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Meseret F, Muluken S, Gebru Gebi T, Embiale Yigrem T. Treatment Outcome and Associated Factors among Type 1 Diabetic Children Admitted with DKA in Bahir Dar City Public Referral Hospital, Northwest, Ethiopia: A Cross-sectional Study. Glob Pediatr Health 2024; 11:2333794X241248320. [PMID: 38660690 PMCID: PMC11041539 DOI: 10.1177/2333794x241248320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 03/01/2024] [Accepted: 04/03/2024] [Indexed: 04/26/2024] Open
Abstract
Background. Outcomes that should be measured during diabetic ketoacidosis management is crucial. However, data associated to this was limited in Ethiopia. Methods. A cross-sectional study was conducted among children with diabetic keto acidosis between 2016 and 2021.Data were stored in Epi-data version 4.6 and exported into STATA 14.0 software for analysis. The association between independent variables and length of hospital stay was assessed using binary logistic regression. Finally, variables with P-value <.05 were considered statistically significant. Result. Median length of hospital stay was 8 ± 6.2 days. Majority of patients (97.5%) improved and discharged. Factors that affected longer hospital stay were Residence(aOR = 4.31;95% CI = 1.25-14.80),family history of diabetes (aOR = 0.12; 95% CI = 0.02-0.64), glycemia at admission (aOR = 1.01; 95% CI = 1.00-1.02),insulin skipping (aOR = 0.08; 95% CI = 0.01-0.98), abdominal pain (aOR = 4.28; 95% CI = 1.11-15.52) and time in which the patient get out of diabetic ketoacidosis(aOR = 6.39; 95% CI = 1.09-37.50). Conclusion. Majority of patients showed improvement and discharged to homes after a long hospital stay. Majority of patients resolved from diabetic ketoacidosis between 24 and 48 hours.
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Le Bec E, Kam M, Aebischer Perone S, Boulle P, Cikomola JC, Gandur ME, Gehri M, Kehlenbrink S, Beran D. Using Clinical Vignettes to Understand the Complexity of Diagnosing Type 1 Diabetes in Sub-Saharan Africa. Res Rep Trop Med 2023; 14:111-120. [PMID: 38024811 PMCID: PMC10656429 DOI: 10.2147/rrtm.s397127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 11/07/2023] [Indexed: 12/01/2023] Open
Abstract
Lack of awareness, access to insulin and diabetes care can result in high levels of morbidity and mortality for children with type 1 diabetes (T1DM) in sub-Saharan Africa (SSA). Improvements in access to insulin and diabetes management have improved outcomes in some settings. However, many people still present in diabetic ketoacidosis (DKA) in parallel to misdiagnosis of children with T1DM in contexts with high rates of communicable diseases. The aim of this study was to highlight the complexity of diagnosing pediatric T1DM in a healthcare environment dominated by infectious diseases and lack of adequate health system resources. This was done by developing clinical vignettes and recreating the hypothetico-deductive process of a clinician confronted with DKA in the absence of identification of pathognomonic elements of diabetes and with limited diagnostic tools. A non-systematic literature search for T1DM and DKA in SSA was conducted and used to construct clinical vignettes for children presenting in DKA. A broad differential diagnosis of the main conditions present in SSA was made, then used to construct a clinician's medical reasoning, and anticipate the results of different actions on the diagnostic process. An examination of the use of the digital based Integrated Management of Childhood Illness diagnostic algorithm was done, and an analysis of the software's efficiency in adequately diagnosing DKA was assessed. The main obstacles to diagnosis were low specificity of non-pathognomonic DKA symptoms and lack of tools to measure blood or urine glucose. Avenues for improvement include awareness of T1DM symptomatology in communities and health systems, and greater availability of diagnostic tests. Through this work clinical vignettes are shown to be a useful tool in analyzing the obstacles to underdiagnosis of diabetes, a technique that could be used for other pathologies in limited settings, for clinical teaching, research, and advocacy.
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Affiliation(s)
- Enora Le Bec
- Internal Medicine, Etablissements Hospitaliers du Nord Vaudois, Yverdon, Switzerland
| | - Madibele Kam
- Pediatric University Hospital Charles de Gaulle, Ouagadougou, Burkina Faso
| | - Sigiriya Aebischer Perone
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Geneva, Switzerland
- Health Unit, International Committee of the Red Cross, Geneva, Switzerland
| | | | | | | | - Mario Gehri
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Sylvia Kehlenbrink
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, Boston, MA, USA
| | - David Beran
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
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3
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Katte JC, McDonald TJ, Sobngwi E, Jones AG. The phenotype of type 1 diabetes in sub-Saharan Africa. Front Public Health 2023; 11:1014626. [PMID: 36778553 PMCID: PMC9912986 DOI: 10.3389/fpubh.2023.1014626] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 01/10/2023] [Indexed: 01/29/2023] Open
Abstract
The phenotype of type 1 diabetes in Africa, especially sub-Saharan Africa, is poorly understood. Most previously conducted studies have suggested that type 1 diabetes may have a different phenotype from the classical form of the disease described in western literature. Making an accurate diagnosis of type 1 diabetes in Africa is challenging, given the predominance of atypical diabetes forms and limited resources. The peak age of onset of type 1 diabetes in sub-Saharan Africa seems to occur after 18-20 years. Multiple studies have reported lower rates of islet autoantibodies ranging from 20 to 60% amongst people with type 1 diabetes in African populations, lower than that reported in other populations. Some studies have reported much higher levels of retained endogenous insulin secretion than in type 1 diabetes elsewhere, with lower rates of type 1 diabetes genetic susceptibility and HLA haplotypes. The HLA DR3 appears to be the most predominant HLA haplotype amongst people with type 1 diabetes in sub-Saharan Africa than the HLA DR4 haplotype. Some type 1 diabetes studies in sub-Saharan Africa have been limited by small sample sizes and diverse methods employed. Robust studies close to diabetes onset are sparse. Large prospective studies with well-standardized methodologies in people at or close to diabetes diagnosis in different population groups will be paramount to provide further insight into the phenotype of type 1 diabetes in sub-Saharan Africa.
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Affiliation(s)
- Jean Claude Katte
- Institute of Clinical and Biomedical Sciences, University of Exeter Medical School, Exeter, United Kingdom,National Obesity Centre and Endocrinology and Metabolic Diseases Unit, Yaounde Central Hospital, Yaoundé, Cameroon,*Correspondence: Jean Claude Katte ✉
| | - Timothy J. McDonald
- Institute of Clinical and Biomedical Sciences, University of Exeter Medical School, Exeter, United Kingdom,Academic Department of Clinical Biochemistry, Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom
| | - Eugene Sobngwi
- National Obesity Centre and Endocrinology and Metabolic Diseases Unit, Yaounde Central Hospital, Yaoundé, Cameroon,Department of Internal Medicine and Specialities, Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroon
| | - Angus G. Jones
- Institute of Clinical and Biomedical Sciences, University of Exeter Medical School, Exeter, United Kingdom,Macleod Diabetes and Endocrine Centre, Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom
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4
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Bacha T, Shiferaw Y, Abebaw E. Outcome of diabetic ketoacidosis among paediatric patients managed with modified DKA protocol at Tikur Anbessa specialized hospital and Yekatit 12 hospital, Addis Ababa, Ethiopia. Endocrinol Diabetes Metab 2022; 5:e363. [PMID: 36102127 PMCID: PMC9471591 DOI: 10.1002/edm2.363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 07/22/2022] [Accepted: 07/25/2022] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Diabetic ketoacidosis (DKA) is a serious acute complication of diabetes mellitus that carries a significant risk of mortality with delayed treatment in low-resource countries. This study aimed to determine the outcome of paediatric DKA patients' managed with a modified DKA treatment protocol using intermittent bolus subcutaneous insulin administration. METHODS A cross-sectional study design with retrospective data collection was conducted among children younger than 14 years of age admitted from January 2013 to February 2017. A modified protocol was prepared based on a reference from the international society for paediatric and adolescent diabetes and other international guidelines. Data were analysed using Statistical package for social science (SPSS) version 22.0. Descriptive statistics were performed. Binary logistic regression was used to identify associations, and significant variables were further considered for multivariate logistic regression to determine the outcome of DKA patients. RESULT Among the 190 patients, 55.5% (n = 105) were newly diagnosed. The overall average time required for resolution of DKA was 48 ± 27.8 h. Mental status on presentation (p = .001), shock on presentation (p < .01) and severity of DKA (p < .001) were found to have a significant association with the mean time for clearance of DKA. Hypoglycaemia was the most common treatment-related complication, which occurred in 23.7% of patients (n = 45) followed by hypokalaemia in 4.3% of patients (n = 8), and no patient developed cerebral oedema and death. CONCLUSION The time required for clearance of DKA was prolonged, and hypoglyceamia was a common complication for children younger than 5 years of age. The modified protocol of DKA is reasonable management for low-resource settings with further modification.
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Affiliation(s)
- Tigist Bacha
- Department of Pediatrics and Child Health, School of Medicine, College of Health SciencesSt Paul Millennium Medical CollegeAddis AbabaEthiopia
| | - Yemisrach Shiferaw
- Department of Pediatrics and Child Health, School of Medicine, College of Health SciencesAddis Ababa UniversityAddis AbabaEthiopia
| | - Ermias Abebaw
- Department of Pediatrics and Child Health, School of MedicineDebre Markos UniversityDebre MarkosEthiopia
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5
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Getie A, Wondmieneh A, Bimerew M, Gedefaw G, Demis A. Determinants of diabetes ketoacidosis among diabetes mellitus patients at North Wollo and Waghimra zone public hospitals, Amhara region, Northern Ethiopia. BMC Endocr Disord 2021; 21:26. [PMID: 33602195 PMCID: PMC7890609 DOI: 10.1186/s12902-021-00692-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 02/08/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Diabetes Mellitus (DM) is a metabolic disorder associated with acute and chronic complications. Diabetic ketoacidosis (DKA) is the most serious diabetic emergency in patients with type one and type two diabetes mellitus. It is the leading cause of mortality in children and young adults. Even though the burden of DKA has increased, no research has been conducted on the determinants of Diabetes ketoacidosis in Ethiopia, particularly in the Amhara region. Thus, this study aimed to identify the determinants of diabetes Ketoacidosis among Diabetes Mellitus patients at North Wollo and Waghimra Zone public Hospitals. METHODS An institution-based unmatched case-control study design was employed among 408 patients at North Wollo and Waghimra Zone Public Hospitals from March 1st to April 30th, 2020. A consecutive sampling method was used to select study participants. The data were collected using structured interviewer-administered questioners and reviewing of patient charts. The analysis was done using a binary logistic regression model. Then, P-value < 0.05 was considered statistically significant. RESULT The mean (±SD) age of the study participants was 46.96 (± 15.175 SD) years. Irregular follow-up in diabetes clinic (AOR:4.19, 95% CI: 2.28-7.71), not received diabetic education (AOR: 2.87, 95% CI:1.44-5.72), alcohol drinking (AOR:2.99, 95% CI: 1.46-6.12), discontinuation of medications (AOR: 4.31, 95% CI:1.92-9.68), presence of comorbidity (AOR:2.57, 95% CI: 1.37-4.84), and being type one of diabetes mellitus (AOR: 2.01, 95% CI:1.11-3.63) were determinant factors of diabetic ketoacidosis . CONCLUSIONS This study showed that the behavioral and clinical characteristics of diabetic patients were determinant factors of DKA. Follow-up in the diabetic clinic, diabetic education, discontinuation of medications, alcohol drinking, presence of comorbidities, and type of diabetes mellitus were independent determinants of diabetic ketoacidosis.
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Affiliation(s)
- Addisu Getie
- Department of Nursing, College of Health Sciences, Woldia University, P.O.Box: 400, Woldia, Ethiopia
| | - Adam Wondmieneh
- Department of Nursing, College of Health Sciences, Woldia University, P.O.Box: 400, Woldia, Ethiopia
| | - Melaku Bimerew
- Department of Nursing, College of Health Sciences, Woldia University, P.O.Box: 400, Woldia, Ethiopia
| | - Getnet Gedefaw
- Department of Midwifery, College of Health Sciences, Woldia University, P.O.Box: 400, Woldia, Ethiopia
| | - Asmamaw Demis
- Department of Nursing, College of Health Sciences, Woldia University, P.O.Box: 400, Woldia, Ethiopia
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Kidie AA, Lakew AM, Ayele T. Frequency of Diabetic Ketoacidosis and Its Determinants Among Pediatric Diabetes Mellitus Patients in Northwest Ethiopia. Diabetes Metab Syndr Obes 2021; 14:4819-4827. [PMID: 34984014 PMCID: PMC8699764 DOI: 10.2147/dmso.s326537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 12/04/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) is one of the most common public health problems and is still a major child killer in sub-Saharan African countries, particularly Ethiopia. There are limited and inconclusive data in Amhara regional state; moreover, predictors for the incidence of DKA were not investigated before. Therefore, this study aimed to assess the frequency of DKA and its determinants among pediatric diabetes mellitus patients in public hospitals in northwest Ethiopia. METHODS An institutional-based retrospective follow-up study was conducted from September 2015 to February 2018 at selected public hospitals in northwest Ethiopia. A simple random sampling method was used to select 389 study subjects. Statistical analysis was done by R-studio version 1.1.4. Akakia's information criteria was used for model comparison and the negative binomial regression model was fitted to identify determinants for the frequency of DKA. An adjusted incidence rate ratio with 95% confidence interval was used to declare statistical significance. RESULTS The average frequency of DKA was 1.01 per individual. The incidence rate of DKA was increased among diabetes mellitus patients with an infection (adjusted incidence rate ratio (AIRR) = 1.41, 95% CI = 1.05-2.14), heart diseases (AIRR = 4.1, 95% CI = 1.17-14.68), treatment discontinuation (AIRR = 2.91, 95% CI = 2.02-4.22), low level of sodium (AIRR = 1.88, 95% CI = 1.22-2.89) and low dose of treatment at baseline (AIRR = 0.96, 95% CI = 0.94-0.97). CONCLUSION Having an infection, heart diseases, taking a low dose of treatment, a low sodium level, and treatment discontinuation were the factors that increase the frequency of DKA.
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Affiliation(s)
- Atitegeb Abera Kidie
- Department of Public Health, College of Medicine and Health Sciences, Woldia University, Woldia, Ethiopia
| | - Ayenew Molla Lakew
- Department of Epidemiology and Biostatistics, Institute of Public Health, University of Gondar, Gondar, Ethiopia
- Correspondence: Ayenew Molla Lakew Email
| | - Tiruneh Ayele
- Department of Epidemiology and Biostatistics, Institute of Public Health, University of Gondar, Gondar, Ethiopia
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7
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Padoa CJ, Rheeder P, Pirie FJ, Motala AA, van Dyk JC, Crowther NJ. Identification of a subgroup of black South Africans with type 1 diabetes who are older at diagnosis but have lower levels of glutamic acid decarboxylase and islet antigen 2 autoantibodies. Diabet Med 2020; 37:2067-2074. [PMID: 31811665 DOI: 10.1111/dme.14204] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/04/2019] [Indexed: 12/21/2022]
Abstract
AIMS To compare the age at diagnosis and prevalence of islet autoantibody [glutamic acid decarboxylase (65 kDa) 65 and islet antigen 2] positivity in black and white participants with type 1 diabetes in South Africa, and to analyse the relationship between age at diagnosis and the presence of autoantibodies. METHODS Participants were recruited from diabetes outpatient departments and autoantibodies to glutamic acid decarboxylase (65 kDa) and islet antigen 2 were measured by enzyme-linked immunosorbent assay. RESULTS We recruited 472 (353 black and 119 white) participants with type 1 diabetes. Age at diagnosis of diabetes was later in black (19.7 ± 10.5) than in white participants (12.7 ± 10.8 years; P < 0.001) with a median (interquartile range) disease duration of 5.0 (2.0-10.0) and 8.5 (4.0-20.0) years (P < 0.001), respectively. An older age at diagnosis (≥ 21 years) was more frequent in black (152 of 340, 45%) than in white participants (24 of 116, 21%; P < 0.001). The prevalence of islet antigen 2 autoantibodies was 19% (66/352) in black and 41% in white participants (48/118; P < 0.001). There was no significant difference in glutamic acid decarboxylase (65 kDa) autoantibody positivity between black (212/353, 60%) and white participants (77/117, 66%; P = 0.269). In black, but not white, participants the prevalence of both glutamic acid decarboxylase (65 kDa) and islet antigen 2 autoantibody positivity was significantly lower in participants diagnosed at age ≥ 21 years (P < 0.001 for both comparisons). CONCLUSIONS The older age at diagnosis, lower prevalence of islet antigen 2 autoantibodies and a distinct subgroup of participants with type 1 diabetes with age at diagnosis of > 20 years in the black compared to white population suggest a difference in the immunological aetiology of type 1 diabetes in these two population groups.
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Affiliation(s)
- C J Padoa
- Department of Chemical Pathology, National Health Laboratory Service, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa
| | - P Rheeder
- Department of Internal Medicine, Steve Biko Academic Hospital, University of Pretoria, Pretoria, South Africa
| | - F J Pirie
- Department of Diabetes and Endocrinology, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - A A Motala
- Department of Diabetes and Endocrinology, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - J C van Dyk
- Private Practice, Life Hospital, Groenkloof, Pretoria, South Africa
| | - N J Crowther
- Department of Chemical Pathology, National Health Laboratory Service, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa
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8
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Ahmed AM, Khabour OF, Ahmed SM, Alebaid IA, Ibrahim AM. Frequency and severity of ketoacidosis at diagnosis among childhood type 1 diabetes in Khartoum state, Sudan. Afr Health Sci 2020; 20:841-848. [PMID: 33163051 PMCID: PMC7609092 DOI: 10.4314/ahs.v20i2.38] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) is a potentially life threatening acute complication of Type I diabetes mellitus (T1DM). This study aimed to determine the frequency and clinical characteristics of pediatric DKA at diagnosis of new-onset T1DM in Khartoum during 2000-2017 period. METHODS The study was retrospective and involved review of medical files of children (<15 years) with T1DM in the city hospitals and diabetes centers. RESULTS The overall frequency of DKA among T1DM children at onset of disease diagnosis was 17.6% (173/982). The episodes of DKA increased from 26% in first 6- year period (2000-2005) to 46.3% in the last 6-year period (2011-2012; p<0.001). No significant difference in the frequency of DKA was observed according to gender (p=0.9) and age (p=0.24). Compared to other age groups, the severity of DKA (pH<7.1) was higher in pre-school children (p<0.01). Approximately, 5% of patients were complicated with cerebral edema with a mortality rate of 1.7%. CONCLUSION The DKA frequency at diagnosis of childhood T1DM in Khartoum was lower than previous reports. In addition, the severity of DKA was high among pre-school age children with a relatively high mortality rate when compared to the global rate.
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Affiliation(s)
- Ahmed M Ahmed
- Department of Medical Laboratory Technology, Faculty of Applied Medical Sciences, Taibah University, AL-Madinah, Saudi Arabia
| | - Omar F Khabour
- Department of Medical Laboratory Sciences, Jordan University of Science and Technology, Irbid 22110, Jordan
| | - Samia M Ahmed
- Department of Medical Laboratory Technology, Faculty of Applied Medical Sciences, Taibah University, AL-Madinah, Saudi Arabia
| | | | - Amna M Ibrahim
- Faculty of Medicine, Omdurman Islamic University, Khartoum, Sudan
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9
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Godman B, Basu D, Pillay Y, Almeida PHRF, Mwita JC, Rwegerera GM, Anand Paramadhas BD, Tiroyakgosi C, Patrick O, Niba LL, Sefah I, Oluka M, Guantai AN, Kibuule D, Kalemeera F, Mubita M, Fadare J, Ogunleye OO, Rampamba EM, Wing J, Mueller D, Alfadl A, Amu AA, Matsebula Z, Kalungia AC, Zaranyika T, Masuka N, Wale J, Hill R, Kurdi A, Timoney A, Campbell S, Meyer JC. Ongoing and planned activities to improve the management of patients with Type 1 diabetes across Africa; implications for the future. Hosp Pract (1995) 2020; 48:51-67. [PMID: 32196395 DOI: 10.1080/21548331.2020.1745509] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 03/18/2020] [Indexed: 06/10/2023]
Abstract
BACKGROUND Currently about 19 million people in Africa are known to be living with diabetes, mainly Type 2 diabetes (T2DM) (95%), estimated to grow to 47 million people by 2045. However, there are concerns with early diagnosis of patients with Type 1 diabetes (T1DM) as often patients present late with complications. There are also challenges with access and affordability of insulin, monitoring equipment and test strips with typically high patient co-payments, which can be catastrophic for families. These challenges negatively impact on the quality of care of patients with T1DM increasing morbidity and mortality. There are also issues of patient education and psychosocial support adversely affecting patients' quality of life. These challenges need to be debated and potential future activities discussed to improve the future care of patients with T1DM across Africa. METHODOLOGY Documentation of the current situation across Africa for patients with T1DM including the epidemiology, economics, and available treatments within public healthcare systems as well as ongoing activities to improve their future care. Subsequently, provide guidance to all key stakeholder groups going forward utilizing input from senior-level government, academic and other professionals from across Africa. RESULTS Whilst prevalence rates for T1DM are considerably lower than T2DM, there are concerns with late diagnosis as well as the routine provision of insulin and monitoring equipment across Africa. High patient co-payments exacerbate the situation. However, there are ongoing developments to address the multiple challenges including the instigation of universal health care and partnerships with non-governmental organizations, patient organizations, and pharmaceutical companies. Their impact though remains to be seen. In the meantime, a range of activities has been documented for all key stakeholder groups to improve future care. CONCLUSION There are concerns with the management of patients with T1DM across Africa. A number of activities has been suggested to address this and will be monitored.
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Affiliation(s)
- Brian Godman
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde , Glasgow, UK
- Division of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University , Pretoria, South Africa
- Division of Clinical Pharmacology, Karolinska Institute, Karolinska University Hospital Huddinge , Stockholm, Sweden
- Health Economics Centre, University of Liverpool Management School , Liverpool, UK
| | - Debashis Basu
- Department of Public Health Medicine, Steve Biko Academic Hospital and the University of Pretoria , Pretoria, South Africa
| | - Yogan Pillay
- National Department of Health, Pretoria, South Africa
| | - Paulo H R F Almeida
- School of Pharmacy, Postgraduate Program in Medicines and Pharmaceutical Services, Federal University of Minas Gerais (UFMG) , Belo Horizonte, Brazil
- Departamento de Gestão e Incorporação de Tecnologias e Inovação em Saúde, Secretaria de Ciência, Tecnologia, Inovação e Insumos Estratégicos em Saúde, Ministry of Health , Brasília, Brazil
| | - Julius C Mwita
- Department of Internal Medicine, Faculty of Medicine, University of Botswana , Gaborone, Botswana
| | - Godfrey Mutashambara Rwegerera
- Faculty of Medicine, Department of Internal Medicine, University of Botswana and Department of Medicine, Princess Marina Hospital , Gaborone, Botswana
| | - Bene D Anand Paramadhas
- Department of Pharmacy, Central Medical Stores, Ministry of Health and Wellness , Gaborone, Botswana
| | - Celda Tiroyakgosi
- Botswana Essential Drugs Action Program, Ministry of Health and Wellness , Gaborone, Botswana
| | - Okwen Patrick
- Effective Basic Services (Ebase) Africa , Bamenda, Africa
- Adelaide University , Adelaide, Australia
| | - Loveline Lum Niba
- Effective Basic Services (Ebase) Africa , Bamenda, Africa
- Department of Public Health, University of Bamenda , Bambili, Cameroon
| | - Israel Sefah
- Department of Pharmacy, Keta Municipal Hospital, Ghana Health Service , Keta, Ghana; Department of Pharmacy Practice, School of Pharmacy, University of Health and Allied Sciences, Ghana
| | - Margaret Oluka
- Department of Pharmacology and Pharmacognosy, School of Pharmacy, University of Nairobi , Nairobi, Kenya
| | - Anastasia N Guantai
- Department of Pharmacology and Pharmacognosy, School of Pharmacy, University of Nairobi , Nairobi, Kenya
| | - Dan Kibuule
- Department of Pharmacy Practice and Policy, Faculty of Health Sciences, University of Namibia , Windhoek, Namibia
| | - Francis Kalemeera
- Department of Pharmacy Practice and Policy, Faculty of Health Sciences, University of Namibia , Windhoek, Namibia
| | - Mwangana Mubita
- Department of Pharmacy Practice and Policy, Faculty of Health Sciences, University of Namibia , Windhoek, Namibia
| | - Joseph Fadare
- Department of Pharmacology and Therapeutics, Ekiti State University , Ado-Ekiti, Nigeria
- Department of Medicine, Ekiti State University Teaching Hospital , Ado-Ekiti, Nigeria
| | - Olayinka O Ogunleye
- Department of Pharmacology, Therapeutics and Toxicology, Lagos State University College of Medicine , Ikeja, Nigeria
- Department of Medicine, Lagos State University Teaching Hospital , Ikeja, Nigeria
| | - Enos M Rampamba
- Division of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University , Pretoria, South Africa
- Department of Health, Tshilidzini Hospital, Department of Pharmacy , Shayandima, South Africa
| | - Jeffrey Wing
- Charlotte Maxeke Medical Research Cluster , Johannesburg, South Africa
| | - Debjani Mueller
- Department of Public Health Medicine, Steve Biko Academic Hospital and the University of Pretoria , Pretoria, South Africa
- Charlotte Maxeke Medical Research Cluster , Johannesburg, South Africa
| | - Abubakr Alfadl
- National Medicines Board, Federal Ministry of Health , Khartoum, Sudan
- Unaizah College of Pharmacy, Qassim University , Unaizah, Saudi Arabia
| | - Adefolarin A Amu
- Eswatini Medical Christian University , Swazi Plaza, Kingdom of Eswatini
| | | | | | - Trust Zaranyika
- Department Of Medicine, University of Zimbabwe College of Health Sciences , Harare, Zimbabwe
| | - Nyasha Masuka
- Independent Health Systems Consultant , Harare, Zimbabwe
| | - Janney Wale
- Independent Consumer Advocate , Brunswick, Australia
| | - Ruaraidh Hill
- Liverpool Reviews and Implementation Group, Whelan Building, University of Liverpool , Liverpool, UK
| | - Amanj Kurdi
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde , Glasgow, UK
- Department of Pharmacology, College of Pharmacy, Hawler Medical University , Erbil, Iraq
| | - Angela Timoney
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde , Glasgow, UK
- NHS Lothian Director of Pharmacy, NHS Lothian , Edinburgh, UK
| | - Stephen Campbell
- Centre for Primary Care, Division of Population Health, Health Services Research and Primary Care, University of Manchester , Manchester, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre, School of Health Sciences, University of Manchester , Manchester, UK
| | - Johanna C Meyer
- Division of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University , Pretoria, South Africa
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10
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Ababulgu RZ, Tesfaye BT. Characteristics and Outcomes of Children with Type-I Diabetes Mellitus Hospitalized for Ketoacidosis. Curr Diabetes Rev 2020; 16:779-786. [PMID: 31490763 DOI: 10.2174/1573399815666190906152125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 07/12/2019] [Accepted: 08/26/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Type 1 diabetes mellitus is a common autoimmune disorder that often presents in children. In these patients, diabetic ketoacidosis is one of the most common and serious acute complications associated with significant morbidity and mortality. Nevertheless, limited studies are conducted in Ethiopia. OBJECTIVE The aim of this study was to assess patient-related characteristics and outcomes of diabetic ketoacidosis, and their relative difference among children with newly diagnosed and previously known type-I diabetes mellitus. METHODS This is a retrospective cross-sectional study of 63 type-1 diabetes patients admitted for ketoacidosis at Jimma university medical center, a tertiary hospital. Data was collected using a checklist, and entered into Epidata 4.2.0.0 and analyzed using STATA 13.0. Descriptive statistics was performed; Mann-Whitney and Chi-square test statistics were employed for comparison. RESULT Of the total, 39 were newly diagnosed type-I diabetes patients. Polydipsia and Polyuria (each in 74.6%) were the predominant symptoms at presentation. ketoacidosis precipitants were undocumented in the majority of the patients (53.97%). Mean (±SD) Random blood sugar was 434.05 (±117.62)mg/dl. Ketoacidosis was mild in severity in 63.49%. Family history of diabetes, unknown precipitants and the first episode of ketoacidosis were significantly different among the new and known type-I diabetes patients. No mortality was documented. CONCLUSION The observed patient characteristics are typical of those reported in many studies and standard resources. Despite no mortality was documented, the need for early diagnosis and management should not be overlooked. Further study, with large sample size, is recommended to point-out the real characteristics difference among new and known type-I diabetes mellitus patients admitted for ketoacidosis.
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Affiliation(s)
| | - Behailu Terefe Tesfaye
- School of Pharmacy, Department of Clinical Pharmacy, Institute of Health Sciences, Jimma University, Jimma, Ethiopia
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11
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Musoma SN, Omar A, Mutai BC, Laigong P. Outcomes of Children and Adolescents Admitted with Diabetic Ketoacidosis at Kenyatta National Hospital (KNH), Kenya. J Diabetes Res 2020; 2020:8987403. [PMID: 33134396 PMCID: PMC7593731 DOI: 10.1155/2020/8987403] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/23/2020] [Accepted: 10/09/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) is an acute, major, life-threatening complication that mainly occurs in patients with type 1 diabetes mellitus and is the foremost cause of death in these children. Overall mortality in children with DKA varies from 3.4% to 13.4% in developing countries. There is a need to understand outcomes among children with DKA in sub-Saharan African countries. OBJECTIVE To determine the death rate and clinical outcomes of children and adolescents aged 0-18 years managed for DKA at Kenyatta National Hospital (KNH). Study Methods. This was a retrospective study carried out among children aged 0-18 years admitted with DKA at KNH between February 2013 and February 2018. The study site was the central records department at KNH. The inclusion criteria were children aged 0-18 years admitted with a diagnosis of DKA based on the ISPAD guidelines biochemical criteria. RESULTS Out of the 159 files reviewed, the median age of children was 13 years (IQR 10-15). 41.1% of patients had severe DKA while 35.7% had moderate DKA. We reported a mortality of 6.9% while 93.1% of children recovered and were discharged home. The median duration of hospital stay was 8 days. High risk of mortality was reported among children who had high serum creatinine (OR 5.8 (95% CI 1.6-21.2)), decreased urine output (OR 9.0 (95% CI 2.2-37.3)), and altered level of consciousness (OR 5.2 (95% CI 1.1-25.1)). CONCLUSION DKA-associated mortality in our study was low at 6.9%. High serum creatinine, decreased urine output, and altered level of consciousness were associated with a significantly higher risk of mortality.
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Affiliation(s)
| | - Anjumanara Omar
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | | | - Paul Laigong
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
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12
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Rowlands A, Ameyaw E, Rutagarama F, Dipesalema J, Majaliwa ES, Mbogo J, Ogle GD, Chanoine JP. Insights from the WHO and National Lists of Essential Medicines: Focus on Pediatric Diabetes Care in Africa. Horm Res Paediatr 2019; 90:82-92. [PMID: 30048982 DOI: 10.1159/000490467] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 05/28/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Access to essential medicines in pediatric endocrinology and diabetes is limited in resource-limited countries. The World Health Organization (WHO) maintains two non-binding lists of essential medicines (EMLs) which are often used as a template for developing national EMLs. METHODS We compared a previously published master list of medicines for pediatric endocrinology and diabetes with the WHO EMLs and national EMLs for countries within the WHO African region. To better understand actual access to medicines by patients, we focused on diabetes and surveyed pediatric endocrinologists from 5 countries and assessed availability and true cost for insulin and glucagon. RESULTS Most medicines that are essential in pediatric endocrinology and diabetes were included in the national EMLs. However, essential medicines, such as fludrocortisone, were present in less than 30% of the national EMLs despite being recommended by the WHO. Pediatric endocrinologists from the 5 focus countries reported significant variation in terms of availability and public access to insulin, as well as differences between urban and rural areas. Except for Botswana, glucagon was rarely available. There was no significant relationship between Gross National Income and the number of medicines included in the national EMLs. CONCLUSIONS Governments in resource-limited countries could take further steps to improve EMLs and access to medicines such as improved collaboration between health authorities, the pharmaceutical industry, patient groups, health professionals, and capacity-building programs such as Paediatric Endocrinology Training Centres for Africa.
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Affiliation(s)
- Amanda Rowlands
- Endocrinology and Diabetes Unit, British Columbia Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada.,Global Pediatric Endocrinology and Diabetes (GPED), Vancouver, British Columbia, Canada
| | - Emmanuel Ameyaw
- Global Pediatric Endocrinology and Diabetes (GPED), Vancouver, British Columbia, Canada.,Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | | | - Joel Dipesalema
- Global Pediatric Endocrinology and Diabetes (GPED), Vancouver, British Columbia, Canada.,Department of Paediatrics and Adolescent Health, University of Botswana, Princess Marina Hospital, Gaborone, Botswana
| | - Edna Siima Majaliwa
- Department of Paediatric and Child Health Muhimbili National Hospital, Dar es salaam, Tanzania
| | - Joyce Mbogo
- Global Pediatric Endocrinology and Diabetes (GPED), Vancouver, British Columbia, Canada.,Aga Khan Hospital, Nairobi, Kenya
| | - Graham D Ogle
- Global Pediatric Endocrinology and Diabetes (GPED), Vancouver, British Columbia, Canada.,International Diabetes Federation Life for a Child Program, Glebe, New South Wales, Australia
| | - Jean-Pierre Chanoine
- Endocrinology and Diabetes Unit, British Columbia Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada.,Global Pediatric Endocrinology and Diabetes (GPED), Vancouver, British Columbia, Canada
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13
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Ameyaw E, Asafo-Agyei SB, Thavapalan S, Middlehurst AC, Ogle GD. Clinical profile of diabetes at diagnosis among children and adolescents at an endocrine clinic in Ghana. World J Diabetes 2017; 8:429-435. [PMID: 28989569 PMCID: PMC5612833 DOI: 10.4239/wjd.v8.i9.429] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 05/31/2017] [Accepted: 06/20/2017] [Indexed: 02/05/2023] Open
Abstract
AIM To determine the clinical features of diabetes in children and adolescents in Ghana.
METHODS Retrospective review of clinical features of all children and adolescents with new-onset diabetes seen at the paediatric endocrinology clinic of Komfo Anokye Teaching Hospital in Kumasi, from February 2012 to Auguest 2016.
RESULTS One hundred and six subjects presented with diabetes. Ninety (84.9%) were diagnosed by clinical features and family history as type 1, and 16 (15.1%) type 2. For type 1 subjects, age range at diagnosis was 0.9-19.9 year (y), peak age of onset 12-13 year, and 3.3% were < 5 year, 21.1% 5- < 10 year, 45.6% 10- < 15 year and 30.0% 15- < 20 year. Seventy-one point one percent were female. Common clinical features were polyuria (100%), polydipsia (98.9%), and weight loss (82.2%). Mean BMI SD was -0.54, range -3.84 to 2.47. 60.0% presented in diabetic ketoacidosis (DKA). Nine had infections at onset (skin, abscess, leg ulcer). Mean ± SD HbA1c at diagnosis was 12.7% ± 1.9% (115 ± 21 mmol/mol). Four have since died: Hypoglycaemia (2), recurrent DKA (1), osteosarcoma (1). Two other type 1 cases died of DKA at presentation in emergency before being seen by the paediatric endocrinologist. Crude mortality rate including these 2 cases was 32.2/1000 patient years. Type 2 cases were 81% female, age of onset 9-19 year. Mean BMI SD was 1.49, range -0.87 to 2.61. Forty-three point eight percent presented in DKA. All type 2 cases had acanthosis nigricans. Overall, 9.8% did not have home refrigeration, most using clay pot evaporative cooling for insulin storage.
CONCLUSION Type 1 occurs with a female preponderance and high DKA rates. Type 2 also occurs. Typology based on clinical features is difficult. Community and professional awareness is warranted.
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Affiliation(s)
- Emmanuel Ameyaw
- Department of Child Health, Komfo Anokye Teaching Hospital, P.O. Box 1934, Kumasi, Ghana
| | - Serwah B Asafo-Agyei
- Department of Child Health, Komfo Anokye Teaching Hospital, P.O. Box 1934, Kumasi, Ghana
| | - Sumithira Thavapalan
- International Diabetes Federation Life for a Child Program, Glebe, NSW 2037, Australia
- Diabetes NSW, Glebe, NSW 2037, Australia
| | - Angela C Middlehurst
- International Diabetes Federation Life for a Child Program, Glebe, NSW 2037, Australia
- Diabetes NSW, Glebe, NSW 2037, Australia
| | - Graham D Ogle
- International Diabetes Federation Life for a Child Program, Glebe, NSW 2037, Australia
- Diabetes NSW, Glebe, NSW 2037, Australia
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Atkilt HS, Turago MG, Tegegne BS. Clinical Characteristics of Diabetic Ketoacidosis in Children with Newly Diagnosed Type 1 Diabetes in Addis Ababa, Ethiopia: A Cross-Sectional Study. PLoS One 2017; 12:e0169666. [PMID: 28135278 PMCID: PMC5279745 DOI: 10.1371/journal.pone.0169666] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 12/20/2016] [Indexed: 11/19/2022] Open
Abstract
Background Diabetic ketoacidosis (DKA) is one of the most serious acute complications of type 1 diabetes (T1D) and the leading cause of morbidity and mortality in children with T1D. This study was aimed at assessing the prevalence and associated factors of DKA in children with newly diagnosed T1D in Addis Ababa. Methods A hospital based cross-sectional study was conducted in selected hospitals in Addis Ababa. Children below the age of 12 years with DKA who were admitted to the pediatric ward in the selected hospitals between January 2009 and December 2014 and the residence of Addis Ababa were included. DKA was defined as children below the age of 12 years who have blood glucose level ≥250mg/dl, ketonuria, and ketonemia and diagnosed being T1D patient for the first time. Descriptive statistics was performed using frequency distribution, mean, median, tables, and graphs. Logistic regression analysis was used to identify independent factors associated with the prevalence of DKA in children with newly diagnosed T1D. Results Of 395 DKA patients who were hospitalized during the five-year period, 142(35.8%) presented with DKA at first diagnosis of diabetes. On the other hand 253 (64.2%) children with DKA had longstanding T1D. Independent factors associated with DKA include: Age category 2–4.49years, 7–9.49 years and ≥9.5years (Adjusted odd ratio (AOR) = 3.14[1.21,8.06]), 3.44(1.39,8.49) and 4.02(1.68,9.60), respectively); parents’ knowledge on the sign and symptoms of DKA (AOR = 0.51[0.27, 0.95]); sign and symptoms of DKA before the onset of DKA (AOR = 0.35[0.21, 0.59]) and infection prior to DKA onset (AOR = 3.45[1.97, 6.04]). Conclusions The overall proportion of children diagnosed with DKA and new onset of T1D in Addis Ababa was high. In particular, children between 9–12 years of age and children whose parents did not know the sign and symptoms of DKA had a high risk of DKA at primary diagnosis of T1D.
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Affiliation(s)
| | - Muluken Gizaw Turago
- Department of Preventive Medicine, School of Public Health, College of Health Sciences Addis Ababa University, Addis Ababa, Ethiopia
| | - Balewgizie Sileshi Tegegne
- Department of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
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Abstract
PURPOSE OF REVIEW This review summarizes the current state of diabetes in African children. RECENT FINDINGS Type 1 diabetes is the most common form of pediatric diabetes in Africa. Significant improvements have been achieved over the last 6 years, including the training of more than 60 pediatric endocrinologists who are now practicing in 14 African nations, greater training of other healthcare providers, increased availability of insulin through the efforts of philanthropic organizations and industry, modestly better availability of testing supplies, and the introduction of patient education materials in native languages. However, there is still a long way to go before the standard-of-care available to children in resource-rich nations is available to children with diabetes in Africa. SUMMARY Here, we review the known epidemiology, pathophysiology, complications, and treatment of diabetes in children in Africa.
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Affiliation(s)
- Thereza Piloya-Were
- aUniversity of Minnesota Department of Pediatrics, Minneapolis, Minnesota, USA bSchool of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda cInternational Diabetes Federation Life for a Child Program, Glebe, Sydney, Australia
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16
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Murunga AN, Miruka DO, Driver C, Nkomo FS, Cobongela SZZ, Owira PMO. Grapefruit Derived Flavonoid Naringin Improves Ketoacidosis and Lipid Peroxidation in Type 1 Diabetes Rat Model. PLoS One 2016; 11:e0153241. [PMID: 27073901 PMCID: PMC4830547 DOI: 10.1371/journal.pone.0153241] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 03/27/2016] [Indexed: 11/22/2022] Open
Abstract
Background Hypoglycemic effects of grapefruit juice are well known but the effects of naringin, its main flavonoid on glucose intolerance and metabolic complications in type 1 diabetes are not known. Objectives To investigate the effects of naringin on glucose intolerance, oxidative stress and ketonemia in type 1 diabetic rats. Methods Sprague-Dawley rats divided into 5 groups (n = 7) were orally treated daily with 3.0 ml/kg body weight (BW)/day of distilled water (group 1) or 50 mg/kg BW of naringin (groups 2 and 4, respectively). Groups 3, 4 and 5 were given a single intra-peritoneal injection of 60 mg/kg BW of streptozotocin to induce diabetes. Group 3 was further treated with subcutaneous insulin (4.0 IU/kg BW) twice daily, respectively. Results Stretozotocin (STZ) only-treated groups exhibited hyperglycemia, polydipsia, polyuria, weight loss, glucose intolerance, low fasting plasma insulin and reduced hepatic glycogen content compared to the control group. Furthermore they had significantly elevated Malondialdehyde (MDA), acetoacetate, β-hydroxybutyrate, anion gap and significantly reduced blood pH and plasma bicarbonate compared to the control group. Naringin treatment significantly improved Fasting Plasma Insulin (FPI), hepatic glycogen content, malondialdehyde, β-hydroxybutyrate, acetoacetate, bicarbonate, blood pH and anion gap but not Fasting Blood Glucose (FBG) compared to the STZ only-treated group. Conclusions Naringin is not hypoglycemic but ameliorates ketoacidosis and oxidative stress. Naringin supplements could therefore mitigate complications of diabetic ketoacidosis.
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Affiliation(s)
- Alfred N. Murunga
- Molecular and Clinical Pharmacology Research Laboratory, Department of Pharmacology, Discipline of Pharmaceutical Sciences, School of Health Sciences, University of KwaZulu-Natal, P.O. Box X5401, Durban, South Africa
| | - David O. Miruka
- Molecular and Clinical Pharmacology Research Laboratory, Department of Pharmacology, Discipline of Pharmaceutical Sciences, School of Health Sciences, University of KwaZulu-Natal, P.O. Box X5401, Durban, South Africa
| | - Christine Driver
- Molecular and Clinical Pharmacology Research Laboratory, Department of Pharmacology, Discipline of Pharmaceutical Sciences, School of Health Sciences, University of KwaZulu-Natal, P.O. Box X5401, Durban, South Africa
| | - Fezile S. Nkomo
- Molecular and Clinical Pharmacology Research Laboratory, Department of Pharmacology, Discipline of Pharmaceutical Sciences, School of Health Sciences, University of KwaZulu-Natal, P.O. Box X5401, Durban, South Africa
| | - Snazo Z. Z. Cobongela
- Molecular and Clinical Pharmacology Research Laboratory, Department of Pharmacology, Discipline of Pharmaceutical Sciences, School of Health Sciences, University of KwaZulu-Natal, P.O. Box X5401, Durban, South Africa
| | - Peter M. O. Owira
- Molecular and Clinical Pharmacology Research Laboratory, Department of Pharmacology, Discipline of Pharmaceutical Sciences, School of Health Sciences, University of KwaZulu-Natal, P.O. Box X5401, Durban, South Africa
- * E-mail:
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17
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Poovazhagi V. Factors associated with mortality in children with diabetic ketoacidosis (DKA) in South India. Int J Diabetes Dev Ctries 2015. [DOI: 10.1007/s13410-015-0441-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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