellitus (DM) prevalence of 2.2% was reported. We aimed to determine the prevalence of and risk factors for DM in Nigeria by performing a systematic review and meta-analysis. METHODS: We searched Medline, EMBASE, PubMed, PapersFirst, the Cochrane Library, Scopus, Bioline, African Journals Online, Institute of Scientific Information, and Google Scholar from the year 1990 to 2017. Using MeSH headings, the terms "diabetes mellitus," "risk factors," "prevalence," and "Nigeria" as well as variations thereof were searched for. The last search was performed on 26 November 2017. We only included studies that utilized the random plasma glucose test, the fasting plasma glucose test, the oral glucose tolerance test (OGTT), or HbA1c to diagnose DM. A total of 23 studies (n = 14,650 persons) were evaluated. A random effects model was used to estimate the pooled prevalence of DM. We estimated the overall pooled prevalence of DM and subgroup-specific DM prevalences while accounting for inter-study and intra-study variability/heterogeneity. RESULTS: The overall pooled prevalence of DM was 5.77% (95% CI 4.3-7.1). The pooled prevalences of DM in the six geopolitical zones of Nigeria were 3.0% (95% CI 1.7-4.3) in the north-west, 5.9% (95% CI 2.4-9.4) in the north-east, 3.8% (95% CI 2.9-4.7) in the north-central zone, 5.5% (95% CI 4.0-7.1) in the south-west, 4.6% (95% CI 3.4-5.9) in the south-east, and 9.8% (95% CI 7.2-12.4) in the south-south zone. Risk factors for the pooled prevalence of DM were a family history of DM (4.6%; 95% CI 3.5-5.6); urban dwelling (6.0%; 95% CI 4.3-7.8); unhealthy dietary habits (8.0%; 95% CI 5.4-10.5); cigarette smoking (4.4%; 95% CI 1.3-10.2); older age (6.6%; 95% CI 4.5-8.7); physical inactivity (4.8%; 95% CI 3.2-6.4); and obesity (5.3%; 95% CI 3.8-6.9). CONCLUSION: There has been an increase in the prevalence of DM in Nigeria. All regions of the country have been affected, with the highest prevalence seen in the south-south geopolitical zone. Urban dwelling, physical inactivity, advanced age, and unhealthy diet are important risk factors for DM among Nigerians. A national diabetes care and prevention policy is highly recommended.

Cost of Illness of Diabetic Foot Ulcer in a Resource Limited Setting: A Study from Northwestern Nigeria.

INTRODUCTION: Diabetic foot ulcer is a major complication of diabetes with a high economic cost of managing. Data from resource limited setting will bring to light how patients in these localities suffer financially in addition to poverty and lack of health insurance. This study estimated cost of illness among patients with diabetic foot ulcer in northwestern Nigeria. METHODS: It was a hospital based cross-sectional study. Questionnaire was used to take the bio data and medical history. Direct medical, direct non-medical and indirect cost were estimated. RESULT: Majority of the patients were males with the mean age of 59.3 ± 15.1 yrs. About 60% of the patients earn less than $100 monthly. The total cost of illness of diabetic foot ulcer was estimated at $140,735.56 (median = $1381.55[IQR 1002.42-]). Direct cost of illness was $107,797.06 (median = $1023.27[IQR 773.93-1568]), while the indirect cost was $32,938.49 (median = $209.90[IQR 128.74-357.08]). Out of pocket payment accounted for 90% of the payment. CONCLUSION: The cost of diabetic foot ulcer is very exorbitant and the patients affected are mostly poor, unemployed and the breadwinners of their families.

Occurrence of hypocortisolism in HIV patients: Is the picture changing?

BACKGROUND: The occurrence of endocrine diseases in people who are infected with HIV is traditionally thought to occur in the setting of AIDS with opportunistic infections and malignancies. However, recent studies find the correlation between hypocortisolism and stage of HIV (CD4 count and WHO clinical stage) inconsistent. METHODS: This descriptive cross-sectional study included three hundred and fifty (350) consecutive patients with HIV infection. They were interviewed, and subsequently underwent laboratory evaluation for the detection of hypocortisolism. Blood samples for serum cortisol estimation were taken at baseline and at 30 minutes following the administration of 1µg of tetracosactrin (Synacthen). In addition, the patients had blood samples taken at 0 minutes (baseline) for CD4+ lymphocyte cell counts. RESULTS: At baseline, 108 (30.9%) participants had serum cortisol levels below 100 µg/L with a median value of 55.48 µg/L (11.36-99.96 µg/L), but only 57 (16.3%) study participants had stimulated serum cortisol levels below 180 µg/L with median of 118 µg/L (19.43-179.62). There was no significant difference in the occurrence of clinical features between participants with low and normal serum cortisol, nor WHO clinical stage, CD4 count and ART regimen. The occurrence of hypocortisolism was higher among participants who had been on ART for a longer period of time. CONCLUSION: There is a high prevalence of hypocortisolism among HIV patients by biochemical testing, especially those who have been on ARVs for a longer duration. Hypocortisolism cannot be predicted based on the participants' WHO clinical stage of disease, CD4 cell count, or the treatment regimen. FUNDING: Personal Funds.

Metabolic syndrome among HIV infected patients: A comparative cross sectional study in northwestern Nigeria.

INTRODUCTION: The increasing availability of antiretroviral drugs has made HIV-positive patients to live longer, and conditions that are associated with longevity such as metabolic syndrome and other cardiovascular related conditions have become relevant in them. This is less well studied among African populations. Therefore the study aimed at estimating and comparing the prevalence of and associated risk factors for the metabolic syndrome (MS) among African HIV infected patients. METHOD: In this comparative cross-sectional study, we analyzed the data of 300 participants matched for age and gender who satisfied the inclusion criteria with half of the subjects on HAART, while the other half was HAART naïve. The MS was diagnosed using ATP-III criteria. RESULTS: The mean age of the patients was 34.8±9.9years. The majority of the patients were females 64%. The prevalence of MS among HAART-exposed patients was found to be 19.3%, while it was 5.3% among HAART naïve patients (p=0.001). Raised triglyceride and elevated blood pressure were the criteria with the highest occurrence among HAART-exposed, 82.8% for each. Advanced age, longer duration of HIV diagnosis and HAART exposure, increased BMI, weight gain after HAART exposure, exposure to PIs and increased mean CD4 cell count were found to be significantly associated with MS (p<0.05). However, only age (OR 4.3, 95% CI 1.6-11.8, p=0.005) and BMI (OR 4.2, 95% CI 1.5-11.9, p=0.007) were found to be independently associated with the development of MS. CONCLUSION: Exposure to HAART particularly protease inhibitor based regimen increases the risk of MS among HIV-infected patients.

Stroke in patients with diabetes mellitus: a study from North Western Nigeria.

BACKGROUND: Stroke is one of the major causes of morbidity and mortality worldwide and apart from being exceedingly harmful in diabetics, stroke is a disabling disorder. The study was undertaken to describe the clinical characteristics, outcome pattern and predictors of mortality in a cohort of diabetic patients presenting with stroke in two tertiary health facilities in North Western Nigeria. METHOD: Out of all stroke patients seen from June 2007 to February 2011, persons with diabetes mellitus presenting with stroke in the emergency unit of the two tertiary hospitals in Kano were consecutively recruited for the study. Classification of stroke into hemorrhagic and infarctive subtypes was based on brain computerized tomography (CT), brain magnetic resonance imaging (MRI) and World Health Organization (WHO) criteria. Follow-up period was for thirty days. RESULT: Out of the five hundred and thirty six stroke patients seen during the study period, 85 (15.9%) patients, comprising 48 (56.5%) males, had diabetes. Thirty eight (44.7%) of the identified diabetics were previously undiagnosed. Sixty four (75.3%) had infarctive stroke. One-month case fatality rate was 30.6%. Factors associated with death included male sex, past history of TIA, abnormal respiratory pattern, hemorrhagic stroke, aspiration pneumonitis, and worsening GCS. Aspiration pneumonitis and worsening GCS were independent predictors of one month mortality of stroke in the patients. CONCLUSION: In DM patients studied, infarctive stroke was more common, case fatality was 30.6%. Male gender, past history of TIA, abnormal respiratory pattern, hemorrhagic stroke, aspiration pneumonitis, and worsening Glasgow Coma Score (GCS) were associated with mortality. Aspiration pneumonitis and worsening GCS were independent predictors of one month mortality of stroke in diabetic patients.

Performance of waist circumference and proposed cutoff levels for defining overweight and obesity in Nigerians.

BACKGROUND: Waist circumference (WC) is a simple tool for measuring central obesity in routine clinic settings. Gender- and ethnic-specific optimal cutoff points for WC are encouraged for populations lacking such data. OBJECTIVES: To derive WC cutoff values, predictive of overweight and obesity in Nigerians and to evaluate the performance of currently recommended values. SUBJECTS AND METHODS: Apparently, healthy urban dwellers from six cities spread across Nigeria were selected for this cross-sectional study. Biophysical profiles such as blood pressure and anthropometric indices were measured according to the World Health Organization's STEPs instrument protocol. Receiver operating characteristics curve analysis was used to determine the optimal cutoff levels using the decision rule of maximum (sensitivity + specificity). The level of significance was set at P< 0.05. RESULTS: A total of 6089 subjects (3234 males and 2855 females) were recruited for the study. WC demonstrated a high area under the curve in both genders. Selected cutoff points ranged from 83 to 96 cm with high sensitivities and specificities. CONCLUSIONS: The currently recommended gender-specific WC cutoff values proved inappropriate in this study group, but WC remains a reliable tool for measuring obesity.