Impact of early diagnosis of impaired glucose regulation in tuberculosis: Comparison of clinical outcomes in people with tuberculosis in Tanzania.

OBJECTIVE: Diabetes mellitus (DM) has been known to compromise tuberculosis (TB) treatment outcomes. Association data are limited for early hyperglycaemia detection and TB treatment outcomes. Thus, we assessed treatment outcomes including time to sputum conversion and death in TB participants with or without hyperglycaemia. METHODS: A prospective cohort study recruited TB participants receiving anti-TB treatment at health facilities in Tanzania between October 2019 and September 2020. Hyperglycaemia was defined as having pre-existing DM or pre-treatment random blood glucose of ≥7.8 mmol/L, in combination categorised as impaired glucose regulation (IGR). Those with IGR were further screened for hyperglycaemia severity using glycated haemoglobin. In case of unknown status, participants were tested for HIV. Time to death was determined at 6 months of TB treatment. RESULTS: Of 1344 participants, 187 (13.9%) had IGR, of whom 44 (23.5%) were HIV co-infected. Overall treatment success was 1206 (89.7%), and was similar among participants with or without IGR (p > 0.05). Time to death for participants with and without IGR was 18 versus 28 days (p = 0.870), respectively. Age ≥ 40 years (p = 0.038), bacteriological positive (p = 0.039), HIV (p = 0.009), or recurrent TB (p = 0.017) predicted death or treatment success during TB treatment in adjusted multivariable models. CONCLUSION: IGR did not influence clinical outcomes in TB patients with or without IGR in a programme of early IGR diagnosis and integration TB, HIV and DM care. Early detection and co-management of multi-morbidities among people diagnosed with TB may reduce likelihood of poor treatment outcomes in a programmatic setting.

Clinical-demographic markers for improving diabetes mellitus diagnosis in people with tuberculosis in Tanzania.

BACKGROUND: Tuberculosis (TB) control is threatened by an increasing prevalence of diabetes mellitus (DM), particularly in endemic countries. Screening for DM is not routinely implemented in Tanzania; therefore, we aimed to screen for DM at TB diagnosis using clinical-demographic markers. METHODS: Our cross-sectional study recruited TB patients who received anti-TB treatment between October 2019 and September 2020 at health care facilities in three regions from Tanzania. Patients were screened for DM using DM symptoms (polydipsia, polyphagia and polyuria) and random blood glucose (RBG) testing. Patients with a history of DM and those with no history of DM but an RBG ≥ 7.8 mmol/L had point-of-care glycated haemoglobin (HbA1c) testing, and were considered to have DM if HbA1c was ≥ 48 mmol/mol. RESULTS: Of 1344 TB patients, the mean age was 41.0 (± 17.0) years, and 64.7% were male. A total of 1011 (75.2%) had pulmonary TB, and 133 (10.4%) had at least one DM symptom. Overall, the prevalence of DM was 7.8%, of which 36 (2.8%) TB patients with no history of DM were newly diagnosed with DM by RBG testing. TB/DM patients were older than those with only TB (50.0 ± 14.0 years vs 40.0 ± 17.0 years, p < 0.001). Patients with RBG ≥ 7.8 mmol/L were more likely to have pulmonary TB (p = 0.003), age ≥ 35 years (p = 0.018), and have at least one DM symptom (p < 0.001). There was a substantial agreement (Kappa = 0.74) between the on-site glucometer and point-of-care HbA1c tests in detecting DM range of hyperglycemia. CONCLUSION: The implementation of clinical-demographic markers and blood glucose screening identified the overall prevalence of DM and those at risk of DM in TB patients. Clinical-demographic markers are independent predictors for DM range hyperglycemia and highlight the importance of further diagnostic testing and early co-management of TB and DM.

Feco-prevalence, endoscopic pattern and associated factors of Helicobacter Pylori infection among symptomatic adult patients in Northern Tanzania.

BACKGROUND: Africa has consistently had the highest prevalence (70.1%) of H. pylori, and this has led to significant cases of dyspepsia, gastric cancers, and upper gastrointestinal bleeding. However, most studies have used sero-prevalence, which might not give the current state of the infection. Among the tests, the stool antigen test is simple, quick, and effective. The study aimed to determine the feco-prevalence, endoscopic pattern, and associated factors of H. pylori infection among symptomatic adult patients in Northern Tanzania. MATERIALS AND METHODS: A hospital-based, cross-sectional study was conducted from October 2022 to April 2023 among adults attending the gastroenterology clinic at Kilimanjaro Chistian Medical Centre. A systematic random sampling was used to select the participants with indications of undergoing esophagogastroduodenoscopy. Questionnaires, stool and blood samples, and endoscopy were used to collect variable data. Numerical and categorical variables were summarized into narrations and tables. Logistic regression was used to assess the factors associated with H. pylori. RESULTS: The feco-prevalence of H. pylori was 43.4%. Chronic gastritis (51.1%) was the most common endoscopic pattern, whereas duodenal ulcers and gastric ulcers were significantly associated with H. pylori infection. Increasing in age (p <0.001) and blood group (p <0.001) were significantly associated with H. pylori infection in the adjusted analysis. CONCLUSION: The feco-prevalence of H. pylori is high in this setting. H. pylori stool antigen can be used as the initial workup for symptomatic patients before the initiation of proton pump inhibitors. Additionally, due to other causes of dyspepsia, it is advised that H. pylori stool antigen testing be part of the initial evaluation and esophagogastroduodenoscopy be considered in the absence of other alarm symptoms if symptoms persist despite an appropriate trial of medical therapy.

Factors Associated With Survival Among Patients With Multiple Myeloma in Northeastern Tanzania.

PURPOSE: This study sought to delineate the clinical, laboratory, and imaging characteristics during multiple myeloma (MM) diagnosis, outline the treatment modalities administered, and ascertain the survival rates among patients with MM over a comprehensive 5-year span in Tanzania. METHODS: This retrospective cohort study investigated patients diagnosed with MM at the Cancer Care Clinic, Kilimanjaro Christian Medical Centre, between January 2017 and June 2022. Demographic data, clinical profiles, and survival outcomes were collected. The study employed the Kaplan-Meier method to determine overall survival (OS) and survival rates, supported by univariate analysis and a multivariate Cox regression model with significance of P < .05. RESULTS: In this study of 76 patients with MM, bone pain was the most common complaint (76.3%), and patients were age typically older than 50 years (82.5%). Laboratory tests showed frequent abnormalities, such as anemia (51.3%) and hypercalcemia (23.9%). Most patients were at stage III according to Durie Salmon Staging (82.7%), with imaging revealing various bone abnormalities. The median OS was 18.0 months, with 46.1% of patients passing away during the study period. Factors linked to shorter survival included anemia, renal failure, and bone involvement. Infection was the primary cause of death among these patients. The presenting complaint of bone pain significantly affected survival outcomes. CONCLUSION: This study provides a comprehensive understanding of MM within the Sub-Saharan African context, highlighting age-related disparities in diagnosis, predominant presenting symptoms like bone pain, factors contributing to delayed diagnoses, and the impact on survival rates. The findings underscore the critical need for early recognition, improved diagnostics, and tailored interventions to enhance outcomes for patients with MM in this region.

Impact of Self-Monitoring Blood Glucose on Glycaemic Control Among Insulin-Treated Patients With Diabetes Mellitus in Northeastern Tanzania: A Randomised Controlled Trial.

Introduction: Tracking of blood glucose levels by patients and care providers remains an integral component in the management of diabetes mellitus (DM). Evidence, primarily from high-income countries, has illustrated the effectiveness of self-monitoring of blood glucose (SMBG) in controlling DM. However, there is limited data on the feasibility and impact of SMBG among patients in the rural regions of sub-Saharan Africa. This study is aimed at assessing SMBG, its adherence, and associated factors on the effect of glycaemic control among insulin-treated patients with DM in northeastern Tanzania. Materials and Methods: This was a single-blinded, randomised clinical trial conducted from December 2022 to May 2023. The study included patients with DM who had already been on insulin treatment for at least 3 months. A total of 85 participants were recruited into the study and categorised into the intervention and control groups by a simple randomization method using numbered envelopes. The intervention group received glucose metres, test strips, logbooks, and extensive SMBG training. The control group received the usual care at the outpatient clinic. Each participant was followed for a period of 12 weeks, with glycated haemoglobin (HbA1c) and fasting blood glucose (FBG) being checked both at the beginning and at the end of the study follow-up. The primary and secondary outcomes were adherence to the SMBG schedule, barriers associated with the use of SMBG, and the ability to self-manage DM, logbook data recording, and change in HbA1c. The analysis included descriptive statistics, paired t-tests, and logistic regression. Results: Eighty participants were analysed: 39 in the intervention group and 41 in the control group. In the intervention group, 24 (61.5%) of patients displayed favourable adherence to SMBG, as evidenced by tests documented in the logbooks and glucometer readings. Education on SMBG was significantly associated with adherence. Structured SMBG improved glycaemic control with a HbA1c reduction of -1.01 (95% confidence interval (CI) -1.39, -0.63) in the intervention group within 3 months from baseline compared to controls of 0.18 (95% CI -0.07, 0.44) (p < 0.001). Conclusion: Structured SMBG positively impacted glycaemic control among insulin-treated patients with DM in the outpatient clinic. The results suggest that implementing a structured testing programme can lead to significant reductions in HbA1c and FBG levels. Trial Registration: Pan African Clinical Trials Registry identifier: PACTR202402642155729.

Point-of-care glycated hemoglobin a1c testing for the identification of hyperglycemia severity among individuals with dual tuberculosis and diabetes mellitus in Tanzania.

Background: Poor glycemic control during tuberculosis (TB) treatment is challenging, as the optimum treatment strategy remains unclear. We assessed hyperglycemia severity using glycated hemoglobin (HbA1c) test and predictors of severe hyperglycemia at the time of TB diagnosis in three resources-diverse regions in Tanzania. Methods: This was a substudy from a large cohort study implemented in three regions of Tanzania. TB individuals with diabetes mellitus (DM) (prior history of DM or newly diagnosed DM) were assessed for hyperglycemic levels using HbA1c test and stratified as mild (<53 mmol/mol), moderate (≥53-<86 mmol/mol), and severe (≥86 mmo/mol). Results: From October 2019 to September 2020, 1344 confirmed TB individuals were screened for DM and 105 (7.8%) individuals had dual TB/DM and were assessed for glycemic levels. Of these, 69 (67.7%) had a prior history of DM and 26 (24.8%) were living with human immunodeficiency virus. Their mean age was 49.0 (±15.0) years and 56.2% were male. The majority (77.1%) had pulmonary TB, and 96.2% were newly diagnosed TB individuals. HbA1c test identified 41(39.0%), 37 (35.2%), and 27 (25.7%) individuals with severe, moderate, and mild the hyperglycaemia respectively. Female sex (odds ratio [OR]: 3.55, 95% confidence interval [CI]: 1.06-11.92, P = 0.040) and previous history of DM (OR: 3.71, 95% CI: 1.33-10.33, P = 0.013) were independent risk factors for severe hyperglycemic at the time of TB diagnosis. Conclusion: By integrating early HbA1c testing, a substantial proportion of individuals with severe hyperglycemia were identified. HbA1c testing can be recommended to identify and triage patients requiring personalized intensified DM management in resource-limited programmatic settings.

Implementing Innovative Approaches to Improve Health Care Delivery Systems for Integrating Communicable and Non-Communicable Diseases Using Tuberculosis and Diabetes as a Model in Tanzania.

Background: Many evidence-based health interventions, particularly in low-income settings, have failed to deliver the expected impact. We designed an Adaptive Diseases Control Expert Programme in Tanzania (ADEPT) to address systemic challenges in health care delivery and examined the feasibility, acceptability and effectiveness of the model using tuberculosis (TB) and diabetes mellitus (DM) as a prototype. Methods: This was an effectiveness-implementation hybrid type-3 design that was implemented in Dar es Salaam, Iringa and Kilimanjaro regions. The strategy included a stepwise training approach with web-based platforms adapting the Gibbs' reflective cycle. Health facilities with TB services were supplemented with DM diagnostics, including glycated haemoglobin A1c (HbA1c). The clinical audit was deployed as a measure of fidelity. Retrospective and cross-sectional designs were used to assess the fidelity, acceptability and feasibility of the model. Results: From 2019-2021, the clinical audit showed that ADEPT intervention health facilities more often identified median 8 (IQR 6-19) individuals with dual TB and DM, compared with control health facilities, median of 1 (IQR 0-3) (p = 0.02). Likewise, the clinical utility of HbA1c on intervention sites was 63% (IQR:35-75%) in TB/DM individuals compared to none in the control sites at all levels, whereas other components of the standard of clinical management of patients with dual TB and DM did not significantly differ. The health facilities showed no difference in screening for additional comorbidities such as hypertension and malnutrition. The stepwise training enrolled a total of 46 nurse officers and medical doctors/specialists for web-based training and 40 (87%) attended the workshop. Thirty-one (67%), 18 nurse officers and 13 medical doctors/specialists, implemented the second step of training others and yielded a total of 519 additional front-line health care workers trained: 371 nurses and 148 clinicians. Overall, the ADEPT model was scored as feasible by metrics applied to both front-line health care providers and health facilities. Conclusions: It was feasible to use a stepwise training and clinical audit to support the integration of TB and DM management and it was largely acceptable and effective in differing regions within Tanzania. When adapted in the Tanzania health system context, the model will likely improve quality of services.

Clinical Audit for Integration of Communicable and Non-Communicable Diseases at the Primary Health Care Level in Tanzania.

Introduction: Poor quality of health care services remains an important challenge in health care delivery systems. Here, we validate clinical audit tools and describe audit results of selected clinical standards related to communicable disease (CD) and non-communicable disease (NCD) integration at the primary health care level. Methodology: A multi-methods approach, including a retrospective cohort and cross-sectional design, was deployed concurrently at Health Centres. Separate evaluators assessed the Health Centres using an audit tool and the inter-rater/inter-observer reliability was estimated. The extent of adherence to clinical standards was measured in proportions for: infection prevention control, tuberculosis (TB) diagnosis including advanced TB/Human Immunodeficiency Virus (HIV), the diagnosis of chronic lung diseases, and the bidirectional screening and clinical management of TB and Diabetes Mellitus (DM). Results: The inter-rater reliability for the clinical audit tools based on 130 individuals' charts was 99.5% (CI:99-100). The total estimated maximum score for infection prevention control was 114 and on average health centres scored 42 (37%). Only 3 (4%) of 80 individuals' medical charts with unexplained productive cough were evaluated for TB. None of the 24 individuals with HIV infection medical charts had vitals measured and only 6 (25%) patients with advanced HIV had a TB test performed, whereas 4 (17%) had a cryptococcal antigen test, and 1 (4%) had a chest radiograph. Also, 24 patients' chart from documented HIV negative with chronic cough had no records of spirometry or peak flowmeter or a chest radiograph. However, a diagnosis of asthma and chronic obstructive pulmonary disease as made in 17 (71%) and 7 (29%), respectively. TB was confirmed for 102 patients among whom only 12(12%) were screened for DM. The DM clinics had no TB presumptive registers. Patients with TB/DM (n=2) had a glycated haemoglobin (HbA1c) measurement done and received appropriate management. Conclusion and recommendation: The developed clinical audit tools were reliable and could contribute to quality measurement for metrics-related integration of CD and NCD in Tanzania. Further investigations will determine if the clinical audit tools widely used in cycles can improve the quality of care in health care delivery systems.

Burden and associated phenotypic characteristics of tuberculosis infection in adult Africans with diabetes: a systematic review.

Diabetes mellitus (DM) increases the risk of developing tuberculosis infection (TBI). However, the evidence on the burden and phenotypic characteristics of TBI in African patients with DM is limited. This study aimed to determine the prevalence and characterisation of TBI in native African patients living with DM. We searched PubMed, EMBASE, and African Journals Online for original studies reporting information on the prevalence and characteristics of TBI in adult Africans with DM. A forest plot was used to describe the pooled prevalence estimate of TBI and the corresponding 95% confidence intervals (CI). Six studies conducted in four African countries involving 721 participants with DM were included in this systematic review. The pooled prevalence estimate of TBI was 40% (95% CI 20-60%, I2 = 98.52%, p < 0.001). Age ≥ 40 years and glycated haemoglobin levels independently predicted TBI positivity in patients with DM in three studies. Africans with DM have a high prevalence of TBI, especially those who are older or with poorly controlled diabetes. This justifies the need for studies to explore how to screen and manage TBI to avert the progression to active TB disease.

Initial treatment of myxedema coma using oral levothyroxine: a case report from Tanzania.

Summary: Myxedema coma is a severe complication of hypothyroidism, commonly affecting women over 60 years of age, causing slow, progressive multi-organ dysfunction, and mental deterioration. Due to improved diagnostics and treatment of hypothyroidism, myxedema coma has become uncommon. However, it is hardly reported in resource-limited settings. We present an elderly female with a history of total thyroidectomy due to multi-nodular goiter. She presented with features of heart failure, excessive weight gain, and cold sensation. Although the patient was on levothyroxine replacement therapy, her laboratory tests were suggestive of overt primary hypothyroidism. During the course of her hospitalization, she developed subcutaneous bleeding with frank hematuria. This led to an altered mental state and hypotension that were suggestive of myxedema coma. Stroke and pulmonary embolism were ruled out as potential differential diagnoses of her current state. She was treated with a high dose of oral levothyroxine followed by 150 µg of oral levothyroxine daily, which resulted in a favorable outcome despite being a fatal emergency. She was also treated with intravenous hydrocortisone and furosemide. Oral thyroid hormone replacement may be an effective option in those resource-limited settings where intravenous thyroid hormone replacement is not available. However, early diagnosis and treatment with an adequate dose of thyroid hormones are crucial to achieve a favorable outcome. Learning points: Myxedema coma is an uncommon complication of hypothyroidism with a fatal outcome. The diagnosis of myxedema coma is based on clinical suspicion, especially in patients with hypothyroidism and in the presence of precipitating factors. Although diagnostic and scoring criteria based on clinical, laboratory, and imaging features have been proposed, no consensus has been reached. This article shows an alternative treatment option for myxedema coma using oral levothyroxine, which led to a favorable outcome.

Experiences and perceptions of participants on the pathway towards clinical management of dual tuberculosis and diabetes mellitus in Tanzania.

BACKGROUND: Diabetes mellitus (DM) is a common comorbidity among people with tuberculosis (TB). Despite the availability of guidelines on how to integrate dual TB/DM in Tanzania, the practice of integration at various healthcare levels is unclear. OBJECTIVE: To explore the participants' experiences and perceptions on the pathway towards clinical management of dual TB/DM. METHOD: The research was carried out in Dar es Salaam, Iringa, and Kilimanjaro regions between January and February 2020. A qualitative, in-depth interview approach was used to collect participants' experiences and perspectives on the acquisition of dual TB/DM services at various levels of healthcare facilities. The information gathered were coded and classified thematically. RESULTS: The participants' perception of TB services within the healthcare facilities was positive due to the support they received from the healthcare providers. On the other hand, participants reported difficulty receiving management in various health facilities for each condition in terms of access to dual TB/DM care and access to DM medication. This was viewed as a significant challenge for the participants with dual TB/DM. CONCLUSIONS: The current disjunction and disruption in healthcare for people with dual TB/DM makes it difficult to access services at various levels of health facilities. For optimal clinical management for people with dual TB/DM, patient-centered strategies and integrated approaches are urgently needed.

Where can Tanzania health system integrate clinical management of patients with dual tuberculosis and diabetes mellitus? A cross-sectional survey at varying levels of health facilities.

Objective: To assess the current Tanzania health facilities readiness in integrating clinical management of dual Tuberculosis (TB) and Diabetes Mellitus (DM) by using the Service Availability and Readiness Assessment (SARA) manual of the World Health Organization prior to implementing an integrated service model. Study design: Cross-sectional study. Methods: A needs assessment survey was conducted at varying levels of health care facilities. The SARA manual evaluated the service delivery outcomes in terms of availability of guidelines, medicines and diagnostic equipment, training of healthcare workers in providing TB and DM care, and patient record review. Data were analyzed using Statistical Package for Social Science version 26. Results: Among 29 health facilities selected, three were regional referral hospitals, eight were district hospitals and eighteen were health centers. Baseline investigations revealed that GeneXpert MTB/RIF machines were present in 10 (34.5%) facilities, and glycated hemoglobin devices were present in two (6.9%) facilities, while all health facilities had a glucometer. The presence of an attending medical doctor in 19 (65.5%) facilities and the presence of operating biochemistry analyzers in 15 (51.7%) facilities were two mandatory variables used to assess readiness. Among the various guidelines observed, none of the facilities had the 2016 DM guidelines. Overall, 15 (51.7%) health facilities were ready to integrate dual TB and DM services. Conclusion: Integrative TB/DM screening and management activities can be achieved only if integration initiatives are prioritized at all levels of health facilities and among health policy makers in Tanzania. At least half of the health facilities were prepared to integrate the management of dual TB/DM. However, there is an urgent need to mobilize significant resources to improve the integration in these facilities, such as management guidelines and diagnostics..

Rifapentine and isoniazid for prevention of tuberculosis in people with diabetes (PROTID): protocol for a randomised controlled trial.

BACKGROUND: Diabetes mellitus (DM) increases the risk of tuberculosis (TB) and will hamper global TB control due to the dramatic rise in type 2 DM in TB-endemic settings. In this trial, we will examine the efficacy and safety of TB preventive therapy against the development of TB disease in people with DM who have latent TB infection (LTBI), with a 12-week course of rifapentine and isoniazid (3HP). METHODS: The 'Prevention of tuberculosis in diabetes mellitus' (PROTID) consortium will randomise 3000 HIV-negative eligible adults with DM and LTBI, as evidenced by a positive tuberculin skin test or interferon gamma release assay, to 12 weeks of 3HP or placebo. Participants will be recruited through screening adult patients attending DM clinics at referral hospitals in Tanzania and Uganda. Patients with previous TB disease or treatment with a rifamycin medication or isoniazid (INH) in the previous 2 years will be excluded. The primary outcome is the occurrence of definite or probable TB disease; secondary outcome measures include adverse events, all-cause mortality and treatment completion. The primary efficacy analysis will be intention-to-treat; per-protocol analyses will also be carried out. We will estimate the ratio of TB incidence rates in intervention and control groups, adjusting for the study site using Poisson regression. Results will be reported as efficacy estimates (1-rate ratio). Cumulative incidence rates allowing for death as a competing risk will also be reported. Approximately 1000 LTBI-negative, HIV-negative participants will be enrolled consecutively into a parallel cohort study to compare the incidence of TB in people with DM who are LTBI negative vs positive. A number of sub-studies will be conducted among others to examine the prevalence of LTBI and active TB, estimate the population impact and cost-effectiveness of LTBI treatment in people living with DM in these African countries and address gaps in the prevention and therapeutic management of combined TB-DM. DISCUSSION: PROTID is anticipated to generate key evidence to guide decisions over the use of TB preventive treatment among people with DM as an important target group for better global TB control. TRIAL REGISTRATION: ClinicalTrials.gov NCT04600167 . Registered on 23 October 2020.

Indicators of optimal diabetes care and burden of diabetes complications in Africa: a systematic review and meta-analysis.

OBJECTIVE: Contemporary data on the attainment of optimal diabetes treatment goals and the burden of diabetes complications in adult populations with type 2 diabetes in Africa are lacking. We aimed to document the current status of attainment of three key indicators of optimal diabetes care and the prevalence of five diabetes complications in adult African populations with type 2 diabetes. METHODS: We systematically searched Embase, PubMed and the Cochrane library for published studies from January 2000 to December 2020. Included studies reported any information on the proportion of attainment of optimal glycated haemoglobin (HbA1c), blood pressure (BP) and low-density lipoprotein cholesterol (LDLC) goals and/or prevalence of five diabetes complications (diabetic peripheral neuropathy, retinopathy, nephropathy, foot ulcers and peripheral arterial disease). Random effect model meta-analysis was performed to determine the pooled proportion of attainment of the three treatment goals and the prevalence of five diabetes complications. RESULTS: In total, 109 studies with a total of 63 890 participants (53.3% being females) were included in the meta-analysis. Most of the studies were conducted in Eastern African countries (n=44, 40.4%). The pooled proportion of attainment of an optimal HbA1c, BP and LDLC goal was 27% (95% CI 24 to 30, I2=94.7%), 38% (95% CI 30 to 46, I2=98.7%) and 42% (95% CI 32 to 52, I2=97.4%), respectively. The pooled prevalence of diabetic peripheral neuropathy, retinopathy, diabetic nephropathy, peripheral arterial disease and foot ulcers was 38% (95% CI 31 to 45, I2=98.2%), 32% (95% CI 28 to 36, I2=98%), 31% (95% CI 22 to 41, I2=99.3%), 19% (95% CI 12 to 25, I2=98.1%) and 11% (95% CI 9 to 14, I2=97.4%), respectively. CONCLUSION: Attainment of optimal diabetes treatment goals, especially HbA1c, in adult patients with type 2 diabetes in Africa remains a challenge. Diabetes complications, especially diabetic peripheral neuropathy and retinopathy, are highly prevalent in adult populations with type 2 diabetes in Africa.

Challenges in the Management of Thyrotoxicosis Associated with Atrial Fibrillation and Heart Failure: Two Case Reports.

BACKGROUND: Thyrotoxicosis is a clinical syndrome with high amounts of free thyroid hormone levels causing elevated thyroid hormone function in body tissues. Prolonged effects of free thyroid hormones may lead to cardiac complications such as atrial fibrillation (AF) and heart failure (HF). CASE 1: A 31-year-old female, was admitted due to difficulty in breathing, generalised body swelling and jaundice. She was dyspnoeic with an irregular heart rate, and presented with abnormal vitals, liver and thyroid function tests which were diagnostic for thyroid storm. She was managed over 32 days in-hospital stay with carbimazole, propranolol, hydrocortisone, digoxin and furosemide. Unfortunately, she was readmitted 6 months later with worsened HF symptoms and passed away. CASE 2: A 57-year-old female, was admitted due to difficulty in breathing, bilateral lower limb swelling and jaundice. She was tachypnoeic with an irregular heart rate, and presented with abnormal liver enzymes and thyroid function tests which were diagnostic for thyrotoxicosis. She was managed with carbimazole, propranolol, digoxin and furosemide, and was discharged on the 6th hospital day. CONCLUSION: Prolonged untreated thyrotoxicosis increases the risk of AF and HF. Early and monitored treatment and follow-up of hyperthyroidism is key to the management of AF and HF in achieving a better outcome.

Status epilepticus and diabetes ketoacidosis: uncommon clinical presentations of acromegaly.

SUMMARY: Acromegaly is a rare disease caused by hypersecretion of the growth hormone (GH). Most cases are caused by either pituitary microadenoma or macroadenoma. The GH producing tumors present with clinical manifestations of acromegaly due to excessive GH secretion or symptoms resulting from mass effects of the enlarging tumor. The physical changes are usually slow and, therefore, recognition of the disease is delayed. These adenomas are never malignant but can have significant morbidity and mortality. A subgroup of patients with acromegaly present with severe hyperglycemia resulting in diabetic ketoacidosis (DKA) which requires insulin. Rarely are pituitary tumors responsible for generalized convulsions except when they are too large. We hereby present two cases, the first is that of a 26-year-old female who presented with new onset status epilepticus, DKA with a 1-year history of diabetes mellitus (DM). On examination, she had clinical features of acromegaly. The second case is that of a 34-year-old female who presented with new onset status epilepticus, hyperglycemia with a history of recently diagnosed DM, and features of gigantism. In both cases, their diagnosis was confirmed by elevated serum GH and later by elevated insulin-like growth factor type 1 levels, and CT of the head demonstrating large pituitary macroadenoma. The importance of clinical history and examination, as well as investigations is vital in the recognition of acromegaly. The prognosis of acromegalic patients depends on early clinical recognition and tumor size reduction by either medical or surgical therapy. LEARNING POINTS: Conditions such as status epilepticus and DKA may be clinical presentations in patients presenting with acromegaly. Seizures are rare in people with pituitary adenoma and typically occur when the tumor invades the suprasellar area due to mass effect on the brain. This article shows how best we were able to manage the acromegaly complications in a low resource setting. Hyperprolactinemia in acromegaly may be due to disruption of the normal dopaminergic inhibition of prolactin secretion due to mass effect of the macroadenoma, and around 25% of GH-secreting adenomas co-secrete prolactin.

Suboptimal Blood Pressure Control, Associated Factors, and Choice of Antihypertensive Drugs among Type 2 Diabetic Patients at KCMC, Tanzania.

BACKGROUND: Hypertension (HTN) can be present in up to two-thirds of patients living with diabetes mellitus (DM). It is a risk factor for the development of diabetes as well as complications like coronary artery disease (CAD), nephropathy, retinopathy, and neuropathy. Hypertension is treatable, and the degree to which it is controlled determines the risk of development of cardiovascular diseases and other complications in a given individual patient. Even though antihypertensive drugs are available and issued to hypertensive diabetic patients, the rate of control of HTN is often inadequate. The aim of this study was to assess the prevalence of suboptimal blood pressure (BP) control, its associated factors, and the choice of antihypertensive drugs among type 2 DM patients at Kilimanjaro Christian Medical Centre (KCMC). METHODS: A hospital-based cross-sectional study was conducted at the KCMC diabetes clinic from October 2018 to March 2019 among type 2 DM patients with HTN based on the inclusion criteria. Data were collected using structured questionnaires, and written informed consent was obtained. Suboptimal BP was defined as BP levels ≥ 140/90 mmHg according to the American Diabetes Association guideline published in 2018. Data analysis was done using the Statistical Package for the Social Sciences (SPSS) version 25. Chi-square analysis was done to identify the independent predictors of BP control, and a p value of <0.05 was considered to be statistically significant. RESULTS: The data of 161 participants was analysed; the mean age was 63.9 ± 20.2 years, with the majority being females (67.1%). Despite all participants being on different classes of antihypertensives, 57.8% had suboptimal BP control. Among the participants with good BP control, 52.7% were on angiotensin-converting enzyme inhibitors (ACE-I). Poor diabetes control was observed in 50.1% participants as indicated by elevated glycated haemoglobin. CONCLUSION: This study demonstrated that BP control in type 2 DM patients was suboptimal in more than half of the participants. The study showed that the use of ACE-I or angiotensin II receptor blockers (ARBs) in the majority of DM patients has a good impact in the control of blood pressure. The early initiation of ACE-I or ARBs among the diabetic patients will improve the optimal BP control.

Clinical Characteristics and Factors Associated with Heart Failure Readmission at a Tertiary Hospital in North-Eastern Tanzania.

INTRODUCTION: Heart failure (HF) is characterized by frequent episodes of decompensation, leading to a high hospitalization burden. More than 50% of index hospitalizations for HF patients return within 6 months of discharge. Once the patient is readmitted, the risk of further disease progression and the mortality rate are increased. A lot of patients are readmitted due to factors such as poor medication adherence, infections, or worsening comorbidities. The aim of our study was to identify the inpatient burden of HF readmission and to identify the factors associated with early readmission. METHODS: A hospital-based cross-sectional analytical study was conducted from November 2018 to April 2019 within the medical wards at Kilimanjaro Christian Medical Centre (KCMC), which is a teaching and referral hospital in north-eastern Tanzania. The study population included all patients with HF admitted within the medical ward. Data were collected using questionnaires and blood and radiological investigations, and analysis was done using Statistical Package for Social Science (SPSS) version 25. Chi-square test was used to compare proportions of categorical variables. Logistic regression was used to determine the likelihood for readmission, and p-value of <0.05 was considered to be statistically significant. RESULTS: A total of 353 patients were identified with HF, of whom 136 (38.5%) had a previous admission. Of the 136 patients analysed, the mean age was 62.8 years (SD 17.1), and 86 (63.2%) were females. Within 30 days after discharge, 34 (25.0%) of the patients were readmissions. Factors for early readmission were unemployment (OR = 2.38, 95% CI = 1.02-5.54, p = 0.043), poor medication adherence (OR = 3.87, 95% CI = 1.67-8.97, p = 0.002), absence of angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) (OR = 2.40, 95% CI = 1.09-5.31, p = 0.030), and pleural effusion (OR 3.25, 95% CI = 1.44-7.32, p = 0.004). CONCLUSION: Heart failure is a burden due to a large number of admissions and readmissions. Factors such as poor medication adherence and absence of adequate HF therapy, especially the absence of regimes containing ACEI or ARB, need to be targeted to reduce the number of readmissions. This will help reduce the risk of further decompensations, disease progression, and mortality rate.

Prevalence, Patterns, and Factors Associated with Peripheral Neuropathies among Diabetic Patients at Tertiary Hospital in the Kilimanjaro Region: Descriptive Cross-Sectional Study from North-Eastern Tanzania.

OBJECTIVE: Diabetic peripheral neuropathy (DPN) is a common microvascular complication of diabetes mellitus (DM) and may progress to diabetic foot, which frequently leads to amputation and/or disability and death. Data is scanty on the burden of diabetic peripheral neuropathy in Tanzania. The aim of this study was to assess the burden of peripheral neuropathy, its severity, and the associated factors. METHODS: The study was a cross-sectional hospital-based study and was carried out from October 2017 to March 2018 among adolescent and adult patients attending Kilimanjaro Christian Medical Center (KCMC) diabetes clinic. RESULTS: A total of 327 diabetic patients, females n=215 (65.7%) and males n=121 (34.3%), were included in the study. The mean age was 57.2 yrs. A total of 238 (72%) had type 2 and 89 (27.2%) had type1 DM. The prevalence of peripheral neuropathy was 72.2% of whom 55% were severe, 19% were moderate, and 26% were mild. The severity of neuropathy increased with the increase in age >40 years (p < 0.001) and increase in body mass index (p<0.001) and duration of diabetes; duration >7 years (p <0.006). The main associated factors were age >40 years, OR 2.8 (1.0-7.7), >60 years, OR 6.4 (2.3-18.2), obesity, OR 6.7 (0.9-27.7), and hypertension, OR 4.3 (2.2-8.2). CONCLUSION: More than half of the patients included in this study were found to have neuropathy, nearly half of whom presented with the severe form. The main risk factors were increasing age, increasing duration of diabetes, obesity, and hypertension. Diabetic peripheral neuropathy is underdiagnosed in northern Tanzania where screening for neuropathy is not routinely done.