Coprevalence of type 2 diabetes mellitus and tuberculosis in low-income and middle-income countries: A systematic review

Exploring the accuracy of third-generation Nanopore Sequencing technology for detecting mycobacterium tuberculosis in patients with diabetes mellitus

OBJECTIVE

To explore the diagnostic value of third-generation nanopore sequencing technology in patients with diabetes mellitus suspected of pulmonary tuberculosis.

METHODS

Samples, including sputum and bronchoalveolar lavage fluid(BALF), were collected from patients with diabetes mellitus suspected of pulmonary tuberculosis who were admitted from October 2021 to August 2023. Nanopore sequencing, acid-fast bacilli (AFB) smear, mycobacterial solid culture, Xpert MTB/RIF, and DNA detection were performed, and their diagnostic efficacy was compared.

RESULTS

Third-generation nanopore sequencing technology exhibited high accuracy in diagnosing pulmonary tuberculosis in patients with diabetes mellitus. Compared to traditional methods, nanopore sequencing showed significantly improved sensitivity (76.80 %), negative predictive value (30.40 %), coincidence (77.92 %), and diagnostic accuracy (AUC = 0.822). Combined detection with Xpert achieved the highest diagnostic performance, with increased sensitivity (81.20 %), positive predictive value (98.20 %), negative predictive value (35.00 %), coincidence (81.82 %), and AUC (0.843). Although acid-fast staining had limitations, its combination with nanopore sequencing improved screening effectiveness.

CONCLUSION

Compared to established diagnostic modalities such as acid-fast staining, mycobacterial solid culture, Xpert MTB/RIF, and DNA detection, third-generation nanopore sequencing technology demonstrates a significant improvement in sensitivity for detecting suspected pulmonary tuberculosis in diabetic patients. Notably, the combined application of nanopore sequencing with Xpert testing offers a further enhancement in diagnostic accuracy.

Drug Exposure and Treatment Outcomes in Patients With Multidrug-Resistant Tuberculosis and Diabetes Mellitus: A Multicenter Prospective Cohort Study From China

BACKGROUND

The management of multidrug-resistant tuberculosis (MDR-TB) remains challenging. Treatment outcome is influenced by multiple factors; the specific roles of diabetes and glycemic control remain uncertain. This study aims to assess the impact of glycemic control on drug exposure, to investigate the association between drug exposure and treatment outcomes, and to identify clinically significant thresholds predictive of treatment outcome, among patients with diabetes.

METHODS

This multicenter prospective cohort study involved patients with confirmed MDR-TB and diabetes. Drug exposure level was estimated by noncompartmental analysis. The minimum inhibitory concentrations (MICs) were determined for the individual Mycobacterium tuberculosis isolates. The influence of poor glycemic control (glycated hemoglobin ≥7%) on drug exposure and the associations between drug exposure and treatment outcome were evaluated by univariate and multivariate analysis. Classification and regression tree analysis was used to identify the drug exposure/susceptibility thresholds.

RESULTS

Among the 131 diabetic participants, 43 (32.8%) exhibited poor glycemic control. Poor glycemic control was independently associated with decreased exposure to moxifloxacin, linezolid, bedaquiline, and cycloserine, but not clofazimine. Additionally, a higher ratio of drug exposure to susceptibility was found to be associated with a favorable MDR-TB treatment outcome. Thresholds predictive of 6-month culture conversion and favorable outcome were bedaquiline area under the concentration-time curve (AUC)/MIC ≥245 and moxifloxacin AUC/MIC ≥67, demonstrating predictive accuracy in patients, regardless of their glycemic control status.

CONCLUSIONS

Glycemic control and optimal TB drug exposure are associated with improved treatment outcomes. This dual management strategy should be further validated in randomized controlled trials of patients with MDR-TB and diabetes.

Lead identification against Mycobacterium tuberculosis using highly enriched active molecules against pantothenate synthetase

The Pantothenate synthetase (PS) from the Mycobacterium tuberculosis (Mtb) holds a crucial role in the survival and robust proliferation of bacteria through its catalysis of coenzyme A and acyl carrier protein synthesis. The present study undertook the PS drug target in complex with a co-crystallized ligand and subjected it to docking and virtual screening approaches. The experimental design encompassed three discrete datasets: an active dataset featuring 136 compounds, an inactive dataset comprising 56 compounds, and a decoys dataset curated from the zinc library, comprising an extensive compilation of approximately 53,000 compounds. The compounds' binding energies were observed to be in the range of -5 to ∼-14 kcal/mol. Additionally, binding energy results were further refined through Enrichment Factor analysis (EF). EF is a new statistical approach which uses the scores obtained from docking-based virtual screening and predicts the precision of the scoring function. Remarkably, the Enrichment Factor (EF) analysis produced exceptionally favorable outcomes, attaining an EF of approximately 49% within the uppermost 1% fraction of the compound distribution. Finally, a total of eight compounds, evenly distributed between the active dataset and the decoys dataset, emerged as potent inhibitors of the Pantothenate synthetase (PS) enzyme. The analysis of inhibition constants and binding energy revealed a notable correlation, with an r-squared value (r2) of 0.912 between the two parameters. Furthermore, the shortlisted compounds were subjected to 100 ns MD simulation to determine their stability and dynamics behavior. The decoy compounds that have been identified, exhibiting properties comparable to the active compounds, are postulated as potential candidates for targeting the Pantothenate synthetase (PS) enzyme to treat Mtb infection. Nevertheless, in the pursuit of a comprehensive investigation, it is advisable to undertake additional experimental validation as a component of the subsequent study.Communicated by Ramaswamy H. Sarma.

Prevalence of Diabetes Mellitus among Patients with Tuberculosis and Its Associated Factors in Sana'a, Yemen, 2021

Diabetes mellitus (DM) is one of tuberculosis' (TB) ending barriers. TB patients with DM are at a higher risk than non-diabetes patients to develop complication, relapse and die. In Yemen, information on TB-DM comorbidity is lacking. This study aimed to determine the prevalence and associated factors of diabetes among TB patients at the National Tuberculosis Center (NTC) in Sana'a. A facility-based cross-sectional study was conducted. All TB patients aged >15 years who attended the NTC from July to November 2021 were screened for DM. Socio-demographic and behavioral information were collected through face-to-face interviews using questionnaires. A total of 331 TB patients were enrolled, 53% were males, 58% aged <40 years, and 74% were newly diagnosed with TB. Overall, DM prevalence was 18%. Higher rates of DM were found among TB patients that were male (OR = 3.0; 95% CI; 1.4-6.7), ≥50 years of age (OR = 10.8; 95% CI; 4.3-27.3), and those with a family history of diabetes (OR = 3.4; 95% CI; 1.6-6.9). Almost one fifth of TB patients had DM. The early detection of DM through immediate screening after a TB diagnosis and periodically during the course of treatment is crucial for TB patients' optimal care. Dual diagnostics for reducing the dual burden of TB-DM comorbidity is recommended.

Effect of Tuberculosis (TB) and Diabetes mellitus (DM) integrated healthcare on bidirectional screening and treatment outcomes among TB patients and people living with DM in developing countries: a systematic review

A systematic review (Prospero CRD42017075562) including articles published between 1 January 1990 and 31 October 2021 was performed to synthesize evidence on the effect of integrating tuberculosis (TB) and diabetes mellitus (DM) healthcare on screening coverage and treatment loss to follow-up as compared to non-integrated care services for TB and DM in low- to middle-income countries (LMICs). Searches were performed in PubMed, Web of Science, WHO Global Index Medicus, and Cochrane Central Library. This review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and we adopted Cochrane data collection form for Randomized Controlled Trials (RCTs) and non-RCTs. Due to heterogeneity and limited data of studies included, meta-analysis was not performed. Of 6902 abstracts, 10 studies from South America, Asia, and Africa were included. One study from Zimbabwe showed 57% increase in DM screening among TB patients in integrated care as compared to non-integrated care; 95% CI: 54.1, 59.8. Seven studies with before-after comparison groups reported increased screening coverage during implementation of integrated healthcare that ranged from 10.1% in Mexico to 99.1% in China. Three studies reported reduction in loss to follow-up among TB patients in integrated care; two in China showed 9.2%, 95% CI: -16.7, -1.7, and -9.5%, 95% CI: -18.4, -0.7 differences, while a study from Mexico showed -5.3% reduction, 95% CI: -9.8, -0.9.With few and heterogenous included studies, the synthesized evidence is weak to establish effect of TB/DM integrated care. Therefore, further robust studies such as randomized clinical trials and well-designed observational studies are needed.

Metformin reduces lipid accumulation in HepG2 cells via downregulation of miR-33b

INTRODUCTION

Here, we aimed to investigate whether the beneficial effects of metformin on lipid accumulation is mediated through regulation of miR-33b.

METHODS

The expression of the genes and miRNAs and protein levels were evaluated using real-time PCR and western blot, respectively. To investigate the potential role of miR-33b in lipid accumulation, the mimic of the miR-33b was transfected into HepG2 cells.

RESULTS

We found that metformin reduces high glucose-induced lipid accumulation in HepG2 cells through inhibiting of SREBP1c and FAS and increasing the expression of CPT1 and CROT. Overexpression of miR-33b significantly prevented the decreasing effect of metformin on lipid content and intra and extra triglyceride levels. Importantly, miR-33b mimic inhibited the increasing effects of metformin on the expression of CPT1 and CROT.

CONCLUSION

These findings suggest that metformin attenuates high glucose-induced lipid accumulation in HepG2 cell by downregulating the expression of miR-33b.

Epidemiological Characteristics and Their Influencing Factors Among Pulmonary Tuberculosis Patients With and Without Diabetes Mellitus: A Survey Study From Drug Resistance Surveillance in East China

Background

The burden of pulmonary tuberculosis (TB) and diabetes mellitus (DM) have become serious global concerns, while the comprehensive evaluations of DM status and drug resistance in TB patients are still lacking.

Methods

All details of TB cases were collected from drug resistance monitoring sentinels in Zhejiang province. Fisher's exact test or Pearson chi-square test (χ²) was used to compare the baseline characteristics among TB with different DM statuses. The logistic regression model was used to estimate the relationship between DM and different drug resistance spectra. Univariate analysis and multivariate logistic model were used to explore the possible risk factors of drug resistance in TB patients with DM and no DM.

Results

936 TB cases with smear-positive in Zhejiang province were collected, in which 76 patients (8.12%) owned the co-morbidity of DM. TB-DM prevalence was higher in older, Han nationality, employed, accompanied by no health insurance and hepatitis B status. Among 860 cases of TB-no DM and 76 cases of TB-DM, drug resistance-TB accounted for 31.51% and 23.68% (P > 0.05), MR-TB accounted for 15.93% and 14.47% (P > 0.05), respectively. MDR-TB was 4.88% and 6.58% (P > 0.05). The incidence of poly-drug resistant tuberculosis (PDR-TB) in TB-no DM patients (10.70 vs. 2.63%, OR: 4.43; 95% CI, 1.07–18.36) was higher than that in the TB-DM group (P < 0.05). In univariate and multivariate analysis, none of the basic factors were statistically significant with drug resistance among TB-DM cases (all P > 0.05). Retreatment was the risk factor of drug resistance among TB-no DM cases.

Conclusions

Our results showed that the drug resistance rate of the TB-DM group was not higher than that of the TB-no DM group. Patients with TB-no DM were at a higher risk for PDR-TB, but not for MDR-TB, MR-TB, and drug resistance-TB. Special attention should be paid to TB-no DM patients who have been previously treated. In the future, large-scale and well-designed prospective studies are needed to clarify the impact of DM on the drug-resistance among TB.

Bidirectional screening and treatment outcomes of diabetes mellitus (DM) and Tuberculosis (TB) patients in hospitals with measures to integrate care of DM and TB and those without integration measures in Malawi

INTRODUCTION

There are efforts in low and middle-income countries (LMICs) to integrate Tuberculosis (TB) and Diabetes mellitus (DM) healthcare services, as encouraged by WHO and other international health organizations. However, evidence on actual effect of different integration measures on bidirectional screening coverages and or treatment outcomes for both diseases in LMICs is scarce.

OBJECTIVES AND METHODS

Retrospective chart review analysis was conducted to determine effects of integrated care on bidirectional screening and treatment outcomes for both TB patients and people with DM (PWD) recruited in eight Malawian hospitals. Data of ≥ 15 years old patients registered between 2016 to August 2019 were collected and analysed.

RESULTS

557 PWDs (mean age 54) and 987 TB patients (mean age 41) were recruited. 64/557 (11.5%) PWDs and 105/987 (10.6%) of TB patients were from an integrating hospital. 36/64 (56.3%) PWDs were screened for TB in integrated healthcare as compared to 5/493 (1.0%) in non-integrated care; Risk Difference (RD) 55.2%, (95%CI 43.0, 67.4), P < 0.001, while 10/105 (9.5%) TB patients were screened for DM in integrated healthcare as compared to 43/882 (4.9%) in non-integrated care; RD 4.6%, (95%CI - 1.1, 10.4), P = 0.065. Of the PWDs screened, 5/41 (12.2%) were diagnosed with TB, while 5/53 (9.4%) TB patients were diagnosed with DM. On TB treatment outcomes, 71/508 (14.8%) were lost to follow up in non-integrated care and none in integrated care were lost to follow-up; RD - 14.0%, (95%CI: - 17.0,-11.0), p < 0.001. Among PWDs, 40/493 (8.1%) in non-integrated care and 2/64 (3.1%) were lost to follow up in integrated care; RD - 5.0%, (95%CI:-10.0, - 0.0); P = 0.046. After ≥ 2 years of follow up, 62.5% PWDs in integrated and 41.8% PWDs in non-integrated care were retained in care, RD 20.7, (95%CI: 8.1, 33.4), P = 0.001.

CONCLUSION

We found higher bidirectional screening coverage and less loss to follow-up in one centre that made more efforts to implement integrated measures for TB and DM care than in 7 others that did not make these efforts. Decisions on local programs to integrate TB/DM care should be taken considering currently rather weak evidence and barriers faced in the local context as well as existing guidelines.

Infectious diseases associated with pediatric type 1 diabetes mellitus: A narrative review

Diabetes mellitus (DM) has been frequently associated with an impaired immune response against infectious agents, making affected patients at risk for more severe disease and sometimes causing worse outcomes. The recent COVID-19 pandemic has seriously affected patients with both diabetes, in particular those carrying comorbidities or with poor glycemic control. As regards pediatric diabetes mellitus, the availability of more accurate and technological tools for glycemic management and the improved markers of metabolic control might mitigate the negative impact of infections. Notably, good metabolic control of diabetes since its diagnosis reduces not only the risk of microangiopathic complications but also of impaired immune response to infectious diseases. Therefore, vaccinations are strongly recommended. Our paper aims to provide the most updated evidence regarding infectious diseases in type 1 pediatric DM.

Diabetes-Associated Susceptibility to Tuberculosis: Contribution of Hyperglycemia vs. Dyslipidemia

Diabetes is a major risk factor for tuberculosis (TB). Diabetes increases the risk of the progression from latent tuberculosis infection (LTBI) to active pulmonary TB and TB patients with diabetes are at greater risk of more severe disease and adverse TB treatment outcomes compared to TB patients without co-morbidities. Diabetes is a complex disease, characterised not only by hyperglycemia but also by various forms of dyslipidemia. However, the relative contribution of these underlying metabolic factors to increased susceptibility to TB are poorly understood. This review summarises our current knowledge on the epidemiology and clinical manifestation of TB and diabetes comorbidity. We subsequently dissect the relative contributions of body mass index, hyperglycemia, elevated cholesterol and triglycerides on TB disease severity and treatment outcomes. Lastly, we discuss the impact of selected glucose and cholesterol-lowering treatments frequently used in the management of diabetes on TB treatment outcomes.

Role of stilbenes against insulin resistance: A review

Insulin resistance (IR) is a state characterized by the inability of tissues to utilize blood glucose particularly liver, muscle, and adipose tissues resulting in hyperglycemia and hyperinsulinemia. A close relationship exists between IR and the development of type 2 diabetes (T2D). Therefore, therapeutic approaches to treat IR also improve T2D simultaneously. Scientific evidence has highlighted the major role of inflammatory cytokines, reactive oxygen species (ROS), environmental & genetic factors, and auto-immune disorders in the pathophysiology of IR. Among therapeutic remedies, nutraceuticals like polyphenols are being used widely to ameliorate IR due to their safer nature compared to pharmaceutics. Stilbenes are considered important metabolically active polyphenols currently under the limelight of research to cope with IR. In this review, efforts are made to elucidate cellular and subcellular mechanisms influenced by stilbenes including modulating insulin signaling cascade, correcting glucose transport pathways, lowering postprandial glucose levels, and protecting β-cell damage and its effects on the hyperactive immune system and proinflammatory cytokines to attenuate IR. Furthermore, future directions to further the research in stilbenes as a strong candidate against IR are included so that concrete recommendation for their use in humans is made.

Diabetes comorbidities in low- and middle-income countries: An umbrella review

Background

Diabetes mellitus, particularly type 2 diabetes, is a major public health burden globally. Diabetes is known to be associated with several comorbidities in high-income countries. However, our understanding of these associations in low- and middle-income countries (LMICs), where the epidemiological transition is leading to a growing dual burden of non-communicable and communicable disease, is less clear. We therefore conducted an umbrella review to systematically identify, appraise and synthesise reviews reporting the association between diabetes and multiple key comorbidities in LMICs.

Methods

We searched Medline, Embase, Global Health, and Global Index Medicus from inception to 14 November 2020 for systematic reviews, with or without meta-analyses, of cohort, case-control or cross-sectional studies investigating the associations between diabetes and cardiovascular disease (CVD), chronic kidney disease (CKD), depression, dengue, pneumonia, and tuberculosis within LMICs. We sought reviews of studies focused on LMICs, but also included reviews with a mixture of high-income and at least two LMIC studies, extracting data from LMIC studies only. We conducted quality assessment of identified reviews using an adapted AMSTAR 2 checklist. Where appropriate, we re-ran meta-analyses to pool LMIC study estimates and conduct subgroup analyses.

Results

From 11 001 articles, we identified 14 systematic reviews on the association between diabetes and CVD, CKD, depression, or tuberculosis. We did not identify any eligible systematic reviews on diabetes and pneumonia or dengue. We included 269 studies from 29 LMICs representing over 3 943 083 participants. Diabetes was positively associated with all comorbidities, with tuberculosis having the most robust evidence (16 of 26 cohort studies identified in total) and depression being the most studied (186 of 269 studies). The majority (81%) of studies included were cross-sectional. Heterogeneity was substantial for almost all secondary meta-analyses conducted, and there were too few studies for many subgroup analyses.

Conclusions

Diabetes has been shown to be associated with several comorbidities in LMICs, but the nature of the associations is uncertain because of the large proportion of cross-sectional study designs. This demonstrates the need to conduct further primary research in LMICs, to improve, and address current gaps in, our understanding of diabetes comorbidities and complications in LMICs.

Mean platelet volume (MPV): new diagnostic indices for co-morbidity of tuberculosis and diabetes mellitus

Background

Tuberculosis (TB) and type 2 diabetes mellitus (DM) are global health diseases with high morbidity and mortality. Few studies have focused on platelet indices in TB-DM coinfection patients. The objective of this work was to analyze the platelet indices in TB, DM and TB-DM patients to assess the predictive value of the platelet index for the risk of these diseases.

Methods

In total, 246 patients admitted to our hospital were distributed into three groups (113TB, 59 DM and 74TB+DM). A total of 133 individuals were also recruited as healthy controls (HC). Platelet indices, namely, platelet count (PC), mean platelet volume (MPV), plateletcrit (PCT) and platelet distribution width (PDW), were compared among the four groups, and the relationship with inflammatory markers was explored by using statistical software.

Results

Our study discovered that MPV and PCT were significantly downregulated in TB+DM patients (9.951.25fL, 0.200.05%, P<0.0001, P=0.0121, separately) compared with DM individuals (10.921.17fL, 0.220.04%). Moreover, the changes in MPV were significantly higher in TB+DM patients (9.951.25fL, P=0.0041) than in TB patients (9.421.01fL). No differences were found in PLT and PDW among the four groups (P>0.05). The sensitivity and specificity of MPV in the differential diagnosis of DM patients vs TB+DM patients were 64.9 and 66.1% (P<0.0001), respectively, and the sensitivity and specificity of MPV between TB patients and TB+DM patients was 60.8 and 66.4%, respectively (P=0.003). MPV improved the diagnosis sensitivity when it was combined with clinical parameters, such as fasting blood glucose in DM and Mycobacterium tuberculosis culture result in TB (76.3% vs 64.9, 72.6% vs 60.8%, P<0.0001, P=0.001, respectively). In addition, the sensitivity and specificity of PCT in the differential diagnosis of DM patients vs TB+DM patients were 69.5 and 59.4%, respectively (P=0.008). PCT improved the diagnosis sensitivity when combined with fasting blood glucose in DM (72.9% vs 64.9%, P=0.004). In addition, MPV was linked to CRP (C-reactive protein) and ESR (erythrocyte sedimentation rate) in the TB+DM patients (r=0.3203, P=0.0054, r=0.2504, P=0.0307) but PCT was not (r=0.1905, r=0.008675, P>0.05, respectively).

Conclusions

Our research shows that MPV and PCT might be good clinical laboratory markers to distinguish TB+DM patients from TB or DM individuals, thus providing support for earlier clinical diagnosis, prevention, and therapy.

Diabetes Mellitus and Its Associated Factors in Tuberculosis Patients in Maekel Region, Eritrea: Analytical Cross-Sectional Study

BACKGROUND

Both diabetes mellitus (DM) and tuberculosis (TB) are among the leading causes of morbidity and mortality in Eritrea. TB-DM comorbidity is known to complicate TB care, control and prevention. However, systematically studied epidemiological data on TB-DM comorbidity and its associated risk factors are lacking in this country.

OBJECTIVE

This study aimed to assess the prevalence of DM and its associated factors among TB patients in the Maekel region, Eritrea.

METHODS

Analytical cross-sectional study was conducted in eleven TB diagnostic and treatment sites. Pretested data extraction tool was used to collect data from medical records. Prevalence data were analysed using frequencies, proportions and median. To determine DM risk factors, univariable and multivariable logistic regression analysis was done with 95% CI and p value < 0.05 considered significant.

RESULTS

Out of total eligible (1134) TB cases, DM prevalence was 9.88%. Age and BMI were identified as independent risk factors for DM among TB patients. Higher odds of DM were found among TB patients aged 45-54 (aOR: 4.85[1.39-16.94], p= 0.013) and those ≥55 (aOR: 6.99[2.12-23.04], p= 0.001). TB cases with normal BMI were two times more likely to have DM (aOR: 2.00[1.23-3.26], p= 0.005) compared to those underweight.

CONCLUSION

The prevalence of DM among TB cases observed in this study is high, a clarion call to scale up current efforts to integrate TB-DM services within routine care. Furthermore, age and BMI were identified as independent risk factors for DM in TB cases, pointing to the need to pay attention to age and BMI status when managing this co-morbidity.

Infections and diabetes: Risks and mitigation with reference to India

BACKGROUND AND AIMS

The link between diabetes and increased risk of infectious disease has long been recognized, but has re-entered sharp focus following the COVID-19 pandemic.

METHODS

A literature search was conducted in PubMed for articles in English on diabetes and infection.

RESULTS

Diabetes predisposes to infections through alterations in innate and acquired immune defenses. Outcomes of infection are worse in people with uncontrolled diabetes, and infection can worsen hyperglycemia in hitherto well controlled diabetes (bidirectional relationship). Diabetes does not increase the risk of infection with COVID-19 per se, but predisposes to severe disease and poor outcomes. COVID-19 has also been linked to deterioration of glycemic control as well as new-onset diabetes.

CONCLUSIONS

Clinicians caring for people with diabetes should be aware of the increased risk of infections in this population, as well as the possibility of worsening hyperglycemia. A holistic approach with frequent monitoring of blood glucose levels and appropriate titration of medications, along with close attention to nutritional status, is essential to ensure the best possible outcomes.

Barriers and facilitators to bidirectional screening of TB-DM in Ghana: Healthcare workers' perspectives

Background

The tuberculosis (TB) and diabetes mellitus (DM) co-epidemic continues to increase globally. Low-and middle-income countries bear the highest burden of co-epidemic, and Ghana is no exception. In 2011, the World Health Organisation (WHO) responded to this global challenge by launching a collaborative framework with a view to guide countries in implementing their DM and TB care, prevention and control plans. Subsequently, several countries, including Ghana, adopted this framework and began implementing bidirectional screening of TB and DM patients. Almost a decade later since the launch of the framework, the implementation of bidirectional screening in Ghana has not been subjected to empirical research. This study explored the barriers and facilitators to bidirectional screening through the lenses of the implementing healthcare workers.

Methods

This was an exploratory qualitative study conducted in three public health facilities offering both TB and DM services in Northern Ghana. In-depth interviews, document review and observations, were used to generate data. In total twenty-three healthcare workers (doctors, nurses, prescriber, health managers and TB task- shifting officers delivering care in TB and DM clinics) were interviewed, using semi-structured interview guides. The interview questions solicited information on the screening process, including knowledge of the collaborative framework, comorbidity, collaboration and workload.

Results

Six themes emerged from the analysis, of which two (Increase in staff capacity, and Institutionalisation of bidirectional screening) were facilitators, and four (Delays in screening, Fear and stigmatization of TB, Poor collaboration between TB and DM units, and Skewed funding for screening) were barriers.

Conclusions

The implementation of bidirectional screening at public health facilities in Ghana was evident in this study and increased staff capacity, funding and institutionalisation enhanced the policy implementation process. However, the screening of TB patients for DM is yet to be prioritised, and emphasis should be put on the design for cost-effective screening approaches for low- and middle-income countries.

Undiagnosed diabetes mellitus and tuberculosis infection: A population-based, observational study from eastern China

BACKGROUND

China has the largest dual diabetes and tuberculosis epidemic globally. No studies from mainland China have assessed the relationship between tuberculosis infection and diabetes. We conducted a population-based, observational study in eastern China to further explore this relationship.

METHODS

A blood glucose, Quantiferon, and tuberculin skin test were administered at baseline. We compared tuberculosis infection in nondiabetics and diabetics. The cohort was additionally screened for tuberculosis progression over 5 years.

RESULTS

Among 5405 participants, diabetics had elevated levels of Quantiferon and tuberculin positivity, largely driven by undiagnosed diabetics (compared with nondiabetics, adjusted odds ratios of 1.53; 95% confidence interval [CI], 1.05-2.23 and 1.58; 95% CI, 1.07-2.35 for tuberculin and Quantiferon positivity). During follow-up, the annual tuberculosis incidence was three times higher for diabetics compared with the entire cohort.

CONCLUSIONS

These results suggest improving diabetic control through rapidly identifying undiagnosed diabetes may have indirect benefits to tuberculosis control. Targeting of preventive therapy to newly diagnosed diabetics at high-risk for progressive tuberculosis in China should be considered.

Diabetes Mellitus and Tuberculosis Comorbidity and Associated Factors Among Bale Zone Health Institutions, Southeast Ethiopia

BACKGROUND

Globally, tuberculosis and diabetes mellitus co-morbidity is higher than tuberculosis and human immunodeficiency virus comorbidity. Considering this, the World Health Organization and the International Union against tuberculosis and lung disease recommend bi-directional screening of the two diseases. However, in Ethiopia, bi-directional screening has not been started yet.

OBJECTIVE

The objective of this study was to assess the prevalence of diabetes mellitus and tuberculosis comorbidity and its predictors among adult tuberculosis patients in Bale Zone Health Institutions, Southeastern Ethiopia.

MATERIALS AND METHODS

Institutional-based cross-sectional study carried out using interviewer administered questionnaire, registration review, anthropometric and blood glucose level measurement from March, 30, 2019 to April, 30, 2019. Three hundred twenty-one tuberculosis patients were selected from tuberculosis registration log book using lottery methods. The collected data were checked for completeness, coded and entered in to EpiData3.0.2 and exported to SPSS version 20. Independent variables that had p value less 0.25 were used as candidates for multiple logistic regressions to control confounders. Variables that had significant association were identified by calculating odds ratio, with 95% confidence interval, and p value less than 0.05 used to declare statistical significance.

RESULTS

Diabetes mellitus and tuberculosis comorbidity among adult tuberculosis patients was 5.1% (95% CI: 2.7%, 7.5%). Age with ≥50 years (AOR=3.98, 95% CI: 1.13, 14.36), having extra pulmonary tuberculosis (AOR=3.31, 95% CI: 1.16, 9.44) and being females (AOR=3.8, 95% CI: 1.17, 12.33) were significantly associated with the comorbidity of the two diseases.

CONCLUSION AND RECOMMENDATION

The prevalence of diabetes mellitus and tuberculosis comorbidity was high. Female tuberculosis patients, tuberculosis patients with age ≥50 years and those having extra pulmonary tuberculosis patients should be screened for diabetes mellitus.

Primary drug resistance among tuberculosis patients with diabetes mellitus: a retrospective study among 7223 cases in China

Background

Given the high burden of tuberculosis (TB) and diabetes mellitus (DM) in China and the worse outcome of TB-DM cases (refers to TB patients with diabetes), and drug-resistant tuberculosis cases (DR-TB), it is of great significance to explore the association between diabetes and primary DR-TB for TB elimination target in China. We assessed the clinical characteristics, drug-resistance profile, and increased risk of resistance among TB-DM patients across China from 2004 to 2017.

Method

7223 cases with drug-susceptibility data were collected from Shandong, China. Categorical baseline characteristics of new TB cases were compared by DM status using Fisher's exact or Pearson Chi-square test. Univariable analysis and multivariable logistic models were used to estimate the association between diabetes and different drug-resistance profiles and the risk factors of primary drug resistance among TB-DM cases.

Result

Of 7223 newly diagnosed TB patients, 426 (5.90%) were TB-DM cases. TB-DM csaes were more likely to be older，accompanied by higher body mass index (BMI) and hypertension than TB-no DM cases (refers to TB patients without diabetes). The rates of DR-TB (21.83% vs 16.96%), polydrug resistant TB (PDR-TB, 6.10% vs 3.80%), isoniazid (INH)+streptomycin (SM)-resistant TB (4.93% vs 3.13%), and SM-resistant TB (16.20% vs 11.7%) among TB-DM group were higher than TB-no DM group, P<0.05. DM was significantly associated with any DR-TB (adjusted (aOR):1.30; 95% CI, 1.02-1.65), SM-related resistance (aOR: 1.43; 95% CI, 1.08-1.88), PDR-TB (OR: 1.57; 95% CI, 1.04-2.36; aOR: 1.59; 95% CI, 1.04-2.44), compared with pan-susceptible TB patients (P<0.05).

Conclusion

Our study indicated that TB-DM groups had a higher proportion of drug resistance than TB groups, and diabetes was identified as a risk factor of total DR, PDR, SM resistance and INH+SM resistance among newly diagnosed TB cases. Good management of diabetes and TB infection screening program among DM patients might be necessary for improving TB control in China.

Unveil the transcriptional landscape at the Cryptococcus-host axis in mice and nonhuman primates

Pathogens and hosts require rapid modulation of virulence and defense mechanisms at the infection axis, but monitoring such modulations is challenging. In studying the human fungal pathogen Cryptococcus neoformans, mouse and rabbit infection models are often employed to shed light on the disease mechanisms but that may not be clinically relevant. In this study, we developed an animal infection model using the non-human primate cynomolgus monkey Macaca fascicularis. In addition, we systematically profiled and compared transcriptional responses between the infected mice and the cynomolgus monkey, using simultaneous or dual RNA next-generation sequencing. We demonstrated that there are shared but distinct transcriptional profiles between the two models following C. neoformans infection. Specifically, genes involved in immune and inflammatory responses are all upregulated. Osteoclastogenesis and insulin signaling are also significantly co-regulated in both models and disrupting an osteoclastogenesis-associated gene (OC-STAMP) or the insulin-signaling process significantly altered the host tolerance to C. neoformans. Moreover, C. neoformans was shown to activate metal sequestration, dampen the sugar metabolism, and control cell morphology during infection. Taking together, we described the development of a non-human primate model of cryptococcosis that allowed us to perform an in-depth analysis and comparison of transcriptome profiles during infections of two animal models and conceptually identify host genes important in disease responses. This study provides new insights in understanding fungal pathogenesis mechanisms that potentially facilitate the identification of novel drug targets for the treatment of cryptococcal infection.

The host-pathogen interaction is highly dynamic and tightly regulated, and yet is difficult to monitor. Traditional investigations provide valuable information for the understanding of pathogenic microbial biology but are time-consuming and often neglect the host immune responses. In addition, current animal models for studying pathogenic fungi are limited in mimicking the responses from humans. The development of a new Cryptococcus neoformans infection model using nonhuman primates and the utilization of simultaneous RNA sequencing analysis provide fast and clinically relevant research data allowing the identification of novel critical players from both the invading fungus and the host. The data from the current study would not only help to decipher disease mechanisms but also promote the discovery of novel antifungal drug targets.

Diabetes in developing countries

There has been a rapid escalation of type 2 diabetes (T2D) in developing countries, with varied prevalence according to rural vs urban habitat and degree of urbanization. Some ethnic groups (eg, South Asians, other Asians, and Africans), develop diabetes a decade earlier and at a lower body mass index than Whites, have prominent abdominal obesity, and accelerated the conversion from prediabetes to diabetes. The burden of complications, both macro- and microvascular, is substantial, but also varies according to populations. The syndemics of diabetes with HIV or tuberculosis are prevalent in many developing countries and predispose to each other. Screening for diabetes in large populations living in diverse habitats may not be cost-effective, but targeted high-risk screening may have a place. The cost of diagnostic tests and scarcity of health manpower pose substantial hurdles in the diagnosis and monitoring of patients. Efforts for prevention remain rudimentary in most developing countries. The quality of care is largely poor; hence, a substantial number of patients do not achieve treatment goals. This is further amplified by a delay in seeking treatment, "fatalistic attitudes", high cost and non-availability of drugs and insulins. To counter these numerous challenges, a renewed political commitment and mandate for health promotion and disease prevention are urgently needed. Several low-cost innovative approaches have been trialed with encouraging outcomes, including training and deployment of non-medical allied health professionals and the use of mobile phones and telemedicine to deliver simple health messages for the prevention and management of T2D.