Sequelae of Hospitalization for Diabetic Foot Ulcers at LASUTH Ikeja Lagos: A Prospective Observational Study.

Abstract: Diabetic foot ulcers (DFUs) remain important sequelae of diabetes (DM) which cause debilitating effects on the sufferer. The evolution of some aspects of epidemiology and the current clinical impact of DFUs was examined. Methods: A single-center prospective observational study. Study subjects were consecutively recruited. Results: Total medical admissions during the study period were 2288, 350 were DM related, out of these 112 were admitted for DFU. 32% of total DM admissions were for DFU. The mean age of the study subjects is 58 ± 11.0 range is from 35 years to 87 years. Males were slightly predominant (51.8%). Most of them were actively employed (92%), and the majority were in the 55 to 64 years age category. Most of them had not been diabetic for longer than 8 years (61%). The mean duration of DM is 8.32±7.27 years. The mean duration of ulcer at presentation was 72.0±138.13 days. The majority of the patients (80.3%) presented with severe (grades 3 to 5) ulcers, Wagner grade four was the most predominant. Regarding clinical outcome, 24 (24.7%) had an amputation, 3 of which were minor. The factor that was associated with amputation was concomitant heart failure - OR 6.00 CI 0.589-61.07, 0.498-4.856. Death occurred in 16 (18.4%). The factors associated with mortality were severe anemia OR 2.00 CI 0.65 - 6.113, severe renal impairment requiring dialysis OR 3.93 CI 0.232-66.5, concomitant stroke OR 8.42 CI 0.71-99.6, and peripheral arterial disease- OR 18.33 CI 2.27 -147 p-value- 0.006. Conclusion: The hallmark of DFU in this report is late presentation, it accounted for a significant proportion of the total medical admissions, although the case fatality of DFU reduced from previous reports from the center, mortality, and amputation rates are still unacceptably high. Concomittant heart failure was a factor of amputation. Mortality was associated with severe anemia, renal impairment and peripheral arterial disease.

Dyslipidaemia as a risk factor in the occurrence of stroke in Nigeria: prevalence and patterns.

INTRODUCTION: Stroke is a major public health problem worldwide. Hypertension, diabetes mellitus, dyslipidaemia and smoking are some of the common modifiable risk factors in the occurrence of stroke. Therefore, this study was designed to assess the prevalence and patterns of dyslipidaemia among individuals with acute stroke. METHODS: This is a retrospective descriptive cross-sectional study, carried out in the Departments of Medicine at the LAUTECH Teaching hospital, Ogbomoso and General Hospital, Orile-Agege, Lagos, South-West, Nigeria, over a 18-month period between September 2012 and February 2014. One hundred and six (106) patients with acute stroke confirmed with computed tomography (CT) brain scan were recruited. Clinical features, risk factors, lipid profiles and stroke patterns were identified. RESULTS: Mean age was significantly higher in ischaemic stroke compared to haemorrhagic (64.08±10.87 Vs, 56.21±12.38years, p=0.001). There was slight male preponderance in both stroke types (1.3:1). Out of 106 patients, 65 (61.3%) had ischaemic stroke, 38 (35.8%) intracerebral haemorrhage and 3 (2.9%) with subarachnoid haemorrhage. Dyslipidaemia is the most frequent risk factor (85.9%), followed by hypertension (66.0%) and diabetes mellitus (15.1%). Dyslipidaemia was significantly higher in the ischaemic stroke compared to haemorrhagic. Reduced HDL-cholesterol is the most prevalent fraction of lipid abnormalities (74.5%). CONCLUSION: Dyslipidaemia, particularly low HDL-C, was the most frequent risk factor in our patients with stroke. Hence, prevention of dyslipidaemia as well as other risk factors is key to reducing the burden of stroke in our country.

Clinical profile of diabetes mellitus in tuberculosis.

OBJECTIVE: The objective is to document the clinical profile of diabetes mellitus (DM) in tuberculosis (TB). TYPE OF STUDY: This was a descriptive observational study. METHODS: A total of 4000 persons aged above 12 years with a confirmed diagnosis of TB and on treatment were recruited. The study subjects were screened for DM and diagnoses were made on the basis of the WHO criteria. Clinical parameters were compared between persons with DM and those without DM. RESULTS: Mean age was higher in patients with TB and DM than in persons without DM, and this difference was statistically significant (40.9 vs 39.6 years, p=0.0002). DM/TB comorbidity was noted in 480 persons and these made up 12.3% of the study population. Some clinical features of patients with TB who had DM included a positive family history of DM, a history of hypertension, and central obesity. CONCLUSIONS: Given the substantial burden of DM and TB comorbidity, we recommend that patients with TB be screened routinely for DM. However, further research is needed to clarify the risk factors for the occurrence of DM in TB.

Diabetes mellitus in Nigeria: The past, present and future.

Diabetes mellitus (DM) is a diverse group of metabolic disorders that is often associated with a high disease burden in developing countries such as Nigeria. In the early nineties, not much was known about DM in Nigeria and traditionally, people related DM to "curses" or "hexes" and diagnosis was made based on blood or urinary tests for glucose. Currently, oral hypoglycaemic agents but not insulin are readily accessible and acceptable to persons with DM. The cost of diabetes care is borne in most instances by individuals and often payment is "out of pocket"-this being a sequel of a poorly functional national health insurance scheme. An insulin requiring individual on a minimum wage would spend 29% of his monthly income on insulin. Complementary and alternative medicines are widely used by persons with DM and form an integral component of DM care. Towards reducing the burden of DM in Nigeria, we suggest that there be concerted efforts by healthcare professionals and stakeholders in the health industry to put in place preventative measures, a better functioning health insurance scheme and a structured DM program.

Treatment of diabetes mellitus-associated neuropathy with vitamin E and Eve primrose.

BACKGROUND: The aim of this report was to assess the efficacy and safety of a combination of vitamin E, an antioxidant, and Eve Primrose in the management of painful diabetes mellitus (DM) neuropathy. MATERIALS AND METHODS: This was an interventional study that evaluated the efficacy and safety of a combination of vitamin E and Eve Primrose in the management of DM neuropathy. The study was conducted at the Diabetic Centre of the Lagos State University Teaching Hospital, Ikeja. Eighty individuals with type 2 DM who had painful neuropathy were recruited for this study, which took place for a duration of 1 year. The study subjects underwent clinical and biochemical assessment at baseline and were given vitamin E in a dose of 400 mg in combination with Eve Primrose in doses ranging 500-1000 mg/day. They were afterward assessed for relief of symptoms and possible untoward effects after 2 weeks and, thereafter, monthly for 3 months. The main outcome measure was amelioration of symptoms of neuropathy. RESULTS: The mean age and age range of the study subjects were 58.2 years and 37-70 years, respectively. A total of 70 patients (88%) of the study population reported relief from neuropathic pains. Clinical parameters were comparable between the responders and non-responders. One characteristic feature of the non-responders was that they all had vibration perception threshold of ≥25 mV, which was indicative of severe neuropathy. CONCLUSION: The combination of vitamin E and Eve Primrose is beneficial in the management of mild to moderate diabetic neuropathy.

The relationship between red blood cell distribution width and blood pressure in patients with type 2 diabetes mellitus in Lagos, Nigeria.

BACKGROUND: High red blood cell distribution width (RDW) is related to impairment of erythropoiesis, reflecting chronic inflammation and increased levels of oxidative stress, both of which are telltale signs of type 2 diabetics. The aim of this study was to evaluate the relationship between the RDW and fasting blood sugar/blood pressure, and compare the results from diabetics with nondiabetic controls. METHODS: This was an unmatched case-control study involving 200 participants consisting of 100 diabetics and 100 nondiabetic controls. Blood (4.5 mL) was collected from all of the diabetics and nondiabetic controls, and placed into EDTA anticoagulant tubes. A full blood count was performed using the Sysmex KX-21N, a three-part auto analyzer able to run 19 parameters per sample, including RDW. Blood pressure was measured during sample collection and in a sitting position. RESULTS: The mean fasting blood sugar level was 95.20±30.10 mg/dL in the controls, and 147.85±72.54 mg/dL in the diabetics. The mean blood pressures for diabetics was 138/90 mmHg and for non-diabetics 120/80 mmHg. The mean RDW-SD (RDW standard deviation) was 46.44±4.64 fl in the controls, and 46.84±3.18 in the diabetics. The mean RDW-CV (RDW coefficient of variation) was 14.74%±1.94% in controls, and 14.80±0.71 for diabetics. No statistically significant correlation was found between the RDW-SD and fasting blood sugar/blood pressure in the diabetics. A statistically significant positive correlation was found between the RDW-CV and blood pressure in the diabetics. CONCLUSION: A positive correlation between the RDW-CV and blood pressure was established in the diabetics in this study.

Undiagnosed diabetes mellitus in tuberculosis: A Lagos report.

BACKGROUND: Tuberculosis (TB) and diabetes mellitus (DM) are two diseases that are individually relatively common and of immense public health significance globally. There is a growing awareness on a global scale on the possible relationship between TB and DM. Nigeria is a country with a high burden of TB and an increasing incidence of DM. We set out to determine the frequency of occurrence of undiagnosed DM in TB patients. MATERIALS AND METHODS: This was an observational study that was carried out in TB patients recruited from 56 DOT centers in Lagos, Nigeria. The main objective of the study was to determine the disease burden of DM in patients with TB by comparing the frequency of occurrence of DM in TB to the occurrence of DM in people without TB. Screening was carried out by staff-nurses and community health workers-of these DOT facilities who all had capacity building on the detection of DM at the start of the project. RESULTS: Of 4000 TB patients, a total of 480 (12.3%) had DM. Of the pool of DM patients, newly diagnosed cases of DM were 310 (8%) in number and previously known persons with DM were 170 (4.3%). The newly diagnosed cases of DM made up 64% of the cases of DM. In the study population without TB, a total of 112 (5.6%) had DM. The number of newly diagnosed cases of DM were 40 in number and these made up 2% of this study group. The number of persons who were already known to have DM was 72 and these made up 3.6% of the study population. New cases of DM made up 44% of the total number of cases of DM detected in persons without TB. CONCLUSION: The detection rates of DM in patients with TB are higher than in persons without TB. Given the fact that DM may negatively impact TB treatment, we suggest that routine screening be carried out for TB in persons with DM.

Serum C-peptide assay of patients with hyperglycemic emergencies at the Lagos State University Teaching Hospital (LASUTH), Ikeja.

INTRODUCTION: HE are common acute complications of diabetes mellitus (DM) and include diabetic ketoacidosis (DKA), normo-osmolar hyperglycemic state (NHS) and hyperosmolar hyperglycemic state (HHS). They contribute a lot to the mortality and morbidity of DM. The clinical features include dehydration, hyperglycemia, altered mental status and ketosis. The basic mechanism of HE is a reduction in the net effective action of circulating insulin, resulting in hyperglycemia and ketonemia (in DKA) causing osmotic diuresis and electrolytes loss. Infection is a common precipitating factor. Measurement of serum C-peptide provides an accurate assessment of residual ß-cell function and is a marker of insulin secretion in DM patients. AIM AND OBJECTIVES: To assess the level of pancreatic beta cell function in HE patients, using the serum C-peptide. METHODOLOGY: The biodata and clinical characteristics of the 99 subjects were collated using a questionnaire. All subjects had their serum C-peptide, glucose, electrolytes, urea, creatinine levels, urine ketones determined at admission. Results of statistical analysis were expressed as mean ± standard deviation (SD). A p value <0.05 was regarded statistically significant. Correlation between levels of serum C-peptide and admission blood glucose levels and the duration of DM respectively was done. RESULTS: The mean age of the subjects was 51 (SD ± 16) years and comparable in both sexes. Mean duration of DM was 6.3 (SD ± 7.1) years, with 35% newly diagnosed at admission. The types of HE in this study are: DKA (24.7%), NHS (36.1%), and HHS (39.2%). Mean blood glucose in this study was 685 mg/dL, significantly highest in HHS and lowest in NHS. Mean serum C-peptide level was 1.6 ng/dL. It was 0.9 ng/dL in subjects with DKA and NHS while 2.7 ng/dL in HHS (p>0.05). Main precipitating factors were poor drug compliance, new-onset of DM and infection. CONCLUSION: Most (70%) of subjects had poor pancreatic beta cell function, this may be a contributory factor to developing HE. Most subjects with high C-peptide levels had HHS.

Screening for hyperglycemia in the developing world: rationale, challenges and opportunities.

BACKGROUND: The prevalence of diabetes and prediabetes are increasingly high in developing countries, where detection rates remain very low. This manuscript discusses the rationale, challenges and opportunities for early detection of diabetes and prediabetes in developing countries. METHODS: PubMed was searched up to March 2012 for studies addressing screening for hyperglycemia in developing countries. Relevant studies were summarized through key questions derived from the Wilson and Junger criteria. RESULTS: In developing countries, diabetes predominantly affects working-age persons, has high rates of complications and devastating economic impacts. These countries are ill-equipped to handle advanced stages of the disease. There are acceptable and relatively simple tools that can aid screening in these countries. Interventions shown to be cost-effective in preventing diabetes and its complications in developed countries can be used in screen-detected people of developing countries. However, effective implementation of these interventions remains a challenge, and the costs and benefits of diabetes screening in these settings are less well-known. Implementing screening policies in developing countries will require health systems strengthening, through creative funding and staff training. CONCLUSIONS: For many compelling reasons, screening for hyperglycemia preferably targeted, should be a policy priority in developing countries. This will help reorient health systems toward cost-saving prevention.

Epidemiology of thyroid diseases in Africa.

BACKGROUND: Thyroid disorders are common endocrine disorders encountered in the African continent. Environmental and nutritional factors are often implicated in the occurrence of some thyroid disorders that occur in this part of the world. This is a narrative review that seeks to document the pattern, prevalence, and management of thyroid disorders in the continent. MATERIALS AND METHODS: The search engine used for this review were PubMed and Google scholar. All available articles on thyroid disorders from the sub-African continent, published until May 2011, were included. RESULTS: Iodine deficiency disorders (IDD) which top the list of thyroid disorders and remain the commonest cause of thyroid disorders in the continent is often affected not only by the iodine status in the region but sometimes also by selenium deficiency and thiocyanate toxicity. The reported prevalence rates of endemic goiter range from 1% to 90% depending on the area of study with myxedematous cretinism still a prominent feature of IDD in only a few regions of the continent. The extent of autoimmune thyroid disorders remains unknown because of underdiagnosis and underreporting but the few available studies note a prevalence rate of 1.2% to 9.9% of which Graves diseases is the commonest of these groups of disorders. Rarer causes of thyroid dysfunction such as thyroid tuberculosis and amiodarone related causes are also documented in this review. The onset of new thyroid diseases following amiodarone usage was documented in 27.6% of persons treated for arrhythmia. Reports on thyroid malignancies (CA) in Africa abound and differentiated thyroid malignancies are noted to occur more commonly than the other forms of thyroid CA. The documented prevalence rates of thyroid CA in the African continent are as follows (papillary: 6.7-72.1%, follicular: 4.9-68%, anaplastic: 5-21.4%, and medullary: 2.6%-13.8%). For the differentiated thyroid CA, there is a changing trend toward the more frequent occurrence of papillary CA compared to follicular CA and this may be attributable to widespread iodization programs. Our review shows that diagnosis and evaluation of thyroid disorders are reliant in most regions of the continent on clinical acumen and suboptimal diagnostic facilities and expertise are what obtain in many practices. The frequently employed management options of thyroid disorders in the continent are pharmacological and surgical treatment modalities. CONCLUSION: Diagnosis and management of thyroid disorders in the African continent remain suboptimal. Thyroid registries may be helpful to determine the scope of the burden of thyroid disorders since this knowledge may help change policies on the approach to the management of these disorders.

Frequency and correlates of sexual dysfunction in women with diabetes mellitus.

INTRODUCTION: Sexual dysfunction (SD) in women with diabetes mellitus (DM) is an important but understudied aspect of DM complications in women with DM. AIM: This report is an attempt to document the prevalence, clinical correlates, and determinants of SD in a cross sectional study of women with diabetes mellitus (DM). MAIN OUTCOME MEASURES: The main outcome measures were demographic, clinical parameters, psychological morbidity, and frequency of SD. METHODS: A total of 58 married women with type 2 DM and 30 age-matched women who did not have DM had their sexual function and psychological status assessed using the Female Sexual Function Index (FSFI) and General Health questionnaires (GHQ 12) respectively. Glycemic control was assessed using glycosylated hemoglobin. RESULTS: The prevalence of SD in women with DM and in the control population was 88% and 80%, respectively. The mean (standard deviation) FSFI score in the women with DM was significantly lower than that of the control group (16.2 [9.5] vs. 21 [8.5], P = 0.02). Women with DM attempted sex less frequently than those in the control group. Poor mental health status which was found to be associated with SD was noted more in women with DM than those in the control group. CONCLUSIONS: SD is high in women with and without DM. A possible determinant of SD in women with DM is psychological morbidity.

Prognostic indices of diabetes mortality.

INTRODUCTION: Diabetes mellitus is an important cause of morbidity and mortality worldwide and the burden associated with it is felt more in developing countries. Communicable diseases, as opposed to non-communicable diseases, remain a top priority in developing countries like Nigeria. This report sets out to highlight the current status of diabetes-related hospitalizations in Nigeria and also to make comparisons with past reports. This goal will be achieved primarily by determining the prognostic factors associated with diabetes mortality and also noting the duration of hospital stay for the major causes of diabetes deaths. METHOD: From January through December 2006, subjects with diabetes mellitus (DM) in a tertiary hospital in Nigeria were prospectively studied after admission to assess their shortterm outcome which was defined as death. The total mortality, causes of death, associated complications and duration of hospital stay were noted. The predictive factors for DM morbidity were evaluated using chi test, logistic regression. Students t test was computed for quantitative data. RESULTS: A total of 1,327 subjects were admitted to the Medical wards for the duration of the study and the crude death rate was 11%. DM related admissions made up 206 (15%) of all the medical admissions and the case fatality rate was 33 (16%). The most common reasons for DM admission were hyperglycaemic emergencies (HE), 88 (40%) and hypertension, 44 (21%). The most common causes of deaths were HE, 15 (46%) and DM foot ulcers (DFU), 10 (30%) while DFU and cerebrovascular accident (CVA) had the highest case fatality rates of 28% and 25% respectively. DFU had the most prolonged duration of admission ranging from 15-122 days. DFU, CVD and having type 2 DM were highly predictive of fatal outcomes. The odds ratio and 95% CI for these factors were 4.5 (1.5-12.7), 3.0 (0.9-9.92 and 3.1 (0.7-14) respectively. CONCLUSION: DFU and HE are potentially remediable causes of mortality in DM. DFU as seen by the prolonged hospital stay imposes a huge burden on health resources. Better and early intervention of DFU is necessary to reduce the resultant disease burden.