Rural-Urban Differences in Risk Factors for Prediabetes and Undiagnosed Diabetes Among Adult Dwellers in Selected Yoruba-Speaking Parts of Nigeria: A Glycated Haemoglobin-Based Population Screening.

BACKGROUND AND OBJECTIVES: Prevalence of prediabetes and undiagnosed diabetes are different in rural and urban dwellings, with varying driving factors. This study aimed to determine the differences in risk factors of prediabetes and undiagnosed diabetes among Yoruba speaking adult dwellers in selected rural and urban communities in Nigeria using haemoglobin A1c. METHODS: A cross-sectional study was conducted in five selected states in Southwestern Nigeria. Using a multistage sampling technique, 2,537 participants with no prior diagnosis of prediabetes or diabetes mellitus (DM) were enrolled and their glycated haemoglobin (HbA1c) determined. Descriptive statistics, univariate and multiple logistic regression analysis was used to determine the prevalence and risk factors of prediabetes and diabetes at 5% level of significance. RESULTS: Increased age, sex, family history of diabetes, being married, participants' history of hypertension, cardiovascular disease and Gestational Diabetes Mellitus (GDM) or delivery of big babies, BMI, systolic and diastolic blood pressure were significantly associated with prediabetes and diabetes in both urban and rural areas. However, adjusted odds ratio showed that family history of diabetes (2.14, 95% CI: 1.26-3.61 versus 1.36, 95% CI: 1.00-1.85) and past GDM among women (2.67, 95% CI: 0.62, 11.39 versus 1.32, 95% CI: 0.61, 2.89) clearly predict dysglycaemia in the rural compared to urban participants, respectively. CONCLUSIONS: Family history of diabetes and past GDM disproportionately predict dysglycaemia in rural compared to urban participants. Periodic screening for dysglycaemia and public health education, especially in child-bearing women, are necessary measures to reduce the burden of dysglycaemia in Nigeria.

CONTEXTE ET OBJECTIFS: La prévalence du prédiabète et du diabète non diagnostiqué diffère entre les zones rurales et urbaines, avec des facteurs déterminants variés. Cette étude visait à déterminer les différences dans les facteurs de risque du prédiabète et du diabète non diagnostiqué chez les adultes yoruba-parlants vivant dans des communautés rurales et urbaines sélectionnées au Nigeria, en utilisant l'hémoglobine A1c. MÉTHODES: Une étude transversale a été menée dans cinq États sélectionnés du sud-ouest du Nigeria. Utilisant une échantillonnage en plusieurs étapes, 2 537 participants sans diagnostic antérieur de prédiabète ou de diabète sucré (DS) ont été recrutés et leur hémoglobine glyquée (HbA1c) déterminée. Des statistiques descriptives, ainsi que des analyses de régression logistique univariée et multivariée, ont été utilisées pour déterminer la prévalence et les facteurs de risque du prédiabète et du diabète à un seuil de signification de 5 %. RÉSULTATS: L'augmentation de l'âge, le sexe, les antécédents familiaux de diabète, le mariage, les antécédents d'hypertension, de maladie cardiovasculaire et de diabète gestationnel (DG) ou l'accouchement de gros bébés, l'IMC, la pression artérielle systolique et diastolique étaient significativement associés au prédiabète et au diabète dans les zones urbaines et rurales. Cependant, les odds ratio ajustés ont montré que les antécédents familiaux de diabète (2,14, IC à 95 % : 1,26-3,61 contre 1,36, IC à 95 % : 1,00-1,85) et les antécédents de DG chez les femmes (2,67, IC à 95 %: 0,62, 11,39 contre 1,32, IC à 95 % : 0,61, 2,89) prédisent clairement la dysglycémie en milieu rural par rapport aux participants urbains, respectivement. CONCLUSIONS: Les antécédents familiaux de diabète et les antécédents de DG prédisent de manière disproportionnée la dysglycémie en milieu rural par rapport au milieu urbain. Un dépistage périodique de la dysglycémie et une éducation sanitaire, en particulier chez les femmes en âge de procréer, sont des mesures nécessaires pour réduire le fardeau de la dysglycémie au Nigeria. MOTS-CLÉS: Prédiabète, diabète non diagnostiqué, Facteurs de risque, Rural-urbain, Différences, Basé sur l'hémoglobine glyquée, Nigeria.

Perception and Learning Satisfaction of Resident Doctors Amid COVID-19 Pandemic: Adaptation Experience at a Virtual Educational Course in Internal Medicine.

OBJECTIVES: This study aimed to assess the perception of the significance of the revision course and satisfaction of resident doctors with the West African College of Physicians (WACP) revision course in internal medicine. METHODS: This was a post-training evaluation of resident doctors who had enrolled for the 2021 membership revision course in internal medicine between August 9-13, 2021. Data were collected through an electronic questionnaire composed of five sections: Sociodemographic characteristics, involvement in research, perception on the significance/expectations from the course, lessons learnt, and perception of the overall coordination of the revision course/recommendations. Descriptive statistics were summarized using frequency tables. Chi-square tests were conducted to determine the association between participants' sociodemographic characteristics and satisfaction with the WACP revision course. RESULTS: The mean age (±SD) of the 119 resident doctors was 34.30 (± 4.81) years and the median duration (range) of residency training was 7 (4-10) years. All participants were currently in medical practice either in teaching hospitals (104,87.4%) or secondary health facilities (15, 12.6%). Overall, 108 (90.8%) doctors were satisfied with the course. Variables that were associated with satisfaction with the WACP revision course included: duration in residency training (doctors that had spent two years or less in the residency training programme) (Chi-square = 21.703, p = <0.001), place of residency training (teaching hospitals) (Chi-square = 67.461, p = <0.001), and participation in research (Chi-square = 47.976, p = <0.001). CONCLUSION: The WACP revision course in internal medicine met its objectives. Engagement of resident doctors in research activities should be undertaken intensely.

OBJECTIFS: Cette étude visait à évaluer la perception de l'importance du cours de révision et la satisfaction des médecins résidents à l'égard du cours de révision en médecine interne du West African College of Physicians (WACP). MÉTHODES: Il s'agissait d'une évaluation post-formation des médecins résidents qui s'étaient inscrits au cours de révision en médecine interne pour les membres de 2021 entre le 9 et le 13 août 2021. Les données ont été recueillies au moyen d'un questionnaire électronique composé de cinq sections : Caractéristiques sociodémographiques, implication dans la recherche, perception de l'importance/attentes du cours, leçons apprises, et perception de la coordination globale du cours de révision/recommandations. Les statistiques descriptives ont été résumées à l'aide de tableaux de fréquence. Des tests de Chi-carré ont été effectués pour déterminer l'association entre les caractéristiques sociodémographiques des participants et la satisfaction du cours de révision WACP. RÉSULTATS: L'âge moyen (±SD) des 119 médecins résidents était de 34,30 (± 4,81) ans et la durée médiane (fourchette) de la formation en résidence était de 7 (4-10) ans. Tous les participants exerçaient actuellement la médecine dans des hôpitaux universitaires (104, 87,4%) ou des établissements de santé secondaires (15, 12,6 %). Dans l'ensemble, 108 (90,8%) médecins étaient satisfaits de la formation. Les variables qui étaient associées à la satisfaction du cours de révision du WACP comprenaient : la durée de la formation en résidence (les médecins ayant passé deux ans ou moins dans le programme de formation en résidence) (Chi-carré = 21.703, p = <0.001), le lieu de formation en résidence (hôpitaux universitaires) (Chi-carré = 67.461, p = <0.001), et la participation à la recherche (Chi-carré = 47.976, p = <0.001). CONCLUSION: Le cours de révision WACP en médecine interne a atteint ses objectifs. L'engagement des médecins résidents dans des activités de recherche devrait être entrepris de manière intensive. Mots-clés: Pratique médicale, Enseignement médical, Formation des résidents, Médecine interne, Afrique.

Atypical Diabetes Presentations in Sub-Saharan Africa Classification Puzzle and Possible Role of Precision Medicine.

Precision in the diagnosis and classification of diabetes mellitus, a complex heterogeneous disease is increasingly required to achieve treatment goals and prevent complications. Several reviews over decades have not completely solved the diabetes classification puzzle. African clinicians are sometimes confronted with the difficulty of classifying a newly diagnosed diabetes patient presenting atypically. These unusual presentations fall into those with diagnosis of either clinical type 1 or 2 diabetes but having some diagnostic and/or therapeutic features at variance with what are seen in the Western nations, those with tropical diabetes and those known as ketosis-prone type 2 diabetes (KPD). Reports from many African countries indicate that patients do not fit the classic pattern seen in the Western nations. In recent times, there has been groundswell of pressures and proposed models to evolve a more accurate classification of diabetes and the recent 2019 WHO diabetes classification seems to have acknowledged and accommodated these concerns. Perhaps advances in genomic knowledge could help with precision in diabetes classification, especially in Africa. This review seeks to highlight the challenges often encountered with classifying diabetes patients in Africa, and proffer suggestions on the way forward including possible benefit from advances in molecular genomics.

VITAMIN B12 LEVELS IN PATIENTS WITH TYPE 2 DIABETES MELLITUS ON METFORMIN.

BACKGROUND: Due to the clinical benefits of metformin, its associated side effects such as vitamin B12 deficiency are usually overlooked and rarely investigated. OBJECTIVE: This study was carried out to determine the serum level of vitamin B12 in Nigerian patients with type 2 diabetes mellitus (T2DM) on metformin. METHODS: Serum vitamin B12 level was determined using high performance liquid chromatography (HPLC) in 81 T2DM patients who have been on metformin for 5 years or more. Vitamin B12 deficiency was defined as serum concentration of <200 pg/dl, borderline deficiency as 200 - 300 pg/dl and >300 pg/dl as normal. Differences in vitamin B12 levels between different groups were assessed using Mann Whitney U test and P<0.05 was considered as statistically significant. RESULTS: Vitamin B12 deficiency and borderline deficiency were recorded in 8.6% and 26.0% of the patients respectively. Vitamin B12 level was significantly lower in patients who have been on metformin for ≥10 years compared with patients with <10 years history of metformin use. Similarly, patients who were on metformin at a dose of >1000 mg/day had significantly lower vitamin B12 level when compared with patients on ≤1000 mg/day. CONCLUSION: Low serum vitamin B12 level is associated with longer duration and higher dose of metformin use. Therefore, routine determination of vitamin B12 level in patients with T2DM on high dose of metformin and those with prolonged use of metformin might help in identifying patients that would benefit from vitamin B12 supplements.

A report of three cases of jaundice with thyrotoxicosis.

BACKGROUND: Jaundice and hepatic dysfunction have been reported in patients with thyrotoxicosis and could be due to different mechanisms. OBJECTIVE: To describe three cases of jaundice occurring in patients with thyrotoxicosis and to illustrate the importance of early institution of thionamides when indicated. METHODS: We present the clinical and laboratory features of three patients presenting within a year with thyrotoxicosis and jaundice and whose clinical conditions improved remarkably following treatment with thionamides. In addition, current literature on the subject is reviewed and summarised. RESULTS: The three patients presented with goitre and jaundice. None of the patients had received blood products, undergone scarification markings or experienced any previous episode of jaundice. Thyroid function tests in the three patients were consistent with a diagnosis of thyrotoxicosis. Liver function tests showed elevated bilirubin and transaminases. All patients improved remarkably following treatment with thionamides. CONCLUSION: It is important to rule out thyrotoxicosis in patients with jaundice of unknown cause and consider early use of thionamides for treatment of the thyrotoxicosis, if confirmed.

Co-occurrence of diabetes and hypertension: pattern and factors associated with order of diagnosis among nigerians

Background : There is a high frequency of co-occurrence of diabetes and hypertension all over the world. Such association results in higher rate of cardiovascular complications. It is however not clear whether the order of occurrence distinguishes two different groups of patients and the implications of this on morbidity and mortality. The main objective of this study is to determine if there are any clinical and metabolic differences between those first diagnosed with diabetes (hypertensive diabetics) compared to those first diagnosed with hypertension (diabetic hypertensives). Methodology : A total of 124 patients with co-existent diabetes and hypertension were consecutively recruited into the study. Demographic and clinical history was captured on a semi-structured questionnaire; followed by measurement of anthropometry and blood pressure. Records of fasting plasma glucose; urinalysis and electrolytes; urea and creatinine were obtained from the case records. Results : There were 83 (66.9) females and 41 (33.1) males with mean age of 61.1 (SD 11.1) years. Sixty or 49.6was hypertensive diabetics while 52 or 43was diabetic hypertensive. The rest had simultaneous diagnosis of diabetes and hypertension. The diabetic hypertensive subjects significantly had higher BMI (p= 0.04) while the hypertensive diabetics group had higher hip/waist ratio (p = 0.01). The diabetic hypertensive group had higher waist circumference statistically significant only in women (p = 0.04). Also significantly more people (21 or 42; p = 0.04) in the diabetic hypertensive group used table salt often. A logistic regression performed showed that only use of table salt was independently associated with order of diagnosis of diabetes or hypertension. Conclusion : There could be significant differences in some clinical characteristics of hypertensive diabetics and diabetic hypertensives; and use of table salt may be an important risk factor contributing to coexistence of both conditions

Excess renal insufficiency among type 2 diabetic patients with dip-stick positive proteinuria in a tertiary hospital.

BACKGROUND: Most patients with Diabetic Nephropathy (DN) in developing countries are detected at the rather late stage of clinical nephropathy by routine semi-quantitative dip-stick urinalysis. Some patients with DN have been reported to have renal insufficiency at the time of diagnosis. Little is known about the GFR status of such macroalbuminuric Nigerian diabetic patients. The aim of this study was to assess levels of creatinine and GFR in dip-stick positive type 2 diabetic patients at the University College Hospital (UCH), Ibadan, Nigeria. METHODOLOGY: A cross-sectional study was carried out. Forty dip-stick positive out of 79 randomly screened patients with T2DM attending the Diabetes Clinic of UCH, Ibadan who met selection criteria were recruited. Data were obtained on demography, diabetes history, and blood pressure. Samples were collected and analysed for 24-hour urinary protein, creatinine, and blood glucose. Creatinine clearance was estimated by Cockroft-Gault formula. RESULTS: There were 25 (62.5%) females and 15 (37.5%) males. The mean age of subjects was 59.4 years (SD 11.25). Twenty-seven (67.5%) had elevated serum creatinine, 33 (82.5%) were macroalbuminuric, while 36 (90%) had creatinine clearance indicating renal insufficiency. Also 18 (45%) patients and 19 (47.5%) had suboptimal blood pressure control and glycaemic control. CONCLUSION: We concluded that there appears to be excess renal insufficiency among type 2 diabetic patients with overt proteinuria in UCH, Ibadan. Diabetic patients with overt proteinuria should immediately be assessed for renal insufficiency and appropriate measures instituted to prevent or delay progression to ESRD.

Co-occurrence of diabetes and hypertension: pattern and factors associated with order of diagnosis among nigerians.

BACKGROUND: There is a high frequency of co-occurrence of diabetes and hypertension all over the world. Such association results in higher rate of cardiovascular complications. It is however not clear whether the order of occurrence distinguishes two different groups of patients and the implications of this on morbidity and mortality. The main objective of this study is to determine if there are any clinical and metabolic differences between those first diagnosed with diabetes (hypertensive diabetics) compared to those first diagnosed with hypertension (diabetic hypertensives). METHODOLOGY: A total of 124 patients with co-existent diabetes and hypertension were consecutively recruited into the study. Demographic and clinical history was captured on a semi-structured questionnaire, followed by measurement of anthropometry and blood pressure. Records of fasting plasma glucose, urinalysis and electrolytes, urea and creatinine were obtained from the case records. RESULTS: There were 83 (66.9%) females and 41 (33.1%) males with mean age of 61.1 (SD 11.1) years. Sixty or 49.6% was hypertensive diabetics while 52 or 43% was diabetic hypertensive. The rest had simultaneous diagnosis of diabetes and hypertension. The diabetic hypertensive subjects significantly had higher BMI (p= 0.04) while the hypertensive diabetics group had higher hip/waist ratio (p = 0.01). The diabetic hypertensive group had higher waist circumference statistically significant only in women (p = 0.04). Also significantly more people (21 or 42%; p = 0.04) in the diabetic hypertensive group used table salt often. A logistic regression performed showed that only use of table salt was independently associated with order of diagnosis of diabetes or hypertension. CONCLUSION: There could be significant differences in some clinical characteristics of hypertensive diabetics and diabetic hypertensives, and use of table salt may be an important risk factor contributing to coexistence of both conditions.

Plasma lipid peroxidation and totalantioxidant status among dyslipidaemic and hypertensive Nigerians with high risk of coronary heart disease.

BACKGROUND: The oxidative modification hypothesis of atherosclerosis predicts that low density lipoprotein-cholesterol (LDL-C) oxidation is an early event in atherosclerosis and that oxidized LDL-C contributes to atherogenesis OBJECTIVE: To determine a link, if any, between the plasma lipid peroxidation and total antioxidant status (TAS) among dyslipidemic and hypertensive Nigerian patients with high risk of coronary heart disease. METHODS: The study groups comprised 58 hypertensive adult Nigerians whose fasting plasma total cholesterol (TC) levels were > 5.5 mmol/L and with high risk coronary heart disease (CHD) lipid fraction i.e. 'the ratio of high density lipoprotein cholesterol to total cholesterol' (HDL-C/TC) < 0.13 were selected for the study. The control groups comprised 58 non hypertensive adult Nigerians with (HDL-C/TC) > 0.30. RESULTS: The mean +/- SD TAS level (1.02 +/- 0.15 mmol/L trolox) for males and (0.99 +/- 0.17 mmol/L) for females were significantly reduced (p < 0.05) compared to the controls; however (MDA) level (5.15 +/- 0.82 mmol/ml) for males and (5.06 +/- 0.73 mmol/ml) for females were significantly increased (p < 0.01) compared to the controls. The mean +/- SD plasma TC and LDL-C malonyl level (5.87 +/- 0.23 mmol/L and 4.65 +/- 0.34 mmol/L) were significantly increased (p < 0.01) in males hypertensive compared to the control. An inverse correlation between the TAS/TC(r = -0.53, p < 0.001) and TAS/LDL-C (r = -0.50, p < 0.001), however a direct correlation between the MDA/TC(r = 0.51, p < 0.001) and MDA/LDL-C (r = 0.48, p < 0.01) for males hypertensive were found. In female subjects the mean +/- SD plasma TC (5.95 +/- 0.13 mmol/L) and LDL-C (4.45 +/- 1.04 mmol/L) were significantly increased (p < 0.05) and (p < 0.01) respectively compared to the controls. Also in hypertensive females inverse correlation between the TAS/TC (r = -0.59, p < 0.001) and TAS/LDL-C (r = -.41, p < 0.01), and a direct correlation between the MDA/TC ( r= .48, p < 0.01) and MDA/LDL-C (r = 0.31, p < 0.05) were found. CONCLUSION: Since dyslipidaemia, hypertension and lipid peroxidation were directly relate to the severity of atherosclerosis, elimination of free radicals in the plasma before the peripheral tissues can take them up might reduce atherosclerosis. In view of our present findings, a management strategy aimed at simultaneously reducing lipid peroxidation and increasing total antioxidant status in dyslipidemic patients may be of benefit.

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

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

Diabetes care in Nigeria: time for a paradigm shift.

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

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

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