Health Resource Utilization among Patients with Type 2 Diabetes Mellitus In Nigeria: An Analysis from the International Diabetes Management Practice Study (IDMPS).

PURPOSE: To assess the data on health resource utilization collected from patients with T2DM in Nigeria, within the seventh wave (2016) of the International Diabetes Management Practices Study (IDMPS). METHODS: In this cross-sectional study, adults (≥25 years) with T2DM, who had requisite diabetes treatment data and were attended by participating physicians during the two-week recruitment period, were included. Results: Thirty-one participating physicians enrolled 304 eligible patients (mostly 40-60 years of age) with the duration of T2DM ranging from 1 to 31 years (median: 7). Only 34.2% (102/298) patients possessed health insurance and 46.8% (138/295) co-paid for medications outside the insurance. About 70.1% of patients had T2DM-related complications; 19.7% of patients were hospitalized in the past 12 months due to these complications. Altogether, 275 patients with T2DM received oral glucose-lowering drugs, with (88/275) or without (187/275) insulin. The cost of medications/strips was the reason reported for not achieving glycemic targets in ~60.0% (50/84) insulin users and 54.3% (114/210) patients self-monitoring blood glucose, respectively. Specialists in diabetes care attended to a lower number of patients/day than non-specialists (31.61±30.74 vs. 49.25±49.64). Most of the specialists (14/22; 63.6%) reported insulin use in 20%-40% patients; while non-specialists (6/9; 66.6%) reported insulin use in <20% patients. Conclusion: In Nigeria, low insurance coverage and high out-of pocket payments for healthcare limit access to healthcare. Physicians are overburdened and medical resources trained in diabetes care seem insufficient. These findings highlight the need to formulate effective healthcare strategies for patients with T2DM.

Objectif: Évaluer les données sur l'utilisation des ressources de santé collectées auprès des patients atteints de DT2 au Nigéria dans le cadre de la septième vague (2016) de l'Étude Internationale sur les Pratiques de Gestion du Diabète (IDMPS). Méthodes: Dans cette étude transversale, les adultes (≥25 ans) atteints de DT2, qui disposaient de données de traitement du diabète nécessaires et qui ont été pris en charge par des médecins participants au cours de la période de recrutement de deux semaines, ont été inclus. Résultats: Trente et un médecins participants ont inscrit 304 patients éligibles (principalement âgés de 40 à 60 ans) avec une durée du DT2 variant de 1 à 31 ans (médiane : 7). Seuls 34,2% (102/298) des patients étaient assurés santé, et 46,8% (138/295) payaient eux-mêmes pour les médicaments en dehors de l'assurance. Environ 70,1% des patients présentaient des complications liées au DT2 ; 19,7% des patients avaient été hospitalisés au cours des 12 derniers mois en raison de ces complications. Au total, 275 patients atteints de DT2 ont reçu des antidiabétiques oraux, avec (88/275) ou sans (187/275) insuline. Le coût des médicaments/ bandelettes était la raison invoquée pour ne pas atteindre les objectifs glycémiques chez ~60,0% (50/84) des utilisateurs d'insuline et 54,3% (114/210) des patients effectuant l'autosurveillance de la glycémie, respectivement. Les spécialistes en diabétologie prenaient en charge un nombre inférieur de patients par jour que les non-spécialistes (31,61±30,74 contre 49,25±49,64). La plupart des spécialistes (14/22 ; 63,6%) ont signalé l'utilisation de l'insuline chez 20 à 40% des patients ; tandis que les non-spécialistes (6/9 ; 66,6%) ont signalé l'utilisation de l'insuline chez moins de 20% des patients. Conclusion: Au Nigéria , une faible couverture d'assurance et des paiements élevés directement par les patients limitent l'accès aux soins de santé. Les médecins sont surchargés et les ressources médicales formées dans la prise en charge du diabète semblent insuffisantes. Ces résultats soulignent la nécessité de formuler des stratégies de santé efficaces pour les patients atteints de Dt2. Mots-clés: Nigeria, diabète, utilisation des ressources, hospitalisation.

Antenatal women's childbearing practices at the Niger Delta university teaching hospital, Okolobiri Nigeria

Background: Overpopulation in a community or a country reflects high fertility desires of its citizens. A country can only progress meaningfully if its resources and amenities can provide for all its citizens. Objectives: To examine the childbearing practices of antenatal attendees at the Niger Delta University Teaching Hospital, Okolobiri, Nigeria and whether there is any suggestion of fertility decline or transition. Materials and Methods: A cross-sectional study of two hundred and fifty-two women who had antenatal care in the hospital during the study period. Data was collected using a structured self-administered questionnaire with a reliability coefficient of 0.85. Data collected were analysed using IBM SPSS Statistics version 25. Statistical significance was a p-value <0.05. Results: The mean age of the respondents was 30.5 ± 5.9 years. More than half (53.6%) had tertiary education and 39.3% had secondary education. Only 29.4% were housewives/unemployed. The median parity was 2 and 229 women accounted for previous deliveries of 596 babies. The median desired total number of children was 4 (range 1 to 8). More than half (56.3%) did not believe in spacing after the first child. Seventy-six (30.2%) had no knowledge of modern contraceptives. There was a significant relationship (p - 0.018) between child sex preference and number of births. Conclusion: With a current median parity of two children/woman and desired total number of children of a median of four children/woman, the childbearing practices of the population studied may not result in a fertility rate far below the Nigeria national average of 5.3 children per woman. Nevertheless, a study to derive the total fertility rate in the study population is necessary to determine whether or not there is ongoing fertility transition.

The Prevalence and Pattern of Thyroid Dysfunction in HAART-Naïve HIV Patients in Enugu, Nigeria: A Cross-Sectional Comparative Study.

BACKGROUND: HIV/AIDS is a multi-system disease that has been associated with several endocrinopathies including thyroid dysfunction. Thyroid dysfunction in patients with HIV/AIDS, among other factors, may arise from the direct cytopathic effects of HIV on the thyroid gland in addition to the adverse effects of highly active anti-retroviral drugs (HAART). STUDY OBJECTIVE: The study aimed to determine the prevalence and pattern of thyroid dysfunction in HAART naïve HIV patients in Enugu. MATERIALS & METHODS: Study was cross sectional, casecontrol based, involving 250 HAART naïve HIV sero-positive patients and 250 HIV sero-negative subjects. Anthropometric measurements and physical examination were done. Assay for fT3, fT4, TSH (for thyroid function) was done using the Enzyme Linked Immunoassay (ELISA) method. Data was analyzed using the Statistical Package for Social Sciences (SPSS) version 23. RESULTS: The HAART naïve sero-positive cohorts comprised 112 males and 138 females while the control subjects consisted of 125 males and 125 females. Mean ages (years) of test and control groups were 38.84± 10.60 and 39.58 ±11.68 respectively. Prevalence of thyroid dysfunction among the study subjects was 36.4% and 7.6% in the controls. Subclinical hypothyroidism was the most common prevalent type of thyroid dysfunction in both test and control groups at 17.6% and 7.2% respectively. In the test group, sick euthyroid syndrome (17.2%) ranked second while in the controls, primary hypothyroidism (7.2%) was the second commonest dysfunction. CONCLUSION: Thyroid dysfunction was more common in HAART-naïve HIV sero-positive subjects than in the general population with subclinical hypothyroidism emerging as the commonest abnormality.

CONTEXTE: Le VIH/SIDA est une maladie multisystémique qui a été associée à plusieurs endocrinopathies, dont la thyroïde associée à plusieurs endocrinopathies, y compris le dysfonctionnement de la dysfunctionnement. Le dysfonctionnement thyroïdien chez les patients atteints du VIH/SIDA, entre autres facteurs, peut être due aux effets cytopathiques directs du cytopathiques directs du VIH sur la glande thyroïde, en plus des effets indésirables des médicaments antirétroviraux hautement actifs (HAART). OBJECTIF DE L'ÉTUDE: L'étude visait à déterminer la prévalence et le modèle de dysfonctionnement thyroïdien chez les patients VIH naïfs de traitement HAART à Enugu. MATÉRIEL ET MÉTHODES: L'étude était transversale, basée sur un cas-témoin, impliquant 250 patients séropositifs n'ayant jamais reçu de HAART et 250 patients séronégatifs et 250 sujets séronégatifs. Des mesures anthropométriques et un examen physique ont été effectués. Les dosages de fT3, fT4, TSH (pour la fonction thyroïdienne) a été effectué à l'aide de l'Enzyme Linked Immunoassay (ELISA). Les données ont été analysées en utilisant le progiciel statistiques pour sciences sociales (SPSS) version 23. RÉSULTATS: Les cohortes séropositives n'ayant jamais reçu de HAART comprenaient 112 hommes et 138 femmes, tandis que les sujets témoins comprenaient 125 hommes et 125 femmes. Les âges moyens (années) des groupes test et groupes témoins étaient respectivement de 38,84± 10,60 et 39,58 ±11,68. La prévalence du dysfonctionnement de la thyroïde parmi les sujets de l'étude était de 36,4 % et 7,6 % chez les témoins. L'hypothyroïdie subclinique était le type de dysfonctionnement thyroïdien le plus répandu dans les groupes test et témoin soit 17,6 % et 7,2 % respectivement. Dans le groupe test, le syndrome d'euthyroïdie maladive (17,2 %) arrivait en deuxième position, tandis que dans le groupe témoin, l'hypothyroïdie primaire (7,2 %) était le deuxième type de dysfonctionnement le plus courant. CONCLUSION: Les dysfonctionnements de la thyroïde étaient plus fréquents chez les personnes suivantes sujets séropositifs n'ayant jamais reçu de traitement antirétroviral que dans la population générale, l'hypothyroïdie subclinique apparaissant comme la l'anomalie la plus fréquente. MOTS-CLÉS: Prévalence, Modèle, HAART-naïf, patients VIH, dysfonctionnement de la thyroïde, Nigéria.

Obesity:The modern Epidemic.

EDITORIAL.

Hyperglycaemic Emergencies in a Tertiary Health Facility in South-Eastern Nigeria.

BACKGROUND: Patterns of hyperglycaemic emergencies (HE) include diabetic ketoacidosis, (DKA), hyperglycaemic hypero-smolar state, (HHS), normo-osmolar non-ketotic hyper-glycaemic state, (NONKHS), or the mixed/indeterminate form. Certain factors are predictive of adverse HE outcome. There is a paucity of literature on the patterns and poor prognostic factors of HE in the South East (SE) region of Nigeria, hence, the need for this study. MATERIALS AND METHODS: This was a prospective observa-tional study done to assess the pattern of prognostic factors for HE managed at the Federal Medical Centre, (FMC), Umuahia, South East, Nigeria. Consecutively recruited adult patients managed for HE at FMC, Umuahia between July 2015 and March 2016 were studied. Patterns of HE were determined via biochemical tests while prognostic factors were determined from biodata, precipitating illnesses, clinical presentations and other comorbid illnesses. Analysis of data was done using SPSS 20.0 and the level of statistical significance was set at p < 0.05. RESULTS: A total of 110 subjects were recruited, made up of 46 (42%) males and 64 (58%) females. Death from HE occurred in 10% of the subjects with case fatality rates of 3.6%, 2.7%, and 0.9% for the mixed type, DKA/NONKHS and HHS respectively. Mixed/indeterminate form was the commonest pattern followed by DKA and then NONKHS. The correlates of HE death included stroke, diastolic hypotension and presence of complication(s) attributable to HE but the independent risk factors for death from HE were diastolic hypotension and stroke Cerebrovascular Accident (CVA) only. CONCLUSION: Mixed form of HE and DKA were the most common presentations of HE in this facility and the independent risk factors for death from HE were diastolic hypotension and stroke (CVA).

Selfmonitoring of blood glucose practices by people living with diabetes who use their personal glucometers in Port Harcourt, Niger Delta Region, Nigeria

Self-monitoring of blood glucose (SMBG) assists persons living with diabetes with the day-to-day behavioral and therapeutic adjustments to their diabetes care. It is a cheaper and more available alternative to glycated haemoglobin (HbA1c) in Nigeria for monitoring glycaemic control. Information on SMBG practices of Nigerians living with diabetes using their personal glucometers is scanty. The aim of the study is to assess the intensity and frequency of SMBG by glucometer owners, and the extent the patients and/or the health care providers (HCP) utilize SMBG to achieve personalized treatment goals via behavioral/treatment adjustments. This was a cross sectional study carried out among persons living with diabetes that accessed diabetes care at the diabetes clinic of the University of Port Harcourt Teaching Hospital (UPTH) and using their personal glucometers. They were consecutively recruited. Data obtained by using interviewer-administered questionnaires were analyzed using SPSS version 20.0, and pvalue <0.05 was considered significant. A total of 128 persons living with diabetes participated in the study of which 40 (31%) were males and 88 (69%) were females; the mean age of the subjects was 52.05 ± 11.24 years with a range of 26­70 years. The majority of the study subjects (72%) were in the active working age group (25­60years). The highest frequency of glucometer use was in the 26 subjects (20%) who checked their blood glucose every morning while 62 (48%) of the subjects checked their blood glucose any morning they felt like. Most of the subjects (60%) did not have any recording device. Glucometer owners were not just the insulin-requiring people living with diabetes as more than half of the subjects, 66 (52%) were on oral anti diabetic drugs (OAD) only. Glucometer ownership was mainly by those that were in the working age group. SMBG protocol (frequency) was variable and SMBG data were not maximally utilized

Self blood glucose monitoring among diabetic patients in Port Harcourt, Nigeria

Self blood glucose monitoring (SBGM) is important in the management of people living with diabetes. This study set out to evaluate the knowledge and practice of SBGM in diabetic patients at our clinic in Port Harcourt, Nigeria. Ninety (90) diabetic patients attending the clinic were assessed with self-administered questionnaires. There were 36 (40%) males and 54 (60%) females with a mean age of 54±23 years, and a mean duration of diabetes of 8 years. Eighty-one (90%) had type 2 diabetes while nine (10%) had type 1 diabetes. Eighteen type 2 patients (20%) were on insulin alone, 52 (58%) on oral drugs, and 20 (22%) were on a combination. Fifty-two patients knew only about using glucose meters for SBGM, 30 knew about using both meters and urine dipsticks, and 4 did not know of any method. Only 24 (27%) patients had glucose meters and no type 1 patient had a meter. The highest frequency of monitoring was once daily in six patients. None of the patients practised urine monitoring. In conclusion, this study has shown that the practice of SBGM in our patients is inadequate despite reasonable knowledge of the technique. This is most likely due to scarce resources. The importance of SBGM should be emphasised more in our practice, especially in patients with type 1 diabetes, and there should be motivation for improved self-monitoring resources

Endocrine and metabolic disorders associated with human immune deficiency virus infection.

BACKGROUND: Many reports have described endocrine and metabolic disorders in the human immunodeficiency virus (HIV) infection. This article reviewed various reports in the literature in order to increase the awareness and thus the need for early intervention when necessary. DATA SOURCE: Data were obtained from MEDLINE, Google search and otherjournals on 'HIV, Endocrinopathies/Metabolic Disorders' from 1985 till 2007. STUDY SELECTION: Studies related to HIV associated endocrinopathies and metabolic disorders in the last two decades were reviewed. DATA EXTRACTION: Information on epidemiology, pathogenesis, diagnosis and treatment of the target organ endocrinopathies and metabolic disorders in HIV/AIDS were extracted from relevant literature. RESULTS: Endocrine and metabolic disturbances occur in the course of HIV infection. Pathogenesis includes direct infection of endocrine glands by HIV or opportunistic organisms, infiltration by neoplasms and side effects of drugs. Adrenal insufficiency is the commonest HIV endocrinopathy with cytomegalovirus adrenalitis occurring in 40-88% of cases. Thyroid dysfunction may occur as euthyroid sick syndrome or sub-clinical hypothyroidism. Hypogonadotrophic dysfunction accounts for 75% of HIV-associated hypogonadism, with prolonged amenorrhoea being three times more likely in the women. Pancreatic dysfunction may result in hypoglycaemia or diabetes mellitus (DM). Highly active antiretroviral therapy (HAART) especially protease inhibitors has been noted to result in insulin resistance and lipodystrophy. CONCLUSION: Virtually every endocrine organ is involved in the course of HIV infection. Detailed endocrinological and metabolic evaluation and appropriate treatment is necessary in the optimal management of patients with HIV infection in our environment.

Pattern of non-communicable diseases among medical admissions in Port Harcourt, Nigeria.

OBJECTIVE: To determine the pattern of non-communicable diseases in the medical wards of the University of Port Harcourt Teaching Hospital (UPTH), over four consecutive years (June 2000 to June 2004). METHODS: The study was retrospective and data were obtained from the medical registers in the medical wards and the records department of the UPTH. Medical admissions due to non-communicable diseases were carefully selected and analyzed. RESULTS: There were 1853 cases of various non-communicable diseases out of a total medical admission of 3294 constituting 56.2% of total medical admissions. Diseases of the cardiovascular, endocrine and renal systems were the most prevalent constituting 35.7%, 18.5% and 16.8% respectively. Hypertension, diabetes mellitus, and chronic renal failure were the most common cardiovascular, endocrine and renal disorders respectively CONCLUSION: Non-communicable diseases are a major cause of morbidity in Port Harcourt. There is need for adequate health education and lifestyle modification to reduce the burden of non-communicable diseases in Nigeria.

Thyrotoxicosis - a Review

"Background: Thyrotoxicosis is the clinical and biochemical manifestations of exposure of tissues to excessive quantities of thyroid hormones; specifically free thyroxine (T4 ); tri-iodothyronine (T3) or both. The terms ""thyrotoxicosis""; ""hyperthyroidism"" and ""Graves' disease"" are used interchangeably because hyperthyroidism due to Graves' disease is the commonest cause of thyrotoxicosis. Studies in most countries reveal an increasing incidence of thyrotoxicosis. Aim: To present an update on the causes and management of thyrotoxicosis with emphasis on Graves' disease. Methods: A review of publications obtained from medline search and Google on ""thyrotoxicosis"" or ""Graves' disease"" or ""hyperthyroidism"" was done. Results: Graves' disease constitutes about 70of cases of thyrotoxicosis.The common clinical features include weight loss despite enhanced appetite; hyperactivity and heat intolerance etc. Features specific to Graves' disease include ophthalmopathy; pretibial myxoedema and thyroid acropachy. Thyrotoxicosis affects about 1of women and 0.1of men globally. It is indicated in most cases by an elevated serum concentration of total T4 and T3 and a suppressed thyroid stimulating hormone (TSH). Thyroid imaging and radiotracer uptake measurements combined with serological data enable specific aetiological diagnosis. The three treatment modalites for Graves' disease are antithyroid drugs; 131I therapy and thyroidectomy. Conclusion: The incidence of thyrotoxicosis is increasing globally. Optimal clinical and laboratory evaluation of the patient is necessary to identify the cause and institute appropriate therapy. There is need for prospective studies to identify the factors for the observed increasing incidence of thyrotoxicosis in our population"

Double diabetes: an emerging disease in children and young adults

Background: Studies in most countries have shown an increasing incidence of diabetes mellitus in children and young adults. Double diabetes is a newly recognized problem in children with different diagnostic and therapeutic measures. Methods: A review of over 30 literature obtained from Google; PUBMED search and journal publications on ""double diabetes"" was done to determine the incidence; pathophysiology; pathogenesis; diagnostic criteria; treatment and prevention of double diabetes in children and young adults. Results: Most of the reports on double diabetes were from western countries and Asia. Type 1 diabetes resulting from antibodies to the insulin-producing pancreatic beta cell was more prevalent in children. However; with increasing obesity the incidence of type 2 diabetes resulting from insulin resistance was high in children and young adults. Most patients with double diabetes were established type 1 diabetics; who while on insulin and on hypercaloric diet developed obesity especially during puberty and hence associated type 2 diabetes. The incidence was more in black than in white children. They presented with some clinical and laboratory features of both types 1 and 2 diabetes. Some authors advocated treatment with both insulin and oral hypoglycaemic drugs mainly metformin to improve insulin sensitivity. Prevention of childhood obesity by encouraging physical activities and dietary control would prevent double diabetes. Conclusion: Double diabetes is increasing in children and young adults. A high index of suspicion is required in obese children with diabetes

The Pattern and distribution of communicable diseases among medical admissions in Port Harcourt, Nigeria

Background: Global and regional estimates show that non-communicable diseases are rising in importance relative to other causes of ill health as populations age and the fight continues against communicable diseases. However; communicable diseases remain a major cause of mortality and morbidity in the developing world.Aim: The study was carried out to determine the pattern of communicable diseases in the medical wards of the University of Port Harcourt Teaching Hospital; (UPTH) over four consecutive years (June2000 June 2004). Methods: The study was retrospective and data were obtained from the medical registers in the medical wards and the records department of the University of Port Harcourt Teaching Hospital. Medical admissions due to communicable diseases were carefully selected and analyzed.Results: There were 1441 cases of various communicable diseases out of a total of 3294 medical admissions constituting 43.8; while non-communicable diseases accounted for 56.2.The top ten communicable diseases identified were tuberculosis; HIV/AIDS; septicaemia; lobar pneumonia; acute viral hepatitis; chronic liver disease(viral); enteric fever; malaria; urinary tract infections and amoebic liver disease. Conclusion: Communicable diseases still remain a major cause of morbidity in Port Harcourt hence the double burden of disease. There is need for improvement in housing; provision of portable water; immunization; health education and improved sanitation amongst other social amenities to reduce the scourge of communicable diseases in Nigeria

The bacteriology of diabetic foot ulcers in Port Harcourt, Nigeria.

BACKGROUND: Diabetic foot ulcer and/or gangrene is a common cause of morbidity and mortality in Nigeria. The lesions are usually infected and early treatment of the infection will reduce the associated problems. The study was carried out to determine the common bacteriological flora of diabetic foot ulcers in Port Harcourt. The antimicrobial sensitivity pattern of the isolates was determined to enhance possible empirical treatment. METHODS: Deep wound swabs were collected from 60 consecutive diabetic patients admitted with foot ulcers and/or gangrene into the medical wards of the University of Port Harcourt Teaching Hospital from January 2001 to April 2002. The bacteriological isolation and antimicrobial sensitivity tests of the isolates was carried out by standard microbiological methods. RESULTS: Aerobes and anaerobes constituted 95.4% and 4.6% of the total bacterial isolates respectively. Staphylococcus aureus was the commonest bacterial isolate; it was cultured from 32 (56.1%) of infected patients and constituted 24.4% of the total isolate. The mean bacterial isolate per patient infected was 2.3. The aerobic isolates showed significant sensitivity to ciprofloxacin (78.4%), pefloxacine (71.2%), ceftazidime (73.6%) and cefuroxime (69.6%). All the anaerobic isolates were sensitive to metronidazole and clindamycin. CONCLUSION: Infections of diabetic foot ulcers are usually polymicrobial. From the in vitro antimicrobial susceptibility pattern of the bacterial isolates, diabetic patients presenting with foot ulcers and/or gangrene could be commenced empirically on a combination of clindamycin or metronidazole and either a fluoroquinolone (ciprofloxacin or pefloxacine) or a second or third generation cephalosporin (e.g. cefuroxime or ceftazidime).