The influence of diabetes, glycemic control, and diabetes-related comorbidities on pulmonary tuberculosis

Tuberculosis (TB) treatment challenges in TB-diabetes comorbid patients: a systematic review and meta-analysis

BACKGROUND

The Directly Observed Treatment-Short Course (DOTS) Programme was implemented by WHO and includes a combination of four anti-tuberculosis (TB) drugs (isoniazid, pyrazinamide, ethambutol and rifampicin) for a period of six months to eradicate the TB infection completely. Diabetes mellitus (DM) is recognized as one of a strong contributor of TB according to World Health Organization (WHO). The presence of diabetes mellitus type 2 (DM type 2) makes TB treatment complicated. Thus, the objective of the current meta-analysis was to identify and quantify the impact of type 2 DM on treatment outcomes of TB patients treated under the DOTS Programme.

METHODS

This meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Through a systematic review of relevant literature, we focused on studies investigating treatment outcomes including extended treatment duration and recurrence for individuals with both TB and DM undergoing DOTS therapy. The extracted information included study designs, sample sizes, patient characteristics and reported treatment results.

RESULTS

In 44 studies from different parts of the world, the pooled HR for the impact of DM on extended treatment duration and reoccurrence were HR 0.72, 95% CI 0.56-0.83, p < .01 and HR 0.93, 95% CI 0.70-1.04, p = .08, respectively. The pooled HR for impact of DM on composite TB treatment outcomes was calculated as 0.76 (95% CI 0.60-0.87), p < .01 with an effect size of 41.18. The heterogeneity observed among the included studies was moderate (I2 = 55.79%).

CONCLUSIONS

A negative impact of DM was found on recurrence and extended treatment duration in TB patients treated with DOTS therapy. DM type 2 is responsible for the TB treatment prolongation and TB recurrence rates. By implementing effective management strategies and advancing research, the challenges can be mitigated, arising due to the complex interaction between DM and TB.

Impact of diabetes mellitus on tuberculosis prevention, diagnosis, and treatment from an immunologic perspective

The coexistence of diabetes mellitus (DM) and tuberculosis (TB) presents a significant global burden, with DM being recognized as a major risk factor for TB. This review comprehensively analyzes the immunological aspects of DM-TB comorbidity, shedding light on the impact of DM on TB pathogenesis and immune responses. It reveals that high blood glucose levels in TB patients contribute to reduced innate immune cell count, compromised phagocytic function, and delayed antigen presentation. These factors ultimately impair the clearance of Mycobacterium tuberculosis (MTB) and delay adaptive immune responses. With the interaction between TB and DM, there is an increase in inflammation and elevated secretion of pro-inflammatory cytokines by immune cells. This exacerbates the inflammatory response and contributes to poor treatment outcomes in TB. Moreover, the review explores the effects of DM on TB prevention, diagnosis, and treatment. It highlights how poor glycemic control, insulin resistance (IR), DM complications, and genetic factors increase the risk of MTB infection in individuals with DM. Additionally, DM-related immune suppression adversely affects the sensitivity of traditional diagnostic tests for TB, potentially resulting in underdiagnosis and delayed intervention. To mitigate the burden of TB in DM patients, the review emphasizes the need for further research on the mechanisms underlying DM reactivation in latent TB infection (LTBI). It shows how important it is to find and treat LTBI in DM patients as soon as possible and suggests looking into biomarkers that are specific to DM to make diagnosis more accurate.

Age-specific Multimorbidity Patterns and Burden on All-Cause Mortality and Public Direct Medical Expenditure: A Retrospective Cohort Study

OBJECTIVE

To evaluate age-specific multimorbidity patterns and morbidity burden on mortality and healthcare expenditure across age groups.

PATIENTS AND METHODS

Retrospective observational study between January 1, 2009 to December 31, 2017 using electronic health records in Hong Kong: Individuals were stratified by age (< 50, 50-64, 65-79, ≥ 80), and sub-classified by number of morbidities (0, 1, 2, 3, ≥ 4) out of 21 common chronic conditions. Clustering analyses were conducted to identify specific patterns of multimorbidity. Association between the number as well as combinations of morbidities and all-cause mortality and public expenditure was examined.

RESULTS

4,562,832 individuals with a median follow-up of 7 years were included. Mental disorders were the top morbidities among young individuals, while cardiovascular diseases were prevalent in the elderly. An increased number of morbidities was associated with a greater relative risk for mortality and medical expenditure, and this relationship was stronger among younger patients. Compared to individuals in the same age group without morbidity, the hazard ratios (HR; 95% CI) of all-cause mortality in patients aged < 50 and ≥ 80 with two comorbidities 3.81 (3.60-4.03) and 1.38 (1.36-1.40), respectively, which increased to 14.22 (9.87-20.47) and 2.20 (2.13-2.26), respectively, as the number of morbidities increased to ≥ 4. The stroke-hypertension cluster was shown to be associated with the highest HR of mortality 2.48 (2.43-2.53) among all identified clusters arising from the clustering analysis.

CONCLUSION

Given the stronger association between multimorbidity and all-cause mortality and greater opportunity costs in younger populations, prevention and management of early-onset multimorbidity are warranted. (248 words).

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.

Effects of diabetes mellitus on retreatment of Tuberculosis: A multi-centered case-control study from Bangladesh

Objectives

Several studies suggested that diabetes mellitus (DM) worsens the tuberculosis (TB) treatment outcome. But information regarding the association of DM with retreatment of TB is very scarce in Bangladesh. Present study aimed to assess the effects of DM on retreatment of TB.

Methods

This case-control study was conducted among 254 patients (127 cases and 127 controls) from January 2022 - December 2022. Patients were recruited by purposive sampling from 92 centers of the Diabetic Association of Bangladesh (BADAS). Data were collected by face-to-face interview and record reviewing with the help of semi-structured questionnaire and checklist respectively. Quality of data was maintained in all stages of the study. Data were analyzed by using IBM SPSS software. Informed written consent was taken from each patient prior to the study. Ethical issues were maintained strictly.

Results

Present study matched the age and sex of cases and controls. The study revealed that majority of case (89.0) and controls (97.6) were married. Among cases 78.0 % had DM and among controls 64.6 % had DM. Among diabetic patients, 78.8 % cases' and 64.6 % controls' HbA1C level was not within normal range. The study found that, the number of episodes of previous TB (AOR = 3.088, ρ = 0.019), presence of DM (AOR = 2.817, ρ = 0.012) and uncontrolled HbA1C level (AOR = 2.500, ρ = 0.028) were independently associated with retreatment of TB.

Conclusion

The study found that presence of DM, uncontrolled HbA1C level and multiple episodes of previous TB were the risk factors for retreatment of TB. So, a separate guideline for treatment of TB-DM patients should be established to prevent retreatment cases.

Facile metabolic reprogramming distinguishes mycobacterial adaptation to hypoxia and starvation: ketosis drives starvation-induced persistence in M. bovis BCG

Mycobacteria adapt to infection stresses by entering a reversible non-replicating persistence (NRP) with slow or no cell growth and broad antimicrobial tolerance. Hypoxia and nutrient deprivation are two well-studied stresses commonly used to model the NRP, yet little is known about the molecular differences in mycobacterial adaptation to these distinct stresses that lead to a comparable NRP phenotype. Here we performed a multisystem interrogation of the Mycobacterium bovis BCG (BCG) starvation response, which revealed a coordinated metabolic shift away from the glycolysis of nutrient-replete growth to depletion of lipid stores, lipolysis, and fatty acid ß-oxidation in NRP. This contrasts with BCG's NRP hypoxia response involving a shift to cholesterol metabolism and triglyceride storage. Our analysis reveals cryptic metabolic vulnerabilities of the starvation-induced NRP state, such as their newfound hypersensitivity to H2O2. These observations pave the way for developing precision therapeutics against these otherwise drug refractory pathogens.

Effect of complicated, untreated and uncontrolled diabetes and pre-diabetes on treatment outcome among patients with pulmonary tuberculosis

BACKGROUND AND OBJECTIVE

Patients with tuberculosis and diabetes have a higher risk of unfavourable anti-tuberculosis treatment outcomes. In the present study, we aimed to evaluate the effects of various diabetes statuses on the outcomes of patients with pulmonary tuberculosis.

METHODS

Among the patients with pulmonary tuberculosis enrolled in the Korea Tuberculosis Cohort (KTBC) registry and the multicentre prospective cohort study of pulmonary tuberculosis (COSMOTB), those with diabetes and complicated diabetes were identified. The primary and secondary outcomes were unfavourable outcomes and mortality, respectively. The effect of diabetes and complicated diabetes on the outcomes was assessed using multivariable logistic regression analysis. Using COSMOTB, subgroup analyses were performed to assess the association between various diabetes statuses and outcomes.

RESULTS

In the KTBC, diabetes (adjusted odds ratio [aOR] = 1.93, 95% CI = 1.64-2.26) and complicated diabetes (aOR = 1.96, 95% CI = 1.67-2.30) were significantly associated with unfavourable outcomes, consistent with the COSMOTB data analysis. Based on subgroup analysis, untreated diabetes at baseline was an independent risk factor for unfavourable outcomes (aOR = 2.72, 95% CI = 1.26-5.61). Prediabetes and uncontrolled diabetes increased unfavourable outcomes and mortality without statistical significance.

CONCLUSION

Untreated and complicated diabetes at the time of tuberculosis diagnosis increases the risk of unfavourable outcomes and mortality.

Impact of hyperglycemia on tuberculosis treatment outcomes: a cohort study

Hyperglycemia is prevalent and closely associated with pulmonary tuberculosis (PTB). This study aimed to investigate the effects of hyperglycemia on the outcomes of PTB treatment. This study comprised 791 patients with PTB in total. Patients with fasting plasma glucose levels of ≥ 6.1 mmol/L were diagnosed with hyperglycemia. Anthropometric and baseline demographic data were also collected. The treatment response was assessed based on clinical symptoms (sputum production, cough, chest pain, fever, hemoptysis, night sweats, loss of appetite, and fatigue), sputum smear, chest computed tomography (CT), and adverse gastrointestinal responses (vomiting, nausea, abdominal distension, diarrhea, and constipation). A generalized estimating equation (GEE) was used to evaluate these relationships. Hyperglycemia affected 266 (33.6%) of the 791 patients with PTB. In GEE analyses, patients with hyperglycemia exhibited a greater incidence of elevated tuberculosis (TB) scores (odds ratio (OR) 1.569; 95% CI 1.040-2.369), cough (OR 1.332; 95% CI 1.050-1.690), and night sweats (OR 1.694; 95% CI 1.288-2.335). Hyperglycemia was linked with a higher risk of positive sputum smears (OR 1.941; 95% CI 1.382-2.727). During therapy, hyperglycemia was also associated with an increased incidence of vomiting (OR 2.738; 95% CI 1.041-7.198), abdominal distension (OR 2.230; 95% CI 1.193-4.171), and constipation (OR 2.372; 95% CI 1.442-3.902). However, the CT results indicated that hyperglycemia did not affect pulmonary lesions in patients with TB. Patients with TB and hyperglycemia are at a higher risk of severe clinical manifestations, positive sputum smears, and adverse gastrointestinal effects and, therefore, the special situation of hyperglycemic patients should be considered in the prevention and treatment of TB.

Glycemic control during TB treatment among Filipinos: The Starting Anti-Tuberculosis Treatment Cohort Study

Poor TB treatment outcomes are observed in patients with type 2 diabetes mellitus (DM) comorbidity and glycemic control throughout treatment may play a role. The objective of this study was to investigate glycemic control longitudinally among Filipino adults undergoing TB treatment using mixed-effects linear and logistic regression. Analyses were conducted in 188 DM-TB patients out of 901 enrolled in the Starting Anti-TB Treatment (St-ATT) cohort, with a median baseline glycosylated hemoglobin (HbA1c) of 8.2% (range 4.5-13.3%). Previous versus new DM diagnosis was associated with higher mean HbA1c (worse glycemic control) during treatment, with a smaller effect amongst those with central obesity (coefficient 0.80, 95% confidence interval [CI] 0.26, 1.57, P = 0.043) than amongst those without central obesity (coefficient 3.48, 95% CI 2.16, 4.80, P<0.001). In those with a new DM diagnosis, central obesity was associated with higher blood glucose (coefficient 1.62, 95% CI 0.72, 2.53, P = 0.009). Of 177 participants with ≥2 HbA1c results, 40% had uncontrolled glycemia (≥2 HbA1c results ≥8%). Of 165 participants with ≥3 HbA1c results, 29.9% had consistently-controlled glycemia, 15.3% had initially-uncontrolled glycemia, and 18.6% had consistently-uncontrolled glycemia. Previous versus new DM diagnosis and glucose-lowering medication use versus no use were associated with having uncontrolled versus controlled glycemia (adjusted odds ratio [aOR] 2.50 95%CI 1.61, 6.05, P = 0.042; aOR 4.78 95% CI 1.61,14.23, P<0.001) and more likely to have consistently-uncontrolled versus consistently-controlled glycemia (adjusted relative risk ratio [aRRR] 5.14 95% CI 1.37, 19.20, P = 0.015; aRRR 10.24 95% CI 0.07, 0.95, P = 0.003). Relapse cases of TB were less likely than new cases to have uncontrolled (aOR 0.20 95%CI 0.06, 0.63, P = 0.031) or consistently-uncontrolled (aRRR 0.25 95%CI 0.07, 0.95, P = 0.042) versus controlled glycemia. Those with long-term DM, suggested by previous diagnosis, glucose-lowering medication use and possibly central obesity, may require additional support to manage blood glucose during TB treatment.

The Impact of Optimal Glycemic Control on Tuberculosis Treatment Outcomes in Patients With Diabetes Mellitus: Systematic Review and Meta-Analysis

BACKGROUND

Diabetes mellitus (DM) increases the risk of developing tuberculosis (TB), and optimal glycemic control has been shown to reduce the risk of complications and improve the TB treatment outcomes in patients with DM.

OBJECTIVE

This study aims to investigate the role of glycemic control in improving TB treatment outcomes among patients with DM.

METHODS

MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials databases were searched for randomized controlled trials (RCTs) assessing the impact of oral glycemic control in patients with TB who have DM. Outcomes of interest were radiological findings, treatment success, sputum positivity, and mortality. Evaluations were reported as risk ratios (RRs) with 95% CIs using weighted random-effects models.

RESULTS

The analysis included 6919 patients from 7 observational studies. Our meta-analysis showed significant differences between patients with optimal glycemic control and those with poor glycemic control with regard to improved treatment outcomes (RR 1.13, 95% CI 1.02-1.25; P=.02; I²=65%), reduced sputum positivity (RR 0.23, 95% CI 0.09-0.61; P=.003; I²=66%), and fewer cavitary lesions (RR 0.59, 95% CI 0.51-0.68; P<.001; I²=0%) in radiological findings. There was no significant difference between the 2 groups in terms of mortality (RR 0.57, 95% CI 0.22-1.49; P=.25; I²=0%), multilobar involvement (RR 0.57, 95% CI 0.22-1.49; P=.25; I²=0%) on radiologic examination, and upper lobe (RR 0.94, 95% CI 0.76-1.17; P=.58; I²=0%) and lower lobe (RR 1.05, 95% CI 0.48-2.30; P=.91; I²=75%) involvement on radiologic examination.

CONCLUSIONS

We concluded that optimal glycemic control is crucial for reducing susceptibility, minimizing complications, and improving treatment outcomes in patients with TB with DM. Emphasizing effective health management and health care strategies are essential in achieving this control. Integrating comprehensive care among patients with TB with DM will enhance patient outcomes and alleviate the burden of disease in this population.

TRIAL REGISTRATION

PROSPERO CRD42023427362; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=427362.

Pulmonary tuberculosis and diabetes mellitus: Epidemiology, pathogenesis and therapeutic management (Review)

The dual burden of pulmonary tuberculosis (PTB) and diabetes mellitus (DM) is a major global public health concern. There is increasing evidence to indicate an association between PTB and DM. DM is associated with immune dysfunction and altered immune components. Hyperglycemia weakens the innate immune response by affecting the function of macrophages, dendritic cells, neutrophils, and natural killer cells, and also disrupts the adaptive immune response, thus promoting the susceptibility of PTB in patients with DM. Antituberculosis drugs often cause the impairment of liver and kidney function in patients with PTB, and the infection with Mycobacterium tuberculosis weaken pancreatic endocrine function by causing islet cell amyloidosis, which disrupts glucose metabolism and thus increases the risk of developing DM in patients with PTB. The present review discusses the association between PTB and DM from the perspective of epidemiology, pathogenesis, and treatment management. The present review aims to provide information for the rational formulation of treatment strategies for patients with PTB-DM.

The impact of diabetes mellitus on the emergence of multi-drug resistant tuberculosis and treatment failure in TB-diabetes comorbid patients: a systematic review and meta-analysis

Background

The existence of Type 2 Diabetes Mellitus (DM) in tuberculosis (TB) patients is very dangerous for the health of patients. One of the major concerns is the emergence of MDR-TB in such patients. It is suspected that the development of MDR-TB further worsens the treatment outcomes of TB such as treatment failure and thus, causes disease progression.

Aim

To investigate the impact of DM on the Emergence of MDR-TB and Treatment Failure in TB-DM comorbid patients.

Methodology

The PubMed database was systematically searched until April 03, 2022 (date last searched). Thirty studies met the inclusion criteria and were included in this study after a proper selection process.

Results

Tuberculosis-Diabetes Mellitus patients were at higher risk to develop MDR-TB as compared to TB-non-DM patients (HR 0.81, 95% CI: 0.60-0.96, p < 0.001). Heterogeneity observed among included studies was moderate (I2 = 38%). No significant change was observed in the results after sub-group analysis by study design (HR 0.81, 95% CI: 0.61-0.96, p < 0.000). In the case of treatment failure, TB-DM patients were at higher risk to experience treatment failure rates as compared to TB-non-DM patients (HR 0.46, 95% CI: 0.27-0.67, p < 0.001).

Conclusion

The results showed that DM had a significant impact on the emergence of MDR-TB in TB-diabetes comorbid patients as compared to TB-non-DM patients. DM enhanced the risk of TB treatment failure rates in TB-diabetes patients as compared to TB-non-DM patients. Our study highlights the need for earlier screening of MDR-TB, thorough MDR-TB monitoring, and designing proper and effective treatment strategies to prevent disease progression.

Impact of diabetes itself and glycemic control status on tuberculosis

Objectives

To explore the impact of diabetes itself and glycemic control status on tuberculosis (TB).

Methods

A total of 3393 patients with TB and diabetes mellitus (DM) who were hospitalized in the Public Health Clinical Center of Chengdu from January 1, 2019, to December 31, 2021, were retrospectively included and divided into three groups according to baseline glycemic control status: two groups according to glycemic status at discharge, two groups according to cavity occurrence, three groups according to sputum results, and three groups according to lesion location. The influencing factors and the differences in cavity occurrence, sputum positivity and lesion location among different glycemic control groups or between different glycemic status groups were analyzed.

Results

In this TB with DM cohort, most of the subjects were male, with a male to female ratio of 4.54:1, most of them were 45-59 years old, with an average age of 57.44 ± 13.22 years old. Among them, 16.8% (569/3393) had cavities, 52.2% (1770/3393) were sputum positive, 30.4% (1030/3393) had simple intrapulmonary lesions, 68.1% (2311/3393) had both intra and extrapulmonary lesions, only 15.8% (537/3393) had good glycemic control,16.0% (542/3393) and 68.2% (2314/3393) had fair and poor glycemic control, respectively. Compared with the non-cavity group, the sputum-negative group and the extrapulmonary lesion group, the cavity group, sputum-positive group, intrapulmonary lesion group and the intra and extrapulmonary lesion group all had higher fasting plasma glucose (FPG) and glycosylated hemoglobin A 1c (HbA1c) and lower good glycemic control rates at admission (all P<0.001). Another aspect, compared with the good glycemic control group, the poor glycemic control group had a higher cavity occurrence rate, sputum positive rate, and greater proportion of intrapulmonary lesions. Moreover, FPG and HbA1c levels and poor glycemic control were significantly positively correlated with cavity occurrence, sputum positivity, and intrapulmonary lesions and were the main risk factors for TB disease progression. On the other hand, cavity occurrence, sputum positivity, and intrapulmonary lesions were also main risk factors for hyperglycemia and poor glycemic control.

Conclusion

Diabetes itself and glycemic control status could impact TB disease. Good glycemic control throughout the whole process is necessary for patients with TB and DM to reduce cavity occurrence and promote sputum negative conversion and lesion absorption.

Health Status and Treatment Outcome of Tuberculosis with Diabetes Mellitus Cases, Rajkot City, Gujarat - A Longitudinal Study

Background

India, with the highest number of tuberculosis (TB) cases in the world, is also facing epidemic growth in diabetes mellitus (DM). TB is curable while DM is a metabolic and incurable disease that if not controlled will affect the health status of a person. This study was conducted to assess the health status and treatment outcome of TB with DM cases.

Materials and Methods

We selected a total of 64 newly registered pulmonary TB (PTB) with DM cases from five tuberculosis units (TUs) in Rajkot city from October 2019 to December 2020. At the end of treatment, 64 cases were analyzed for treatment outcome and 56 cases (5 deaths; 3 lost to follow-up) were followed up to observe progression in health status. The information was collected in pretested proforma by interview.

Results

There was a significant improvement in TB symptoms (cough, weight loss, weakness, anorexia, evening rise of temperature, dyspnea, chest pain, hemoptysis), DM symptoms (frequent urination, excessive thirst and hunger, tingling and numbness), symptoms of mental health (fatigue, sleep disturbance, negative emotions, socially inactive), and adverse drug reactions (ADRs) on consecutive visits (McNemar's test, P < 0.001) and at the end of treatment (Cochran's Q test, P < 0.001). Improvement of nutritional status was also found statistically significant on consecutive visits (Wilcoxon test, P < 0.001) and at the end of treatment (Friedman's test, P < 0.001). The cure rate was 82.8% and 4.7% of cases had completed treatment.

Conclusion

At the end of treatment, there was a significant improvement in health status and treatment outcome; also good cure rate was reported among cases.

Glycemic control and the risk of tuberculosis in patients with diabetes: A cohort study in a Mediterranean city

Background

Diabetes mellitus (DM) is one of the leading chronic diseases globally and one of the most common causes of death, morbidity, and poor quality of life. According to the WHO, DM is also one of the main risk factors for developing active tuberculosis (TB). Subjects with DM are at a higher risk of infections, in addition to frequent micro and macrovascular complications, and therefore sought to determine whether poor glycemic control is linked to a higher risk of developing TB.

Methods

We used a retrospective cohort of diabetic subjects to predict the incidence of TB. All DM patients were recruited from Ciutat Vella (the inner-city of Barcelona) from January 2007 until December 2016, with a follow-up period until December 2018 (≥2 years). Data were extracted from Barcelona's Primary Care medical record database - SIDIAP, and linked to the Barcelona TB Control Program. The incidence of TB and the impact of glycemic control were estimated using time-to-event curves analyzed by Cox proportional hazard regression. Hazard ratios (HRs) and 95% confidence intervals (CIs), unadjusted and adjusted by potential confounding variables, were also assessed, which included age, sex, diabetes duration, macrovascular and microvascular signs, BMI, smoking habit, alcohol consumption and geographical origin.

Results

Of 8,004 DM patients considered for the study (equating to 68,605 person-years of follow-up), 84 developed TB [incidence rate = 70 (95% CI: 52-93) per 100,000 person-years]. DM subjects with TB were younger (mean: 52.2 vs. 57.7 years old), had higher values of glycosylated hemoglobin (HbA1c) (7.66 vs. 7.41%) and total triglycerides (122 vs. 105 mg/dl), and had twice the frequency of diabetic nephropathy (2.08 vs. 1.18%). The calculated incidence rate increased with increasing HbA1c: 120.5 (95% CI 77.2-179.3) for HbA1c ≥ 7.5%, 143 (95% CI 88.3-218.1) for HbA1c ≥ 8% and 183.8 (95% CI 105-298) for HbA1c ≥ 9%. An increase in the risk of TB was also observed according to a poorer optimization of glycemic control: adjusted HR 1.80 (95% CI 0.60-5.42), 2.06 (95% CI 0.67-6.32), and 2.82 (95% CI 0.88-9.06), respectively.

Conclusion

Diabetic subjects with worse glycemic control show a trend toward a higher risk of developing TB.

Pulmonary tuberculosis and diabetes mellitus: Clinical profile and outcomes

Background

India is endemic for Tuberculosis (TB), contributing to the world's highest number of active cases. Diabetes (DM), with its increasing burden in India, could contribute to adverse outcomes among patients with TB.

Methods

Consecutive patients with sputum smear positive pulmonary tuberculosis were included in the study. We defined cases as those patients with diabetes at recruitment. Controls were non diabetics (NDM). Sputum samples for AFB smears, AFB culture and Xpert PCR along with blood samples for glycosylated Haemoglobin and glucose levels were collected at recruitment and at 6 months from patients with sputum positive pulmonary TB. Blood glucose levels and sputum smears were repeated at 2 months and monthly till they tested negative. The primary outcome studied was mortality at 6 month follow-up. The secondary outcomes included the time to conversion of sputum smears and cure rates between cases and controls.

Results

We recruited 124 patients of which 68 were cases. Mortality after therapy was 15% in cases and 7% in controls, however, the difference was not statistically significant. Equal proportions in each group (Diabetics: 9% vs. NDM 9%) had persistent smear positivity at 2 months. There was no association between delayed sputum conversion and uncontrolled diabetes. Only about 57% of cases and 50% of controls were documented to have completed treatment or been cured. A significant reduction in HbA1c after 6 months of Antituberculous therapy was noted among the cases. [Mean difference - 1.76, P-value - 0.001, 95% CI of difference - (1.01 - 2.52)].

Conclusions

Diabetes did not have adverse outcomes in the form of increased mortality or delayed sputum conversion rates. The high proportion of loss to follow-up seems to be a trend of concern, which should be addressed emergently.

High Pretreatment Level of Neutrophil to Lymphocyte Ratio, Monocyte to Lymphocyte Ratio and Other Factors Associated with Delayed Sputum Conversion in Patients with Pulmonary Tuberculosis

Introduction

Patients with delayed intensive phase sputum conversion have a higher risk of multidrug resistant-tuberculosis (MDR-TB) and poorer treatment outcomes. Both, host (immune response and comorbidity) and pathogen factors play important roles in determining sputum conversion after treatment initiation. Impaired host immune response, especially the cellular components, as defined by the increased pre-treatment level of neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR) and other additional factors, were associated with severe active TB.

Purpose

To evaluate whether impaired immune responses (high pre-treatment level of NLR and MLR) and other factors associate with delayed sputum conversion at the end of the intensive phase treatment.

Patients and Methods

This was a case–control study from 2016 to 2020, which retrospectively analyzed the pre-treatment level of NLR, MLR and other factors among patients with new cases of pulmonary tuberculosis (PTB).

Results

A total of 62 patients (31 cases and 31 control). The cut-off value of high pretreatment level of NLR and MLR was 5.065 and 0.585, respectively. Bivariate analysis showed that pretreatment NLR ≥5.065 (OR 8.23, CI 95% 2.48–27.32, p < 0.001), MLR ≥0.585 (OR 10.18, 95% CI 3.13–33.18, p < 0.001) and BMI <18.5 (OR 2.91, 95% CI 1.03–8.20, p = 0.041) were associated with an increased risk of delayed sputum conversion. Multivariate analysis, however, showed that pretreatment NLR ≥5.065 was not significantly associated with delayed sputum conversion (AOR 3.370, 95% CI 0.71–15.91, p value 0.125). A high pretreatment of MLR (AOR 30.802, 95% CI 3.22–287.55, p value 0.003) and lower BMI (AOR 10.942, 95% CI 1.121–98.563, p value 0.033) were significantly associated with an increased risk of delayed intensive phase sputum conversion.

Conclusion

High MLR pretreatment and a low BMI were significantly associated with an increased risk of delayed sputum conversion at the end of the PTB intensive phase treatment. High NLR pretreatment, smoking, diabetes, and HIV were not associated with sputum conversion.

Alkaloidal Phytoconstituents for Diabetes Management: Exploring the Unrevealed Potential

The main characteristic feature of diabetes mellitus is the disturbance of carbohydrate, lipid, and protein metabolism, which results in insulin insufficiency and can also lead to insulin resistance. Both the acute and chronic diabetic cases are increasing at an exponential rate, which is also flagged by the World Health Organization (WHO) and the International Diabetes Federation (IDF). Treatment of diabetes mellitus with synthetic drugs often fails to provide desired results and limits its use to symptomatic treatment only. This has resulted in the exploration of alternative medicine, of which herbal treatment is gaining popularity these days. Owing to their safety benefits, treatment compliance, and ability to exhibit effects without disturbing internal homeostasis, research in the field of herbal and ayurvedic treatments has gained importance. Medicinal phytoconstituents include micronutrients, amino acids, proteins, mucilage, critical oils, triterpenoids, saponins, carotenoids, alkaloids, flavonoids, phenolic acids, tannins, and coumarins, which play a dynamic function in the prevention and treatment of diabetes mellitus. Alkaloids found in medicinal plants represent an intriguing potential for the inception of novel approaches to diabetes mellitus therapies. Thus, this review article highlights detailed information on alkaloidal phytoconstituents, which includes sources and structures of alkaloids along with the associated mechanism involved in the management of diabetes mellitus. From the available literature and data presented, it can be concluded that these compounds hold tremendous potential for use as monotherapies or in combination with current treatments, which can result in the development of better efficacy and safety profiles.

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.

Respiratory Tract Infections in Diabetes - Lessons From Tuberculosis and Influenza to Guide Understanding of COVID-19 Severity

Patients with type-2 diabetes (T2D) are more likely to develop severe respiratory tract infections. Such susceptibility has gained increasing attention since the global spread of Coronavirus Disease 2019 (COVID-19) in early 2020. The earliest reports marked T2D as an important risk-factor for severe forms of disease and mortality across all adult age groups. Several mechanisms have been proposed for this increased susceptibility, including pre-existing immune dysfunction, a lack of metabolic flexibility due to insulin resistance, inadequate dietary quality or adverse interactions with antidiabetic treatments or common comorbidities. Some mechanisms that predispose patients with T2D to severe COVID-19 may indeed be shared with other previously characterized respiratory tract infections. Accordingly, in this review, we give an overview of response to Influenza A virus and to Mycobacterium tuberculosis (Mtb) infections. Similar risk factors and mechanisms are discussed between the two conditions and in the case of COVID-19. Lastly, we address emerging approaches to address research needs in infection and metabolic disease, and perspectives with regards to deployment or repositioning of metabolically active therapeutics.

The relationship between computed tomography appearance of pulmonary tuberculosis and blood glucose levels in 763 diabetes mellitus patients with pulmonary tuberculosis: a comparative study

INTRODUCTION

Glucose tolerance is often impaired in pulmonary tuberculosis (TB) patients. We aimed to explore the relationship between computed tomography (CT) findings of TB and blood glucose levels in diabetes mellitus (DM) patients.

METHODS

763 diabetes mellitus patients with pulmonary tuberculosis (DMTB) from March 2015 to March 2018 were selected and their clinical data were retrospectively evaluated. CT appearance of DMTB was reviewed and compared according to blood glucose levels and CT scores. TB scores were calculated according to the combination of typical and atypical CT appearance. The relationship between blood glucose levels and CT scores was analyzed via Pearson correlation coefficient.

RESULTS

TB lesions mainly occurred in the left lung and the lower lobes in the DMTB patients. Nodules and cavities are the main typical complications in these DMTB patients, and especially the number and size of cavities predominantly contribute to CT scan scores. The size of cavities (diameters (cm), median (95% CI of median)) was 0.72 (0.66-0.77), 1.20 (1.09-1.28), and 3.45 (2.92-3.94) from the low-, middle- and high-CT-score groups, respectively. The patients with high CT scores had a higher level of fasting plasma glucose (mean 13.48 mM, 95% CI of median 12.56-14.44 mM) than the patients in the low-CT-score (mean 8.73 mM, 95% CI of median 8.49-9.36 mM) and middle-CT-score groups (mean 10.16 mM, 95% CI of median 9.89-10.49 mM) (P < 0.0001). CT scores have a consistent relationship with the levels of blood glucose (rho = 0.60, P < 0.0001).

CONCLUSIONS

CT appearance stands for the severity of tuberculosis and is closely associated with blood glucose levels in diabetic TB patients.

[Epidemiologic-clinical, biological and radiological features of pulmonary tuberculosis in patients with diabetes in Antananarivo, Madagascar]

Pulmonary tuberculosis is frequently associated with diabetes mellitus and, sometimes, it may present with atypical signs. The purpose of this study is to identify the epidemiological, clinical, biological and radiological features of pulmonary tuberculosis in patients with diabetes versus patients without diabetes in order to improve treatment. We conducted a retrospective, cross-sectional descriptive and analytical study in the Department of Endocrinology and Pneumology at the Joseph Raseta Befelatanana University Hospital Center and in the Department of Respiratory Diseases at the Soavinandriana Hospital Center in Antananarivo, Madagascar. It involved patients diagnosed with pulmonary tuberculosis who presented a positive bacilloscopy exam from January 2018 to January 2020 (25 months). In our study, the overall prevalence of diabetes among TB patients was 20.31 %. Older age, insidious clinical course, severe biologic inflammatory syndrome, fewer caves but more systematized opacities and diffuse radiological lesions in the basal zone (more commonly unilateral right lesions) were mainly detected in patients with diabetes compared to patients without diabetes. Knowledge of signs of pulmonary TB in patients with diabetes can help health care workers to make a diagnosis, even in patients with atypical signs. Moreover, as the majority of pulmonary tuberculosis occur in patients with unstable diabetes, a good glycemic balance can certainly reduce its incidence.

An Integrative Network Approach to Identify Common Genes for the Therapeutics in Tuberculosis and Its Overlapping Non-Communicable Diseases

Tuberculosis (TB) is the leading cause of death from a single infectious agent. The estimated total global TB deaths in 2019 were 1.4 million. The decline in TB incidence rate is very slow, while the burden of noncommunicable diseases (NCDs) is exponentially increasing in low- and middle-income countries, where the prevention and treatment of TB disease remains a great burden, and there is enough empirical evidence (scientific evidence) to justify a greater research emphasis on the syndemic interaction between TB and NCDs. The current study was proposed to build a disease-gene network based on overlapping TB with NCDs (overlapping means genes involved in TB and other/s NCDs), such as Parkinson’s disease, cardiovascular disease, diabetes mellitus, rheumatoid arthritis, and lung cancer. We compared the TB-associated genes with genes of its overlapping NCDs to determine the gene-disease relationship. Next, we constructed the gene interaction network of disease-genes by integrating curated and experimentally validated interactions in humans and find the 13 highly clustered modules in the network, which contains a total of 86 hub genes that are commonly associated with TB and its overlapping NCDs, which are largely involved in the Inflammatory response, cellular response to cytokine stimulus, response to cytokine, cytokine-mediated signaling pathway, defense response, response to stress and immune system process. Moreover, the identified hub genes and their respective drugs were exploited to build a bipartite network that assists in deciphering the drug-target interaction, highlighting the influential roles of these drugs on apparently unrelated targets and pathways. Targeting these hub proteins by using drugs combination or drug repurposing approaches will improve the clinical conditions in comorbidity, enhance the potency of a few drugs, and give a synergistic effect with better outcomes. Thus, understanding the Mycobacterium tuberculosis (Mtb) infection and associated NCDs is a high priority to contain its short and long-term effects on human health. Our network-based analysis opens a new horizon for more personalized treatment, drug-repurposing opportunities, investigates new targets, multidrug treatment, and can uncover several side effects of unrelated drugs for TB and its overlapping NCDs.

Tuberculosis and comorbidities: treatment challenges in patients with comorbid diabetes mellitus and depression

Tuberculosis is one of the leading causes of death worldwide, primarily affecting low- and middle income countries and individuals with limited-resources within fractured health care systems. Unfortunately, the COVID-19 pandemic has only served to aggravate the already existing diagnostic gap, decreasing the number of people who get diagnosed and thereby complete successful treatment. In addition to this, comorbidities act as an external component that when added to the TB management equation, renders it even more complex. Among the various comorbidities that interact with TB disease, diabetes mellitus and depression are two of the most prevalent among non-communicable diseases within the TB population and merits a thoughtful consideration when the healthcare system provides care for them. TB patients with diabetes mellitus (TB-DM) or depression both have an increased risk of mortality, relapse and recurrence. Both of these diseases when in presence of TB present a ‘vicious-circle-like’ mechanism, meaning that the effect of each disease can negatively add up, in a synergistic manner, complicating the patient’s health state. Among TB-DM patients, high glucose blood levels can decrease the effectiveness of anti-tuberculosis drugs; however, higher doses of anti-tuberculous drugs could potentially decrease the effects of DM drugs. Among the TB-depression patients, not only do we have the adherence to treatment problems, but depression itself can biologically shift the immunological profile responsible for TB containment, and the other way around, TB itself can alter the hormonal balance of several neurotransmitters responsible for depression. In this paper, we review these and other important aspects such as the pharmacological interactions found in the treatment of TB-DM and TB-depression patients and the implication on TB care and pharmacological considerations.

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.

Transient Impact of Dysglycemia on Sputum Conversion among Smear-Positive Tuberculosis Patients in a Tertiary Care Facility in Ghana

BACKGROUND

Apart from increasing the risk of tuberculosis (TB), diabetes may be associated with more severe disease and lower rates of sputum conversion among TB patients.

METHODS

We conducted a baseline cross-sectional study with a longitudinal follow-up of newly diagnosed smear-positive TB patients for 6 months. Sputum conversion rates between those with dysglycemia and those without were compared at 2 months (end of the intensive phase) and 6 months (end of the treatment). Descriptive statistics and logistic regression were computed to assess factors associated with dysglycemia as well as sputum conversion.

RESULTS

A significantly higher proportion of normoglycemic patients had negative sputum compared with those with dysglycemia (83% vs 67%, P-value < .05) at 2 months but not at 6 months (87% vs 77%, P-value > .05). After controlling for age group and adjusting for other covariates, patients with dysglycemia were 66% less likely to convert sputum than those with normoglycemia. Females were at least 7 times more likely than males and those with high waist-to-hip ratio (WHR) of 88% were less likely compared with those with low WHR for sputum conversion at 2 months, respectively. At 6 months, females (compared with males) and those with high WHR (compared with those with normal WHR) were at over 9 times increased odds and 89% less likely for sputum conversion, respectively.

CONCLUSION

A significantly lower proportion of smear-positive TB patients with dysglycemia converted to smear negative after 2 months of treatment but not at the end of the treatment, thus suggesting a transient impact of dysglycemia on sputum conversion.

Completion Rate and Safety of Programmatic Screening and Treatment for Latent Tuberculosis Infection in Elderly Patients With Poorly Controlled Diabetic Mellitus: A Prospective Multicenter Study

BACKGROUND

Poor control of diabetes mellitus (DM) increases active tuberculosis (TB) risk. Understanding risk factors for latent TB infection (LTBI) in this population and intervention completion rates is crucial for policy making.

METHODS

Under a collaborative multidisciplinary team consisting of public health professionals, endocrinologists, and pulmonologists, patients aged >45 years with poorly controlled DM (pDM), defined as having a glycated hemoglobin level of ≥9% within the preceding year, were enrolled by endocrinologists from 2 hospitals; these patients underwent LTBI screening by using QuantiFERON (QFT). Once-weekly isoniazid and rifapentine for 12 weeks (3HP) or daily isoniazid for 9 months (9H) was administered by pulmonologists. QFT-positivity predictors were evaluated using logistic regression. Completion rates and safety were also investigated.

RESULTS

Among 980 patients with pDM (age: 64.2 ± 9.7 years), 261 (26.6%) were QFT-positive. Age, DM duration, chronic kidney disease stage ≥3, and dipeptidyl peptidase-4 inhibitor use, not using metformin, were associated with QFT-positivity. Preventive therapy (3HP: 138; 9H: 62) was administered in 200 (76.6%) QFT-positive patients. The completion rates of 3HP and 9H were 84.1% and 79.0%, respectively (P = .494). Nine (6.5%) and zero patients in the 3HP and 9H groups, respectively, developed systemic drug reactions (P = .059); 78.3% and 45.2% had ≥1 adverse drug reactions (P < .001); and post-treatment QFT conversion rates were 32% and 20%, respectively (P = .228).

CONCLUSIONS

LTBI prevalence exceeds 25% in elderly patients with pDM. Under care from a collaborative multidisciplinary team, the completion rate of preventive therapy, regardless of regimen could approach, or even exceed 80% in this population.

Metformin as a potential protective therapy against tuberculosis in patients with diabetes mellitus: A retrospective cohort study in a single teaching hospital

AIMS/INTRODUCTION

The convergence of tuberculosis (TB) and diabetes mellitus (DM) is a new challenge in Asia as a result of the rising prevalence of diabetes mellitus with higher TB infection rates, and also because diabetes mellitus itself enhances TB disease activity and consequently the spread of TB. We aimed to address the risk presented by diabetes mellitus for TB infection.

MATERIALS AND METHODS

Patients with diabetes mellitus were retrospectively recruited. The baseline assessments included age, sex, body mass index, fasting blood glucose, glycated hemoglobin, urine albumin-to-creatinine ratio and estimated glomerular filtration rate. TB was determined by meeting the international classification of disease, for TB diagnosis and receiving anti-TB treatment for at least 2 months.

RESULTS

In total, 9,750 individuals with diabetes mellitus were recruited. The event rate of TB was 47 (0.48%). Younger age, lower proportion of men, higher fasting blood glucose and glycated hemoglobin values, and better renal function (estimated glomerular filtration rate and urine albumin-to-creatinine ratio) were observed in the metformin-exposed groups. Old age and male sex were associated with higher TB infection risk on multivariate analysis. Metformin users had a significantly lower risk for TB infection, whereas insulin users had a higher risk for TB infection. However, glycemic status had no effect on TB infection risk.

CONCLUSIONS

This study provides clinical evidence from a survey of TB in individuals with diabetes mellitus. Old age, male sex and insulin use were risk factors for TB infection. Metformin remains the first choice of treatment for diabetes mellitus and has a potential protective effect against TB infection.

Evaluation and management of COVID-19-related severity in people with type 2 diabetes

INTRODUCTION

People with type 2 diabetes (T2D) have an increased rate of hospitalization and mortality related to COVID-19. To identify ahead of time those who are at risk of developing severe diseases and potentially in need of intensive care, we investigated the independent associations between longitudinal glycated hemoglobin (HbA1c), the impact of common medications (metformin, insulin, ACE inhibitors (ACEIs), angiotensin receptor blockers (ARBs), and corticosteroids) and COVID-19 severity in people with T2D.

RESEARCH DESIGN AND METHODS

Retrospective cohort study was conducted using deidentified claims and electronic health record data from the OptumLabs Data Warehouse across the USA between January 2017 and November 2020, including 16 504 individuals with T2D and COVID-19. A univariate model and a multivariate model were applied to evaluate the association between 2 and 3-year HbA1c average, medication use between COVID-19 diagnosis and intensive care unit admission (if applicable), and risk of intensive care related to COVID-19.

RESULTS

With covariates adjusted, the HR of longitudinal HbA1c for risk of intensive care was 1.12 (per 1% increase, p<0.001) and 1.48 (comparing group with poor (HbA1c ≥9%) and adequate glycemic control (HbA1c 6%-9%), p<0.001). The use of corticosteroids and the combined use of insulin and metformin were associated with significant reduction of intensive care risk, while ACEIs and ARBs were not associated with reduced risk of intensive care.

CONCLUSIONS

Two to three-year longitudinal glycemic level is independently associated with COVID-19-related severity in people with T2D. Here, we present a potential method to use HbA1c history, which presented a stronger association with COVID-19 severity than single-point HbA1c, to identify in advance those more at risk of intensive care due to COVID-19 in the T2D population. The combined use of metformin and insulin and the use of corticosteroids might be significant to prevent patients with T2D from becoming critically ill from COVID-19.

Effect of Diabetes Mellitus on Renal and Audiology Toxicities in Patients with Drug-Resistant Pulmonary Tuberculosis

Background: People with diabetes mellitus (DM) have a higher risk for drug-resistant tuberculosis (DR-TB). DR-TB patients with comorbidity of DM were also vulnerable to experience adverse effects of DR-TB treatment. Management of DR-TB with comorbidity of DM is complicated. Also, DM may affect TB response treatment and cause more adverse effects. Objectives: This study was conducted on DR pulmonary TB (DR-PTB) patients to evaluate the effect of DM on adverse effects, especially renal function impairment and audiology impairment, as well as treatment outcomes due to treatment regimens containing kanamycin. Methods: A retrospective study was conducted from 2016 to 2017 at Dr. Soetomo Hospital. Patients who received DR-TB regimens containing kanamycin were included in this study. HbA1c >7 was used to define DM. The adverse effects in this study were impaired renal function (increased serum creatinine) and audiology impairment. Results: Patients who experienced increased serum creatinine were 28/82 (34.1%) with DM and 20/120 (16.7%) without DM, audiology impairment were 22/82 (26.8%) with DM and 19/120 (15.8%) without DM, and unfavorable outcome were 37/82 (45%) with DM and 46/120 (38%) without DM. Moreover, DM is associated with adverse effects and treatment outcomes. Patients with DM have a risk ratio (RR) for increased serum creatinine, audiology impairment, and unfavorable outcome with RR 2.049 (95% CI: 1.242 – 3.379), RR 1.694 (95% CI: 0.982 – 2.925), and RR 1.177 (95% CI: 0.847 – 1.636), respectively. Conclusions: Diabetes mellitus increases the risk of adverse effects, increased serum creatinine, and audiology impairment. Also, it increases the risk of unfavorable treatment outcomes in patients with DR-PTB who receive DR-TB regimens containing kanamycin.

Diabetes in a TB and HIV-endemic South African population: Analysis of a virtual cohort using routine health data

BACKGROUND

It is widely accepted that people living with diabetes (PLWD) are at increased risk of infectious disease, yet there is a paucity of epidemiology studies on the relationship between diabetes and infectious disease in SSA. In a region with a high burden of infectious disease, this has serious consequences for PLWD.

METHODS AND FINDINGS

Using routinely collected longitudinal health data, we describe the epidemiology of diabetes in a large virtual cohort of PLWD who have a high burden of HIV and TB, from the Khayelitsha subdistrict in the Western Cape Province in South Africa. We described the relationship between previous TB, newly diagnosed TB disease and HIV infection on diabetes using HbA1c results as an outcome measure. The study population was predominately female (67%), 13% had a history of active TB disease and 18% were HIV positive. The HIV positive group had diabetes ascertained at a significantly younger age (46 years c.f. 53 years respectively, p<0.001) and in general had increased HbA1c values over time after their HIV diagnosis, when compared to the HIV-negative group. There was no evidence of TB disease influencing the trajectory of glycaemic control in the long term, but diabetes patients who developed active TB had higher mortality than those without TB (12.4% vs 6.7% p-value < 0.001). HIV and diabetes are both chronic diseases whose long-term management includes drug therapy, however, only 52.8% of the study population with an HIV-diabetes comorbidity had a record of diabetes treatment. In addition, the data suggest overall poor glycaemic control in the study population with only 24.5% of the participants having an HbA1c <7% at baseline despite 85% of the study population being on diabetes treatment.

CONCLUSION

The epidemiologic findings in this exploratory study highlight the need for further research into diabetes outcomes in a high TB and HIV burden setting and demonstrate that routine health data are a valuable resource for understanding disease epidemiology in the general population.

Diabetes among tuberculosis patients and its impact on tuberculosis treatment in South Asia: a systematic review and meta-analysis

The escalating burden of diabetes is increasing the risk of contracting tuberculosis (TB) and has a pervasive impact on TB treatment outcomes. Therefore, we conducted this systematic review and meta-analysis to examine the burden of diabetes among TB patients and assess its impact on TB treatment in South Asia (Afghanistan, Bangladesh, Bhutan, Maldives, Nepal, India, Pakistan, and Sri Lanka). PubMed, Excerpta Medica Database (EMBASE), and CINAHL databases were systematically searched for observational (cross-sectional, case-control and cohort) studies that reported prevalence of diabetes in TB patients and published between 1 January 1980 and 30 July 2020. A random-effect model for computing the pooled prevalence of diabetes and a fixed-effect model for assessing its impact on TB treatment were used. The review was registered with PROSPERO number CRD42020167896. Of the 3463 identified studies, a total of 74 studies (47 studies from India, 10 from Pakistan, four from Nepal and two from both Bangladesh and Sri-Lanka) were included in this systematic review: 65 studies for the prevalence of diabetes among TB patients and nine studies for the impact of diabetes on TB treatment outcomes. The pooled prevalence of diabetes in TB patients was 21% (95% CI 18.0, 23.0; I2 98.3%), varying from 11% in Bangladesh to 24% in Sri-Lanka. The prevalence was higher in studies having a sample size less than 300 (23%, 95% CI 18.0, 27.0), studies conducted in adults (21%, 95% CI 18.0, 23.0) and countries with high TB burden (21%, 95% CI 19.0, 24.0). Publication bias was detected based on the graphic asymmetry of the funnel plot and Egger's test (p < 0.001). Compared with non-diabetic TB patients, patients with TB and diabetes were associated with higher odds of mortality (Odds Ratio (OR) 1.7; 95% CI 1.2, 2.51; I2 19.4%) and treatment failure (OR 1.7; 95% CI 1.1, 2.4; I2 49.6%), but not associated with Multi-drug resistant TB (OR 1.0; 95% CI 0.6, 1.7; I2 40.7%). This study found a high burden of diabetes among TB patients in South Asia. Patients with TB-diabetes were at higher risk of treatment failure and mortality compared to TB alone. Screening for diabetes among TB patients along with planning and implementation of preventive and curative strategies for both TB and diabetes are urgently needed.

Slow radiological improvement and persistent low-grade inflammation after chemotherapy in tuberculosis patients with type 2 diabetes

Background

Diabetes mellitus type 2 (DM) may impede immune responses in tuberculosis (TB) and thus contribute to enhanced disease severity. In this study, we aimed to evaluate DM-mediated alterations in clinical, radiological and immunological outcomes in TB disease.

Methods

Newly diagnosed pulmonary TB patients with or without DM (TB n = 40; TB-DM n = 40) were recruited in Dhaka, Bangladesh. Clinical symptoms, sputum smear and culture conversion as well as chest radiography were assessed. Peripheral blood and sputum samples were collected at the time of diagnosis (baseline) and after 1, 2 and 6 months of standard anti-TB treatment. Blood samples were also obtained from healthy controls (n = 20). mRNA expression of inflammatory markers in blood and sputum samples were quantified using real-time PCR.

Results

The majority of TB-DM patients had poor glycemic control (HbA1c > 8%) and displayed elevated pulmonary pathology (P = 0.039) particularly in the middle (P < 0.004) and lower lung zones (P < 0.02) throughout the treatment period. However, reduction of clinical symptoms and time to sputum smear and culture conversion did not differ between the groups. Transcripts levels of the pro-inflammatory cytokines IL-1β (P = 0.003 at month-1 and P = 0.045 at month-2) and TNF-α (P = 0.005 at month-1) and the anti-inflammatory cytokine IL-10 (P = 0.005 at month-2) were higher in peripheral blood after anti-TB treatment in TB-DM compared to TB patients. Conversely in sputum, TB-DM patients had reduced CD4 (P < 0.009 at month-1) and IL-10 (P = 0.005 at month-1 and P = 0.006 at month-2) transcripts, whereas CD8 was elevated (P = 0.016 at month-2). At 1- and 2-month post-treatment, sputum IL-10 transcripts were inversely correlated with fasting blood glucose and HbA1c levels in all patients.

Conclusion

Insufficient up-regulation of IL-10 in the lung may fuel persistent local inflammation thereby promoting lung pathology in TB-DM patients with poorly controlled DM.

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.

Liaison of Sugar Control With Time to Sputum Culture Conversion in Multi-Drug Resistant Tuberculosis

Background

Many elements have been studied repeatedly that influence time to sputum culture conversion in multi-drug resistant tuberculosis (MDR-TB). Deranged sugars not only hamper one’s infection contesting ability but also increase the chances of drug resistance. Our aim was to establish whether or not glycemic control alters MDR-TB treatment outcome.

Methods

A prospective cohort study was conducted at the TB Clinic of Jinnah Postgraduate Medical Center, Karachi, Pakistan. Newly diagnosed MDR-TB cases were started on WHO-recommended treatment regime. HbA1c (hemoglobin A1c or glycated hemoglobin) was tested at the start of treatment irrespective of the previous diabetic status. Sputum samples, 30 days apart, were taken during the initial phase of the MDR TB treatment until two consecutive samples showed conversion. Pearson's correlation coefficient was calculated to see the link between time to sputum culture conversion and HbA1c.

Results

Among 47 patients, 19 (40.4%) new cases, whereas 28 (59.8%) were previously treated for drug-sensitive TB. Our 39 patients converted during six months, of which 18 (46%) converted in one month, 14 (35.9%) in two months, 6 (15.4%) in three months, and only 1 in five months. Mean time to sputum culture conversion was 1.77 ± 0.9 months. There was a slightly negative correlation between HbA1c and sputum culture conversion time (r = -0.075, p = 0.649).

Conclusions

Sugar control does not affect sputum culture conversion in MDR-TB when an optimal treatment regime is applied.

Aspirin enhances the clinical efficacy of anti-tuberculosis therapy in pulmonary tuberculosis in patients with type 2 diabetes mellitus

Background: Tuberculosis in patients with diabetes mellitus is characterised by rapid disease progression, poor treatment efficacy, poor prognosis and poses a new challenge in tuberculosis treatment and control.Methods: Patients with pulmonary TB and type 2 DM were recruited at Yijishan Hospital of Wannan Medical College. A total of 348 patients were randomly assigned to two groups. The aspirin group (aspirin + TB/DM) included 174 patients who received anti-TB therapy and enteric-coated aspirin tablets (100 mg/tablet). The control group (placebo + TB/DM) included 174 patients who received anti-TB therapy and enteric-coated placebo tablets (an identical tablet containing no drug). Eighty-two patients in the aspirin group and 86 in the control group completed the trial and were included in the analysis. Clinical characteristics, laboratory test results, imaging data and side effects of aspirin were monitored.Results: Aspirin treatment affect certain signs and symptoms. The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels were lower in the aspirin group than in the control group after treatment (Both p = .000). The sputum-negative conversion rate was 86.7% in the aspirin group, significantly higher than in the control group (53.8%) (p = .031). After two months of treatment, the differences in the number of cases with cavities, the number of cavities, and maximum diameter of cavities in the aspirin group were statistically significant (p = .003, p = .023 and p = .015 respectively).Conclusion: Our findings suggest that aspirin may improve treatment in patients with pulmonary TB and type 2 DM.

Patterns and predictors of co-morbidities in Tuberculosis: A cross-sectional study in the Philippines

Diabetes and undernutrition are common risk factors for TB, associated with poor treatment outcomes and exacerbated by TB. We aimed to assess non-communicable multimorbidity (co-occurrence of two or more medical conditions) in Filipino TB outpatients, focusing on malnutrition and diabetes. In a cross-sectional study, 637 adults (70% male) from clinics in urban Metro Manila (N = 338) and rural Negros Occidental (N = 299) were enrolled. Diabetes was defined as HbA1c of ≥6.5% and/or current diabetes medication. Study-specific HIV screening was conducted. The prevalence of diabetes was 9.2% (54/589, 95%CI: 7.0-11.8%) with 52% newly diagnosed. Moderate/severe undernutrition (body mass index (BMI) <17 kg/2) was 20.5% (130/634, 95%CI: 17.4-23.9%). Forty percent of participants had at least one co-morbidity (diabetes, moderate/severe undernutrition or moderate/severe anaemia (haemoglobin <11 g/dL)). HIV infection (24.4%, 74/303) was not associated with other co-morbidities (but high refusal in rural clinics). Central obesity assessed by waist-to-hip ratio was more strongly associated with diabetes (Adjusted Odds Ratio (AOR) = 6.16, 95%CI: 3.15-12.0) than BMI. Undernutrition was less common in men (AOR = 0.44, 95%CI: 0.28-0.70), and associated with previous history of TB (AOR = 1.97, 95%CI: 1.28-3.04) and recent reduced food intake. The prevalence of multimorbidity was high demonstrating a significant unmet need. HIV was not a risk factor for increased non-communicable multimorbidity.

Severe pulmonary radiological manifestations are associated with a distinct biochemical profile in blood of tuberculosis patients with dysglycemia

Background

Diabetes mellitus (DM) is thought to affect tuberculosis (TB) clinical presentation and treatment response. Whether DM impacts radiological manifestations of pulmonary TB is still not clear. This study investigated the impact of glycemic status on radiological manifestations of pulmonary TB cases and its relationship with concentration of biochemical parameters in peripheral blood.

Methods

A retrospective cross-sectional study used data from 132 microbiologically confirmed pulmonary TB patients from Lima, Peru, evaluated in a previous investigation performed between February and December 2017. Chest radiographs were analyzed by a radiologist and a pulmonologist. Radiographic lesions were identified as cavities, alveolar infiltrates and fibrous tracts. Hyperglycemia in TB patients was identified by use of fasting plasma glucose, HbA1c and oral glucose tolerance test. Clinical, biochemical and hematological parameters were also analyzed.

Results

TB patients with hyperglycemia presented more frequently with cavities, alveolar infiltrates and fibrous tracts than those with normoglycemia. Hierarchical clustering analysis indicated that patients with more diverse and higher number of lung lesions exhibited a distinct laboratorial profile characterized by heightened white blood cell counts and circulating levels of total cholesterol, triglycerides and transaminases and simultaneously low levels of albumin and hemoglobin. Multivariable regression analyses adjusted for age, sex, prior TB, hemoglobin levels and acid-fast bacilli ≥2+ in sputum smears, demonstrated that presence of prediabetes or diabetes in TB patients was associated with increased odds of having 3 pulmonary lesion types (p = 0.003 and p < 0.01 respectively) or ≥ 4 lesions (p = 0.001 and p = 0.01 respectively).

Conclusion

Hyperglycemia (both DM and prediabetes) significantly affected the presentation of radiographic manifestations and the number of lesions in pulmonary TB patients as well as the biochemical profile in peripheral blood.

Forecasting the impact of diabetes mellitus on tuberculosis disease incidence and mortality in India

Background

In context of the rapidly expanding diabetes mellitus (DM) epidemic in India and slowly declining tuberculosis (TB) incidence, we aimed to estimate the past, current, and future impact of DM on TB epidemiology.

Methods

An age-structured TB-DM dynamical mathematical model was developed and analyzed to assess the DM-on-TB impact. The model was calibrated using a literature review and meta-analyses. The DM-on-TB impact was analyzed using population attributable fraction metrics. Sensitivity analyses were conducted by accommodating less conservative effect sizes for the TB-DM interactions, by factoring the age-dependence of the TB-DM association, and by assuming different TB disease incidence rate trajectories.

Results

In 1990, 11.4% (95% uncertainty interval (UI) = 6.3%-14.4%) of new TB disease incident cases were attributed to DM. This proportion increased to 21.9% (95% UI = 12.1%-26.4%) in 2017, and 33.3% (95% UI = 19.0%-44.1%) in 2050. Similarly, in 1990, 14.5% (95% UI = 9.5%-18.2%) of TB-related deaths were attributed to DM. This proportion increased to 28.9% (95% UI = 18.9%-34.1%) in 2017, and 42.8% (95% UI = 28.7%-53.1%) in 2050. The largest impacts originated from the effects of DM on TB disease progression and infectiousness. Sensitivity analyses suggested that the impact could be even greater.

Conclusions

The burgeoning DM epidemic is predicted to become a leading driver of TB disease incidence and mortality over the coming decades. By 2050, at least one-third of TB incidence and almost half of TB mortality in India will be attributed to DM. This is likely generalizable to other Asian Pacific countries with similar TB-DM burdens. Targeting the impact of the increasing DM burden on TB control is critical to achieving the goal of TB elimination by 2050.

The relationship between HbA1c control levels and antituberculosis treatment effects: a meta-analysis

BACKGROUND

Multiple studies of tuberculosis (TB) treatment have indicated that patients with diabetes mellitus (DM) may experience poor outcomes. We performed a meta-analysis to summarize evidence for the relationship between HbA1c control levels and anti-TB treatment effects in patients afflicted with both TB and DM.

METHODS

Both English and Chinese databases were searched. Chinese databases included CNKI, WanFang, SinoMed, and VIP. PubMed, Ovid MEDLINE, Embase, Cochrane Library, and Web of Science were searched for English articles. We included studies that were restricted to the relationship between HbA1c levels and anti-TB treatment effects (sputum conversion rate [SCR] and TB focus absorption) in diabetic patients receiving treatment for TB. We used RevMan 5.3 software to analyze the data.

RESULTS

We included 12 studies, of which five reported SCR at 2 months, seven reported the conversion at 3 months, and seven reported TB focus absorption. According to the five studies which reported 2 months-SCR, patients with diabetes and TB had an odds ratio (OR) of 2.14 (95% CI: 0.84-5.43) for the 2 months-SCR between controlled (HbA1c <7.0) and uncontrolled diabetes (HbA1c ≥7.0). However, additional seven studies reporting 3 months-SCR showed that controlled diabetics had higher SCR than uncontrolled (OR 3.39, 95% CI: 2.12-5.43). Moreover, seven of the 12 studies demonstrated that there were differences in TB focus absorption between controlled and uncontrolled diabetes (OR 2.69, 95% CI: 1.91-3.79).

CONCLUSION

HbA1c control levels influence the SCR at 3 months and the TB focus absorption at the end of the anti-TB intensive treatment phase. This study highlights a need for increased attention to HbA1c or glucose control in patients afflicted with both TB and DM.

Diabetes Mellitus among new tuberculosis patients in Bamako, Mali

Introduction

Diabetes Mellitus (DM) increases worldwide, mostly in low- and middle-income countries. In Mali, the prevalence in the adult population is estimated at 1.8%, but tuberculosis (TB) patients are not systematically screened. The goal of our study was to determine the prevalence of DM among newly diagnosed TB patients.

Methods

We conducted a cross sectional study and a pilot prospective cohort study in four health centers in Bamako. All patients underwent fasting capillary-blood glucose (FCBG) test at Day 0, and repeated after one-week of TB treatment. Venous FBG test was performed for discrepancies between the two FCBG results. Thereafter, FCBG was performed for pilot study at month-2 (M2) and M5 of TB treatment.

Results

Two hundred and one patients were enrolled in this study. Impaired fasting blood glucose was identified in 17 (8.5%), of whom 11 (5.5%) had DM (VFBG >7 mmol/L). Among patients with DM, seven (63.6%) had successful TB treatment outcome, versus 142 (74.7%) of those without DM (p = 0.64), and (OR: 1.69, 95%CI 0.47–6.02).

Conclusion

The prevalence of DM among TB patients in Bamako exceeds that of the general population and screening at TB diagnosis suffices to identify those with DM. Systematic screening of both diseases will allow better treatment.

High prevalence and heterogeneity of Dysglycemia in patients with tuberculosis from Peru: a prospective cohort study

BACKGROUND

The accuracy of different laboratory tests for diagnosis of diabetes mellitus (DM) and prediabetes (preDM) in populations exposed to tuberculosis (TB) remains poorly understood. Here, we examined the prevalence of DM and preDM in TB affected people in Lima, Peru.

METHODS

A prospective cohort study of patients affected TB and their household contacts (HHC), was conducted between February and November 2017 in Lima, Peru. Fasting plasma glucose (FPG), HbA1c and oral glucose tolerance test (OGTT) were used to detect DM and preDM in a prospective cohort of TB patients (n = 136) and household contacts (n = 138). Diagnostic performance of the laboratory tests was analyzed. Potential effects of sociodemographic and clinical factors on detection of dysglycemia were analyzed.

RESULTS

In TB patients, prevalence of DM and preDM was 13.97 and 30.88% respectively. Lower prevalence of both DM (6.52%) and preDM (28.99%) were observed in contacts. FPG, HbA1c and OGTT had poor agreement in detection of preDM in either TB cases or contacts. TB-DM patients had substantially lower hemoglobin levels, which resulted in low accuracy of HbA1c-based diagnosis. Classic sociodemographic and clinical characteristics were not different between TB patients with or without dysglycemia.

CONCLUSION

High prevalence of DM and preDM was found in both TB patients and contacts in Lima. Anemia was strongly associated with TB-DM, which directly affected the diagnostic performance of HbA1c in such population.

Immunological Impacts of Diabetes on the Susceptibility of Mycobacterium tuberculosis

The interaction between diabetes and major world infections like TB is a major public health concern because of rapidly rising levels of diabetes. The dual burden of tuberculosis (TB) and diabetes mellitus (DM) has become a major global public health problem. Diabetes mellitus is a major risk factor for the development of active and latent tuberculosis. Immune mechanisms contributing to the increased susceptibility of diabetic patients to TB are due to the defects in bacterial recognition, phagocytic activity, and cellular activation which results in impaired production of chemokines and cytokines. The initiation of adaptive immunity is delayed by impaired antigen-presenting cell (APC) recruitment and function in hyperglycemic host, which results in reduced frequencies of Th1, Th2, and Th17 cells and its secretion of cytokines having a great role in activation of macrophage and inflammatory response of tuberculosis. In addition, impaired immune response and killing of intracellular bacteria potentially increase bacterial load, chronic inflammation, and central necrosis that facilitate bacterial dissemination and miliary tuberculosis. Understanding of the immunological and biochemical basis of TB susceptibility in diabetic patients will tell us the rational development of implementation and therapeutic strategies to alleviate the dual burden of the diseases. Therefore, the aim of this review was focused on the association between diabetes and tuberculosis, focusing on epidemiology, pathogenesis, and immune dysfunction in diabetes mellitus, and its association with susceptibility, severity, and treatment outcome failure to tuberculosis.

Synergism between diabetes and human immunodeficiency virus in increasing the risk of tuberculosis

SETTING

Community health screenings in KwaZulu-Natal Province, South Africa.

OBJECTIVE

To study the synergism between diabetes mellitus (DM) and human immunodeficiency virus (HIV) infection in increasing the risk of tuberculosis (TB).

DESIGN

In this cross-sectional study, we analyzed data from two community health projects, one at congregate settings, and one at household settings (n = 7708), in a rural resource-limited region where integrated communicable and non-communicable disease screening services were offered. Odds ratios (ORs) for demographic factors, socio-economic factors, DM status, and HIV positivity were calculated using multivariate analysis, and the statistical interaction between HIV and DM was tested. The primary outcome was the presence of TB symptoms.

RESULTS

Among 7708 individuals, age >65 years (OR 1.72, 95%CI 1.47-2.02), HIV infection (OR 1.66, 95%CI 1.40-1.97) and DM (OR 1.36, 95%CI 1.11-1.67) were independently associated with increased odds of TB symptoms. Receiving monthly grants (OR 0.78, 95%CI 0.66-0.91), access to a toilet (OR 0.54, 95%CI 0.35-0.83), and access to solar or electric energy (OR 0.86, 95%CI 0.77-0.97) reduced the odds. There was evidence of significant interaction between DM and HIV on the multiplicative scale.

CONCLUSION

DM and HIV synergistically increased the odds of TB symptoms according to these retrospective data. Future studies should prospectively evaluate synergism between HIV and DM in increasing the risk of active TB.

Diabetes mellitus comorbidity in patients enrolled in tuberculosis drug efficacy trials around the world: A systematic review

AIMS

With a prevalence of 16%, diabetes mellitus (DM) is one of the most frequent non-communicable comorbidities of tuberculosis (TB). DM is a major risk factor for adverse TB outcomes and may require personalized TB drug dosing regimens. However, information on the inclusion of DM in TB drug trials is lacking. We aimed to assess the percentage of recent TB drug efficacy trials that included DM patients.

METHODS

A systematic review was performed and reported according to PRISMA guidelines. PubMed, Science Direct, and ClinicalTrials.gov databases were systematically searched for TB drug trials published between 1 January 2012 and 12 September 2017. Primary outcome was the percentage of TB drug trials performed around the world that included DM patients.

RESULTS

Out of the included 41 TB drug trials, 12 (29.3%) reported DM comorbidity among the study participants. Nine trials (21.9%) excluded all patients with DM comorbidity, ten (24.4%) excluded only insulin-dependent or uncontrolled DM, and 10 (24.4%) did not mention whether DM was included or excluded. Of the 12 trials that included DM comorbidity, the majority did not report the diagnostic criteria for DM and none reported outcomes in the DM subpopulation. Inclusion of DM was higher in drug-resistant-TB trials (67%, P = .003, vs drug-susceptible) and trials performed in Asia (60%, P = .006, vs Africa).

CONCLUSIONS

Fewer than 1/3 recent TB drug trials reported the inclusion of DM. To better reflect real-world DM prevalence and differential TB drug effectiveness, inclusion of DM patients requires increased attention for future TB drug trials.

Mid-upper arm circumference predicts death in adult patients admitted to a TB ward in the Philippines: A prospective cohort study

Background

The Philippines is ranked 3^rd globally for tuberculosis incidence (554/100,000 population). The tuberculosis ward at San Lazaro Hospital, Manila receives 1,800–2,000 admissions of acutely unwell patients per year with high mortality. Objectives of this prospective cohort study were to quantify the association of under-nutrition (primary) and diabetes (secondary) with inpatient mortality occurring between 3–28 days of hospital admission in patients with suspected or previously diagnosed TB.

Methods and results

We enrolled 360 adults (≥18 years); 348 were eligible for the primary analysis (alive on day 3). Clinical, laboratory, anthropometric and enhanced tuberculosis diagnostic data were collected at admission with telephone tracing for mortality up to 6 months post-discharge. In the primary analysis population (mean age 45 years, SD = 15.0 years, 70% male), 58 (16.7%) deaths occurred between day 3–28 of admission; 70 (20.1%) between day 3 and discharge and documented total post-day 3 mortality including follow-up was 96 (27.6%). In those in whom it could be assessed, body mass index (BMI) ranged from 11.2–30.6 kg/m² and 141/303 (46.5%) had moderate/severe undernutrition (BMI<17 kg/m²). A sex-specific cut-off for mid-upper arm circumference predictive of BMI<17 kg/m² was associated with inpatient Day 3–28 mortality in males (AOR = 5.04, 95% CI: 1.50–16.86; p = 0.009; p = 0.032 for interaction by sex). The inability to stand for weight/height for BMI assessment was also associated with mortality (AOR = 5.59; 95% CI 2.25–13.89; p<0.001) as was severe compared to normal/mild anaemia (AOR = 9.67; 95% CI 2.48–37.76; p<0.001). No TB specific variables were associated with Day 3–28 mortality, nor was diabetes (HbA1c ≥6.5% or diabetes treatment). Similar effects were observed when the same multivariable model was applied to confirmed TB patients only and to the outcome of all post-day 3 in-patient mortality.

Conclusion

This research supports the use of mid-upper arm circumference for triaging acutely unwell patients and the design and testing of nutrition-based interventions to improve patient outcomes.

Analytical Exploration of Potential Pathways by which Diabetes Mellitus Impacts Tuberculosis Epidemiology

We aimed to develop a conceptual framework of diabetes mellitus (DM) effects on tuberculosis (TB) natural history and treatment outcomes, and to assess the impact of these effects on TB-transmission dynamics. The model was calibrated using TB data for India. A conceptual framework was developed based on a literature review, and then translated into a mathematical model to assess the impact of the DM-on-TB effects. The impact was analyzed using TB-disease incidence hazard ratio (HR) and population attributable fraction (PAF) measures. Evidence was identified for 10 plausible DM-on-TB effects. Assuming a flat change of 300% (meaning an effect size of 3.0) for each DM-on-TB effect, the HR ranged between 1.0 (Effect 9-Recovery) and 2.7 (Effect 2-Fast progression); most effects did not have an impact on the HR. Meanwhile, TB-disease incidence attributed directly and indirectly to each effect ranged between -4.6% (Effect 7-TB mortality) and 34.5% (Effect 2-Fast progression). The second largest impact was for Effect 6-Disease infectiousness at 29.9%. In conclusion, DM can affect TB-transmission dynamics in multiple ways, most of which are poorly characterized and difficult to assess in epidemiologic studies. The indirect (e.g. onward transmission) impacts of some DM-on-TB effects are comparable in scale to the direct impacts. While the impact of several effects on the HR was limited, the impact on the PAF was substantial suggesting that DM could be impacting TB epidemiology to a larger extent than previously thought.

Tuberculosis-diabetes screening: how well are we doing? A mixed-methods study from North India

Setting

Public health care facilities in Sonipat District, Haryana State, India.

Objectives

To assess 1) the proportion of tuberculosis (TB) patients screened for diabetes mellitus (DM) and vice versa, 2) factors associated with screening, and 3) the enablers, barriers and solutions related to screening.

Design

A mixed-methods study with quantitative (cohort study involving record reviews of patients registered between November 2016 and April 2017) and qualitative (interviews of patients, health care providers [HCPs] and key district-level staff) components.

Results

Screening for TB among DM patients was not implemented, despite documents indicating that it had been. Of 562 TB patients, only 137 (24%) were screened for DM. TB patients registered at tertiary and secondary health centres were more likely to be screened than primary health centres. Low patient awareness, poor knowledge of guidelines among HCPs, lack of staff and inadequate training were barriers to screening. Enablers were the positive attitude of HCPs and programme staff. The key solutions suggested were to improve awareness of HCPs and patients regarding the need for screening, training of HCPs and wider availability of DM testing facilities.

Conclusion

The implementation of bidirectional screening was poor. Adequate staffing, regular training, continuous laboratory supplies for DM diagnosis and widespread publicity should be ensured.

Impact of Diabetes Mellitus on the Presentation and Response to Treatment of Adults With Pulmonary Tuberculosis in Qatar

BACKGROUND

Persons with diabetes mellitus (DM) have a 3-fold increased risk of tuberculosis (TB). Atypical radiographic findings and differences in bacteriologic response during anti-TB treatment have been reported in earlier studies; however, the findings have varied. We evaluated the effect of DM on manifestations and response to treatment in adults with pulmonary TB in Qatar.

METHODS

The impact of DM on the clinical and radiographic presentations of pulmonary TB and bacteriologic response during anti-TB treatment was evaluated between January 2007 and December 2011, comparing patients with and without DM. This is a retrospective unmatched case-control study conducted at a large national hospital. Cases and controls were randomly selected from patients diagnosed with pulmonary TB over a 5-year period. Sputum culture conversion was assessed after 2 months of anti-TB treatment.

RESULTS

Clinical symptoms were similar between patients with and without DM. Patients with DM had a higher initial sputum acid-fast bacillus (AFB) smear grade and were less likely to have cavitary lesions on initial chest radiographs than patients without DM. Of 134 adults with DM and TB, 71 (53%) remained sputum culture positive after 2 months of anti-TB treatment, compared with 36 (27%) patients without DM.

CONCLUSIONS

DM was associated with atypical radiographic findings and delayed sputum culture conversion at 2 months in adults with pulmonary TB in Qatar. Increased health education of patients with DM about symptoms of TB, low thresholds for evaluation for active TB, and close monitoring of bacteriologic response to treatment among patients with TB and DM are warranted.

Risk of adverse treatment outcomes among new pulmonary TB patients co-infected with diabetes in Pakistan: A prospective cohort study

PURPOSE

The escalating burden of diabetes in countries tackling high burden of tuberculosis (TB) has adverse implications for co-infected individuals and National TB control efforts. We aimed to study whether there was a difference in treatment outcome among diabetic and non-diabetic pulmonary TB patients and identify the determinants of treatment outcome among the two groups.

MATERIALS AND METHODS

This prospective cohort study recruited new patients of pulmonary tuberculosis (PTB) aged 15 years and above who were diagnosed at and registered with Gulab Devi Chest Hospital, Lahore, Pakistan for anti-tuberculosis treatment (ATT). PTB patients were screened for diabetes using random and fasting blood glucose tests. Diabetic and non-diabetic PTB patients were followed up at second, fifth and sixth month of ATT and 6 months after ATT completion to determine treatment outcome. Multivariate logistic regression analysis was conducted to assess association between various factors and treatment outcome.

RESULTS

Of 614 PTB patients, (n = 113 [18%]) were diabetic and (n = 501 [82%]) non-diabetic. Final model showed that diabetics were more likely to experience an unfavorable outcome as compared to non-diabetics (adjusted odds ratio [aOR] = 2.70, 95% Confidence Interval [CI] = 1.30 to 5.59). Other predictors of unfavorable outcome included rural residence (aOR = 1.98, 95% CI = 1.14 to 3.47), body mass index less than 18.50 (aOR = 1.89, 95% CI = 1.03 to 3.47) and being a smoker (aOR = 2.03, 95%CI = 1.04 to 3.94).

CONCLUSION

Our study shows unfavorable treatment outcome among diabetic PTB patients. Integrated models of care with screening/testing and management for diabetes and TB could improve TB treatment outcomes.