Diabetes, glycemic control, and risk of tuberculosis: a population-based case-control study

Diabetes Causes Significant Alterations in Pulmonary Glucose Transporter Expression

Diabetes has been identified as a significant and independent risk factor for the development or increased severity of respiratory infections. However, the role of glucose transport in the healthy and diseased lung has received little attention. Specifically, the protein expression of the predominant glucose transporter (GLUT) isoforms in the adult lung remains largely to be characterized in both healthy and diabetic states. Type 1 diabetes was induced via streptozotocin and rescued via subcutaneous semi-osmotic insulin pump for 8 weeks. The gene and/or protein expression of the most predominant GLUT isoforms from Classes I and III, including the major insulin-sensitive isoform (i.e., GLUT4) and novel isoforms (i.e., GLUT-8 and GLUT-12), was quantified in the lung of healthy and diabetic mice via qRT-PCR and/or Western blotting. Pulmonary cell surface GLUT protein was measured using a biotinylated photolabeling assay, as a means to evaluate GLUT trafficking. Diabetic mice demonstrated significant alterations of total pulmonary GLUT protein expression, which were isoform- and location-dependent. Long-term insulin treatment rescued the majority of GLUT protein expression alterations in the lung during diabetes, as well as GLUT-4 and -8 trafficking to the pulmonary cell surface. These alterations in glucose homeostasis during diabetes may contribute to an increased severity of pulmonary infection during diabetes and may point to novel metabolic therapeutic strategies for diabetic patients with concurrent respiratory infections.

Trends of type 2 diabetes with pulmonary tuberculosis patients,2013-2022, and changes after the coronavirus disease 2019 (COVID-19) pandemic

BACKGROUND

To describe the trends of Type 2 Diabetes with Pulmonary Tuberculosis (T2DM-TB) patients from 2013 to 2022 and to investigate the impact of COVID-19 lockdown on glycemic control and associated factors in T2DM-TB.

METHODS

In this population-based study of the First Affiliated Yijishan Hospital of Wannan Medical College in China, we described the 10-year trends of patients diagnosed with T2DM-TB. We included patients diagnosed with TB, T2DM-TB and T2DM-TB patients for comparative analysis, aged 15 years or older. Data were missing, and both multidrug-resistant (MDR) TB patients and non-T2DM patients were excluded from our study.

RESULTS

We pooled Type 2 Diabetes (T2DM) and Tuberculosis (TB) data from The First Affiliated Yijishan Hospital of Wannan Medical College in China, gathered between January 1, 2013, and December 31, 2022. The data included 14,227 T2DM patients, 6130 TB patients, and 982 T2DM-TB patients. During the past 10 years, the number of inpatients with TB decreased, while the number of patients with T2DM and T2DM-TB increased year by year. To rule out any influence factors, we analyzed the ratio of the three groups. The ratio of TB/T2DM decreased year by year (p < 0.05), while the ratio of TB-T2DM/TB increasing year by year (p = 0.008). During the COVID-19 epidemic period, there was no significant change in the ratio of TB-T2DM/T2DM (p = 0.156). There was no significant change in the proportion of male patients with TB and TB-T2DM (p = 0.325; p = 0.190), but the proportion of male patients with T2DM showed an increasing trend (p < 0.001). The average age of TB patients over the past 10 years was 54.5 ± 18.4 years and showed an increasing trend year by year (p < 0.001). However, there was no significant change in the age of T2DM or TB-T2DM patients (p = 0.064; p = 0.241). Patients data for the first (2013-2017) and the last (2018-2022) five years were compared. We found that the number of T2DM and TB-T2DM in the last five years was significantly higher than in the first five years, but the number of TB was significantly lower than in the first five years. There is a significant statistical difference in the proportion of TB/T2DM and TB-T2DM/TB, which is similar to the previous results. The average age (56.0 ± 17.6 years) of TB patients in the last five years is significantly higher than in the first five years (53.1 ± 18.9) (p < 0.001). The number of male patients with T2DM in the last five years is higher than that in the first five years, with significant difference (p < 0.001).

CONCLUSION

The trends of T2DM-TB among hospitalized TB patients have increased significantly over the past 10 years, which may be related to the increase in the number of T2DM cases. The COVID-19 pandemic has been effective in controlling the transmission of TB, but it has been detrimental to the control of T2DM. Male patients with T2DM and elderly TB patients are the key populations for future prevention and control efforts.

Associations between type 1 diabetes and pulmonary tuberculosis: a bidirectional mendelian randomization study

BACKGROUND

Type 1 diabetes mellitus (T1DM) has been associated with higher pulmonary tuberculosis (PTB) risk in observational studies. However, the causal relationship between them remains unclear. This study aimed to assess the causal effect between T1DM and PTB using bidirectional Mendelian randomization (MR) analysis.

METHODS

Single nucleotide polymorphisms (SNPs) of T1DM and PTB were extracted from the public genetic variation summary database. In addition, GWAS data were collected to explore the causal relationship between PTB and relevant clinical traits of T1DM, including glycemic traits, lipids, and obesity. The inverse variance weighting method (IVW), weighted median method, and MR‒Egger regression were used to evaluate the causal relationship. To ensure the stability of the results, sensitivity analyses assess the robustness of the results by estimating heterogeneity and pleiotropy.

RESULTS

IVW showed that T1DM increased the risk of PTB (OR = 1.07, 95% CI: 1.03-1.12, P < 0.001), which was similar to the results of MR‒Egger and weighted median analyses. Moreover, we found that high-density lipoprotein cholesterol (HDL-C; OR = 1.28, 95% CI: 1.03-1.59, P = 0.026) was associated with PTB. There was no evidence of an effect of glycemic traits, remaining lipid markers, or obesity on the risk of PTB. In the reverse MR analysis, no causal relationships were detected for PTB on T1DM and its relevant clinical traits.

CONCLUSION

This study supported that T1DM and HDL-C were risk factors for PTB. This implies the effective role of treating T1DM and managing HDL-C in reducing the risk of PTB, which provides an essential basis for the prevention and comanagement of concurrent T1DM and PTB in clinical practice.

Human immunodeficiency virus retinopathy with presumed cytomegalovirus retinitis with macular oedema in a diabetic

A man in his early 50s on regular follow-up for a stable non-proliferative diabetic retinopathy (NPDR) presented with decreased vision, worsening of retinal pathology and macular oedema in both eyes. His corrected distance visual acuity (CDVA) was 6/9 in the right eye and 6/15 in the left eye and fundus examination showed multiple intraretinal haemorrhages in all quadrants. His systemic workup revealed a severe thrombocytopaenia, which prompted a further detailed systemic evaluation revealing him to be positive for HIV with retinopathy complicating the pre-existing NPDR. Given the significant inflammation and macular oedema, a cocktail of intravitreal bevacizumab, ganciclovir and dexamethasone was administered. The retinopathy and macular oedema resolved and the CDVA improved to 6/6 in both eyes over a 6-month follow-up period. Any sudden worsening of fundus findings in a patient with diabetes necessitates immediate and detailed ocular and systemic evaluation, especially when the immune status is unknown.

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.

Diabetes mellitus and tuberculosis, a systematic review and meta-analysis with sensitivity analysis for studies comparable for confounders

INTRODUCTION

Meta-analyses conducted so far on the association between diabetes mellitus (DM) and the tuberculosis (TB) development risk did not sufficiently take confounders into account in their estimates. The objective of this systematic review was to determine whether DM is associated with an increased risk of developing TB with a sensitivity analyses incorporating a wider range of confounders including age, gender, alcohol consumption, smoke exposure, and other comorbidities.

METHODS

Pubmed, Embase, Web of Science and Global Index Medicus were queried from inception until October 2020. Without any restriction to time of study, geographical location, and DM and TB diagnosis approaches, all observational studies that presented data for associations between DM and TB were included. Studies with no abstract or complete text, duplicates, and studies with wrong designs (review, case report, case series, comment on an article, and editorial) or populations were excluded. The odds ratios (OR) and their 95% confidence intervals were estimated by a random-effect model.

RESULTS

The electronic and manual searches yielded 12,796 articles of which 47 were used in our study (23 case control, 14 cross-sectional and 10 cohort studies) involving 503,760 cases (DM or TB patients) and 3,596,845 controls. The size of the combined effect of TB risk in the presence of DM was OR = 2.3, 95% CI = [2.0-2.7], I2 = 94.2%. This statistically significant association was maintained in cohort (OR = 2.0, CI 95% = [1.5-2.4], I2 = 94.3%), case control (OR = 2.4, CI 95% = [2.0-2.9], I2 = 93.0%) and cross-sectional studies (OR = 2.5, CI 95% = [1.8-3.5], I2 = 95.2%). The association between DM and TB was also maintained in the sensitivity analysis including only studies with similar proportions of confounders between cases and controls. The substantial heterogeneity observed was mainly explained by the differences between geographic regions.

CONCLUSIONS

DM is associated with an increased risk of developing latent and active TB. To further explore the role of DM in the development of TB, more investigations of the biological mechanisms by which DM increases the risk of TB are needed.

REVIEW REGISTRATION

PROSPERO, CRD42021216815.

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.

The association of glycemic level and prevalence of tuberculosis: a meta-analysis

BACKGROUND

Diabetes is a well-known risk factor for tuberculosis and poorly glycemic control may increase the risk of tuberculosis. We performed a meta-analysis to explore the association of glycemic control in diabetic patients and their tuberculosis prevalence.

METHODS

We included observational studies that investigated the prevalence of tuberculosis associated with glycemic control. The markers of glycated hemoglobin A1c (HbA1c) and fasting plasma glucose were used to evaluate the exposure of interest in the study. We searched related articles in PubMed, EMBASE and Web of Science through 14 December 2019. The Newcastle-Ottawa scale was used to assess the risk of bias of included studies.

RESULTS

Seventeen studies (four cohort studies, five case-control studies and eight cross-sectional studies) were included, involving 1,027,074 participants. The meta-analysis found the pooled odds ratio of prevalent tuberculosis increased a 2.05-fold (95%CI: 1.65, 2.55) for the patients with HbA1c ≥7.0% compared to those with HbA1c concentration < 7.0%. Furthermore, we found the mean of HbA1c was higher in the diabetes mellitus with tuberculosis group than the diabetes-only group (P = 0.002). In the sensitivity analysis, the finding remains consistent.

CONCLUSION

Our study provides the evidence that poorly controlled diabetes in diabetics may be associated with increased prevalence of tuberculosis. More efforts should focus on screening tuberculosis in uncontrolled diabetes.

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

Background

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

Methods

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

Results

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

Conclusions

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

Real-world use of cardioprotective glucose-lowering drugs in patients with type 2 diabetes and cardiovascular disease: A Danish nationwide cohort study, 2012 to 2019

AIMS

To investigate temporal trends in time to initiation of sodium-glucose co-transporter-2 inhibitors and glucagon-like peptide 1 analogues (cardioprotective glucose-lowering drugs [GLDs]) in patients with a new dual diagnosis of type 2 diabetes (T2DM) and cardiovascular disease (CVD).

MATERIALS AND METHODS

In a cohort study, we identified patients with a new dual diagnosis of T2DM and CVD using linked healthcare data from nationwide registries on drug prescriptions and diagnosis codes. For each calendar year between 2012 and 2018, we examined time to initiation and cumulative user proportions (CUPs) for cardioprotective GLD use 1 and 2 years after the dual diagnosis.

RESULTS

Among all individuals living in Denmark in the period 2012 to 2018, 41 733 patients with a new dual diagnosis of T2DM and CVD were identified (median [interquartile range] age 71 [64-79] years, 61% male, and 57% with CVD as the latest diagnosis). Incidence curve slopes and 1- and 2-year CUPs for cardioprotective GLDs increased during the study period (1-year CUP 4.0%, 95% confidence interval [CI] 3.6-4.5) in 2012 to 14.7, 95% CI 13.7-15.7, in 2018; 2-year CUP 5.5, 95% CI 5.0-6.1, in 2012 to 16.7, 95% CI 15.8-17.7, in 2017). T2DM patients with CVD as the second (latest) diagnosis had higher 1-year CUPs than CVD patients with T2DM as the latest diagnosis: 2012: 7.0 (95% CI 6.2-8.0) versus 1.4 (95% CI 1.0-1.8); 2018: 18.1 (95% CI 16.8-19.6) versus 10.0 (95% CI 8.8-11.3).

CONCLUSIONS

In patients with T2DM and CVD, the incidence of cardioprotective GLD initiation increased between 2012 and 2018, however, within 2 years of dual diagnosis, it remained low.

Association between metabolic risk factors and optic disc cupping identified by deep learning method

PURPOSE

This study aims to investigate correlation between metabolic risk factors and optic disc cupping and the development of glaucoma.

METHODS

This study is a retrospective, cross-sectional study with over 20-year-old patients that underwent health screening examinations. Intraocular pressure (IOP), fundus photographs, Body Mass Index (BMI), waist circumference (WC), serum triglycerides, serum HDL cholesterol (HDL-C), serum LDL cholesterol (LDL-C), systolic blood pressure (BP), diastolic BP, and serum HbA1c were obtained to analyse correlation between metabolic risk factors and glaucoma. Eye with glaucomatous optic neuropathy(GON) was defined as having an optic disc with either vertical cup-to-disc ratio(VCDR) ≥ 0.7 or a VCDR difference ≥ 0.2 between the right and left eyes by measuring VCDR with deep learning approach.

RESULTS

The study comprised 15,585 subjects and 877 subjects were diagnosed as GON. In univariate analyses, age, BMI, systolic BP, diastolic BP, WC, triglyceride, LDL-C, HbA1c, and IOP were significantly and positively correlated with VCDR in the optic nerve head. In linear regression analysis as independent variables, stepwise multiple regression analyses revealed that age, BMI, systolic BP, HbA1c, and IOP showed positive correlation with VCDR. In multivariate logistic analyses of risk factors and GON, higher age (odds ratio [OR], 1.054; 95% confidence interval [CI], 1.046-1.063), male gender (OR, 0.730; 95% CI, 0.609-0.876), more obese (OR, 1.267; 95% CI, 1.065-1.507), and diabetes (OR, 1.575; 95% CI, 1.214-2.043) remained statistically significant correlation with GON.

CONCLUSIONS

Among the metabolic risk factors, obesity and diabetes as well as older age and male gender are risk factors of developing GON. The glaucoma screening examinations should be considered in the populations with these indicated risk factors.

Incidence of pulmonary tuberculosis in Chinese adults with type 2 diabetes: a retrospective cohort study in Shanghai

To estimate the incidence of pulmonary tuberculosis (PTB) in Chinese diabetes patients and to evaluate the effect of blood glucose on PTB risk, a retrospective cohort study was built based on the diabetes management system in Shanghai and included 240,692 adults aged 35 or above. Incidences of PTB in all diabetes patients and by subgroups were calculated and compared. Multivariable Cox regression models with restricted cubic splines were used to evaluate the association of fasting plasma glucose (FPG) with the risk of PTB. A total of 439 incident PTB cases were identified in the cohort after an average of 3.83 years of follow-up. The overall PTB incidence rate was 51.3/100,000 in diabetes patients, and annual incidence remained higher than that in general population. The PTB incidence rate of diabetes patients was higher in men than in women (86.2 vs. 22.1 per 100,000) and was highest in patients with body mass index (BMI) < 18.5 kg/m² (215.2/100,000) or FPG ≥ 10 mmol/L (143.2/100,000). Our results suggest that the risk of tuberculosis may be greater at higher levels of FPG in diabetes patients of normal weight. Specific tuberculosis screening strategies for different characteristic diabetes population should be provided to prevent and control tuberculosis in China.

Changes in SGLT2i and GLP-1RA real-world initiator profiles following cardiovascular outcome trials: A Danish nationwide population-based study

BACKGROUND

We investigated changes in clinical characteristics of SGLT2i and GLP-1RA real-world initiators in Denmark before/after landmark cardiovascular outcome trials.

METHODS

We compared first-time SGLT2i (25,070) and GLP-1RA (14,671) initiators to initiators of DPP-4i (n = 34,079), a class without proven cardiovascular benefits. We used linked population-based healthcare data to examine initiation incidence, medication patterns, and pre-existing atherosclerotic cardiovascular disease (ASCVD) during 2014-2017.

RESULTS

Nationwide incidence of SGLT2i initiators increased 3.6-fold (53/100,000 to 172/100,000 per year) vs. a 1.5-fold increase for GLP-1RA. DPP-4i initiation remained stable. From the end of 2015, SGLT2i was increasingly used as 2nd-line therapy, while medication patterns were much more stable for GLP-1RA. Among SGLT2i users, ASCVD increased slightly from 28% to 30%; age- and gender-adj. prevalence ratio (aPR) = 1.03 (95% CI:0.97-1.10). In contrast, among GLP-1RA initiators, baseline ASCVD declined from 29% to 27% (aPR: 0.90 (95% CI:0.84-0.97)), and in DPP-4i initiators from 31% to 29% (aPR: 0.91 (95% CI:0.88-0.96)).

CONCLUSIONS

Following the EMPA-REG OUTCOME trial in 2015, SGLT2i have become increasingly used as 2nd-line treatment in everyday clinical practice, with only minor increases in patient proportions with ASCVD. For GLP-1RA, we observed more stable therapy lines and slightly decreasing ASCVD in new users despite the LEADER trial.

Burden of diabetes among patients with tuberculosis: 10-year experience from a tertiary care referral teaching hospital in South India

Context

Tuberculosis (TB) and diabetes mellitus (DM) are converging epidemics, each worsening the morbidity of the other. A study of the prevalence of DM in TB patients assumes great importance.

Aims

The study aims to evaluate the association between DM and TB over a 10-year period in a tertiary care hospital.

Settings and Design

A retrospective observational study in a southern Indian tertiary care teaching hospital was conducted.

Materials and Methods

All patients with TB diagnosed and treated during the 10-year study period were identified from the hospital database. All relevant clinical, microbiological, and laboratory results pertaining to diagnosis of DM were collected. The diagnosis of TB and DM was made as per the standard criteria.

Statistical Analysis

Categorical variables were analyzed using Chi-square test while continuous variables using independent sample t-test.

Results

From 2001 to 2012, we studied 1979 TB patients among whom data on DM were available. The prevalence of DM was 29%, 21%, and 14%, in smear positive, smear negative and extrapulmonary TB respectively (overall 24%). Diabetics were more likely to be men (77.3% vs. 61%;P = 0.001); >40 years of age (81.7% vs. 38.9%;P < 0.001); heavier (59.96 vs. 50.37;P = 0.004); tobacco smokers (16.1% vs. 8.1%;P < 0.001); and alcohol consumers (6.8% vs. 4%;P = 0.02). They were less likely to be HIV coinfected (1.8% vs. 6.1%;P < 0.001). HIV coinfection was seen in 5% of patients and was substantially higher in extrapulmonary TB group (19.4%). Multidrug-resistant TB was lower in DM (11.7%) compared to non-DM (15.9%) (P = 0.02). Overall, 48% of the DM patients were diagnosed at the time of TB diagnosis. Over 10 years, no obvious changes in the trend were evident.

Conclusions

Over a 10-year study period, 24% of the TB patients were diabetic, nearly half were detected at the time of TB diagnosis. There may be a good case for screening all TB patients for DM.

IL-22 produced by type 3 innate lymphoid cells (ILC3s) reduces the mortality of type 2 diabetes mellitus (T2DM) mice infected with Mycobacterium tuberculosis

Previously, we found that pathological immune responses enhance the mortality rate of Mycobacterium tuberculosis (Mtb)-infected mice with type 2 diabetes mellitus (T2DM). In the current study, we evaluated the role of the cytokine IL-22 (known to play a protective role in bacterial infections) and type 3 innate lymphoid cells (ILC3s) in regulating inflammation and mortality in Mtb-infected T2DM mice. IL-22 levels were significantly lower in Mtb-infected T2DM mice than in nondiabetic Mtb-infected mice. Similarly, serum IL-22 levels were significantly lower in tuberculosis (TB) patients with T2DM than in TB patients without T2DM. ILC3s were an important source of IL-22 in mice infected with Mtb, and recombinant IL-22 treatment or adoptive transfer of ILC3s prolonged the survival of Mtb-infected T2DM mice. Recombinant IL-22 treatment reduced serum insulin levels and improved lipid metabolism. Recombinant IL-22 treatment or ILC3 transfer prevented neutrophil accumulation near alveoli, inhibited neutrophil elastase 2 (ELA2) production and prevented epithelial cell damage, identifying a novel mechanism for IL-22 and ILC3-mediated inhibition of inflammation in T2DM mice infected with an intracellular pathogen. Our findings suggest that the IL-22 pathway may be a novel target for therapeutic intervention in T2DM patients with active TB disease.

Effect of diabetes mellitus on risk of latent TB infection in a high TB incidence area: a community-based study in Taiwan

OBJECTIVE

To investigate the association between diabetes and latent tuberculosis infections (LTBI) in high TB incidence areas.

DESIGN

Community-based comparison study.

SETTING

Outpatient diabetes clinics at 4 hospitals and 13 health centres in urban and rural townships. A community-based screening programme was used to recruit non-diabetic participants.

PARTICIPANTS

A total of 2948 patients with diabetes aged older than 40 years were recruited, and 453 non-diabetic participants from the community were enrolled.

PRIMARY AND SECONDARY OUTCOME MEASURES

The interferon-gamma release assay (IGRA) and the tuberculin skin test were used to detect LTBI. The IGRA result was used as a surrogate of LTBI in logistic regression analysis.

RESULTS

Diabetes was significantly associated with LTBI (adjusted OR (aOR)=1.59; 95% CI 1.11 to 2.28) and age correlated positively with LTBI. Many subjects with diabetes also had additional risk factors (current smokers (aOR=1.28; 95% CI 0.95 to 1.71), comorbid chronic kidney disease (aOR=1.26; 95% CI 1.03 to 1.55) and history of TB (aOR=2.08; 95% CI 1.19 to 3.63)). The presence of BCG scar was protective (aOR=0.66; 95% CI 0.51 to 0.85). Duration of diabetes and poor glycaemic control were unrelated to the risk of LTBI.

CONCLUSION

There was a moderately increased risk of LTBI in patients with diabetes from this high TB incidence area. This finding suggests LTBI screening for the diabetics be combined with other risk factors and comorbidities of TB to better identify high-risk groups and improve the efficacy of targeted screening for LTBI.

Burden and Characteristics of the Comorbidity Tuberculosis-Diabetes in Europe: TBnet Prevalence Survey and Case-Control Study

Background

The growing burden of diabetes mellitus (DM) is posing a threat to global tuberculosis (TB) control. DM triples the risk of developing TB, modifies the presenting features of pulmonary TB, and worsens TB treatment outcomes. We aimed to analyze the prevalence of DM among TB patients and to describe the characteristics and clinical presentation of TB-DM patients in Europe.

Methods

We performed a cross-sectional survey on the prevalence of DM among consecutively diagnosed adult TB patients in 11 European TB referral centers located in France, Germany, Greece, Italy, Russia, Slovakia, Spain, and the United Kingdom over the period 2007–2015. We also selected DM-TB cases and TB only controls with a 1:3 ratio to perform a case-control analysis, including patients selected from the countries mentioned above plus Norway and Ukraine.

Results

Among 3143 TB enrolled patients, DM prevalence overall was 10.7% and ranged from 4.4% in Greece to 28.5% in the United Kingdom. Patients’ median ages ranged from 36 to 49 years, and all centers had >60% males; the proportion of foreign-born patients varied widely across sites. In the case-control study, DM was independently associated with older age and, among older patients, with being foreign-born. Among patients with pulmonary involvement, cavities on chest imaging were more frequently observed among those with DM.

Conclusions

Diabetes mellitus represents a challenge for TB control in Europe, especially in foreign-born and in elderly patients. Specific screening strategies should be evaluated.

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.

Tuberculosis and diabetes: bidirectional association in a UK primary care data set

BACKGROUND

Many studies have found an increased risk of pulmonary tuberculosis (PTB) among those with diabetes mellitus (DM). However, evidence on whether the association is bidirectional remains sparse. This study investigates DM rates among those with and without prior tuberculosis (TB) disease as well as the reverse.

METHODS

Data on a UK general practice population, between 2003 and 2009, were obtained from The Health Improvement Network database. A series of retrospective cohort studies were completed. Individuals were successively classified as 'exposed' or 'unexposed' to TB, PTB, extrapulmonary TB (EPTB) or DM. Multivariate negative binomial regression was used to calculate incidence rate ratios (IRR) among each exposure group for outcomes of interest (TB, PTB, EPTB or DM in turn) adjusting for plausible confounding variables (age, sex, region, Townsend quintile and smoking status). Potential confounding due to ethnicity was adjusted for using McNamee's external method.

RESULTS

DM risk was substantially raised among individuals with a history of TB disease (IRR 5.65 (95% CI 5.19 to 6.16)), PTB (IRR 5.74 (95% CI 5.08 to 6.50)) and EPTB (IRR 4.66 (95% CI 3.94 to 5.51)) compared with those without; results were attenuated after external adjustment for ethnicity (IRR 2.33 (95% CI 2.14 to 2.53)). TB risk was raised modestly among individuals with DM (IRR 1.50 (95% CI 1.27 to 1.76)) and was attenuated slightly after adjustment for ethnicity (IRR 1.26 (95% CI 1.07 to 1.48)).

CONCLUSION

DM risk was raised among those with previous TB disease; this finding has implications for follow-up and screening of patients with TB, who may be at high risk of developing DM or related complications.

Diabetes screening among active tuberculosis patients in Western Australia Tuberculosis Control Program using HbA1c

BACKGROUND

Diabetes mellitus is an important risk factor for tuberculosis (TB), and studies in high TB burden countries have shown diabetes screening to be both feasible and to have a high yield. However, scarce information is available for low TB burden countries. Diabetes screening was previously not part of our routine practice.

AIM

To screen and determine the prevalence of diabetes in the Western Australian Tuberculosis Control Program.

METHODS

We measured HbA1c and random plasma glucose in patients with active TB. We also collected details on their demographics, TB and diabetes.

RESULTS

A total of 105 patients was recruited over a year. Of those, 17 (16.2%) had diabetes. Seven cases (6.7%) were newly diagnosed diabetics. Age, cavitating disease and family history of diabetes were found to be significantly associated with diabetes. Multilobar disease, gender, body mass index, smear and culture positivity were not significantly different between groups.

CONCLUSION

Our study showed high prevalence of diabetes among active TB patients. Diabetes screening at diagnosis of active TB presents as a good opportunity to detect diabetes even in low prevalence country and has become part of our standard care.

Risk of active tuberculosis among people with diabetes mellitus: systematic review and meta-analysis

OBJECTIVE

To assess the risk of active TB in people with DM and the factors associated with this risk.

METHODS

Systematic review and meta-analysis. We searched the literature for studies that reported the effect of DM on TB controlled for the effect of age. Studies that had not established the diagnosis of DM prior to detecting active TB were excluded. Study quality was assessed by Newcastle-Ottawa scale and we conducted a meta-analysis using random-effects models.

RESULTS

Of 14 studies (eight cohort and six case-control studies) that involved 22 616 623 participants met the selection criteria and were included in the analysis. There was substantial variation between studies in the estimates of the effect of DM on TB. However, the pooled estimates from seven high-quality studies showed that diabetic people have a 1.5-fold increased risk of developing active TB vs. those without DM (95%CI 1.28-1.76), with relatively small heterogeneity (I²  = 44%). The increased risk of TB was observed predominantly among DM populations with poor glycaemic control.

CONCLUSION

There is evidence suggesting an increased risk of developing TB among people with DM, and that improving glycaemic control in DM patients would reduce the risk of developing TB. An integrated approach is needed to control the dual burden of DM and TB.

Patients with type 1 diabetes mellitus have impaired IL-1β production in response to Mycobacterium tuberculosis

Patients with diabetes mellitus have an increased risk of developing tuberculosis. Although the underlying mechanism is unclear, evidence suggests a role for chronic hyperglycaemia. We examined the influence of hyperglycaemia on Mycobacterium tuberculosis-induced cytokine responses in patients with type 1 diabetes mellitus (T1D). Peripheral blood mononuclear cells (PBMCs) from 24 male T1D patients with sub-optimal glucose control [HbA1c > 7.0% (53 mmol/L)] and from 24 age-matched male healthy controls were stimulated with M. tuberculosis lysate. Cytokine analysis, assessment of aerobic glycolysis, receptor recognition and serum cross-over experiments were performed to explore the mechanistic differences. PBMCs from T1D patients produced less bioactive interleukin (IL)-1β in response to M. tuberculosis. IL-6 and interferon (IFN)-γ production trended towards a decrease, whilst other cytokines such as tumour necrosis factor (TNF)-α, IL-17 and IL-1Ra were normal. The decrease in cytokine production was not correlated to HbA1c or plasma glucose levels. Cross-over serum experiments did not alter the cytokine profile of T1D or control patients, arguing for an intrinsic cellular defect. Cellular metabolism and the expression of M. tuberculosis-related pattern recognition receptors (PRRs) such as TLR2, TLR4 and NOD2 did not differ between T1D patients and healthy controls. Compared to matched controls, T1D patients have a reduced capacity to produce pro-inflammatory cytokines in response to M. tuberculosis. The impaired IL-1β production in T1D patients may contribute to the increased susceptibility to tuberculosis. This effect appears not to be related to prevailing glucose levels but to an intrinsic cellular deficit.

Association between diabetes mellitus and active tuberculosis: A systematic review and meta-analysis

The burgeoning epidemic of diabetes mellitus (DM) is one of the major global health challenges. We systematically reviewed the published literature to provide a summary estimate of the association between DM and active tuberculosis (TB). We searched Medline and EMBASE databases for studies reporting adjusted estimates on the TB–DM association published before December 22, 2015, with no restrictions on region and language. In the meta-analysis, adjusted estimates were pooled using a DerSimonian-Laird random-effects model, according to study design. Risk of bias assessment and sensitivity analyses were conducted. 44 eligible studies were included, which consisted of 58,468,404 subjects from 16 countries. Compared with non-DM patients, DM patients had 3.59–fold (95% confidence interval (CI) 2.25–5.73), 1.55–fold (95% CI 1.39–1.72), and 2.09–fold (95% CI 1.71–2.55) increased risk of active TB in four prospective, 16 retrospective, and 17 case-control studies, respectively. Country income level (3.16–fold in low/middle–vs. 1.73–fold in high–income countries), background TB incidence (2.05–fold in countries with >50 vs. 1.89–fold in countries with ≤50 TB cases per 100,000 person-year), and geographical region (2.44–fold in Asia vs. 1.71–fold in Europe and 1.73–fold in USA/Canada) affected appreciably the estimated association, but potential risk of bias, type of population (general versus clinical), and potential for duplicate data, did not. Microbiological ascertainment for TB (3.03–fold) and/or blood testing for DM (3.10–fold), as well as uncontrolled DM (3.30–fold), resulted in stronger estimated association. DM is associated with a two- to four-fold increased risk of active TB. The association was stronger when ascertainment was based on biological testing rather than medical records or self-report. The burgeoning DM epidemic could impact upon the achievements of the WHO “End TB Strategy” for reducing TB incidence.

Comorbidities, mortality and causes of death among patients with tuberculosis in Denmark 1998-2010: a nationwide, register-based case-control study

OBJECTIVE

To evaluate the impact of comorbidities, age and clinical presentation of TB on mortality among Danish patients with TB.

METHODS

Danish patients with an ICD-10 (International Statistical Classification of Diseases and Related Health Problems 10th Revision) diagnosis of TB in 1998-2010 were identified in the National Patient Registry and matched with controls (1:4) on age, gender, civil status and geography. Comorbid diagnoses up to 3 years before and after TB diagnosis or enrolment as control as well as survival data were obtained from national databases RESULTS: We included 8433 cases and 33 707 controls. Respiratory diseases were the most common comorbidities among cases (12.4% of cases, 3.8% of controls (p<0.001)). Overall HR of death was 2.45 (2.31; 2.59). Relative mortality was especially increased among younger adults (HR 8.70 (95% CI 5.53 to 13.69) among the 30 to 39-year-olds). While overall mortality increased with Deyo-Charlson comorbidity (DCC) score, relative mortality among cases was highest in the low-DCC group. Additionally, male gender, low income and central nervous system TB were risk factors for death among TB cases. The most common cause of death in both groups was non-lung cancers, among TB cases followed by COPD, TB and lung cancer, all being significantly more common among TB cases.

CONCLUSION

In Denmark, TB carries substantial mortality. Among those who die, 12% are reported to die from TB. A high relative mortality among younger adults underscores the importance of continually targeting high-risk TB groups in low-incidence countries.

Impact of Glycemic Control on Risk of Infections in Patients With Type 2 Diabetes: A Population-Based Cohort Study

Infections are a major clinical challenge for type 2 diabetes patients, but little is known about the impact of glycemic control. We used Cox regression analyses to examine the association between baseline and time-varying hemoglobin A1c (HbA1c) values and development of community antiinfective-agent-treated and hospital-treated infections in 69,318 patients with type 2 diabetes diagnosed between 2000 and 2012 in Northern Denmark. Incidence rates were 394/1,000 patient-years for community-treated infections and 63/1,000 patient-years for hospital-treated infections. The adjusted hazard ratios for community-treated infection at an HbA1c level of ≥10.50%, as compared with 5.50%-<6.49%, were 0.97 (95% confidence interval (CI): 0.94, 1.00) for HbA1c measured at early baseline, 1.09 (95% CI: 1.03, 1.14) for updated mean HbA1c, 1.13 (95% CI: 1.08, 1.19) for updated time-weighted mean HbA1c, and 1.19 (95% CI: 1.14, 1.26) for the latest updated HbA1c. Corresponding estimates for hospital-treated infections were 1.08 (95% CI: 1.02, 1.14) for early baseline HbA1c, 1.55 (95% CI: 1.42, 1.71) for updated mean HbA1c, 1.58 (95% CI: 1.44, 1.72) for updated time-weighted mean HbA1c, and 1.64 (95% CI: 1.51, 1.79) for the latest updated HbA1c. Our findings provide evidence for an association between current hyperglycemia and infection risk in type 2 diabetes patients.

Alcohol consumption as a risk factor for tuberculosis: meta-analyses and burden of disease

Meta-analyses of alcohol use, alcohol dosage and alcohol-related problems as risk factors for tuberculosis incidence were undertaken. The global alcohol-attributable tuberculosis burden of disease was also re-estimated.Systematic searches were conducted, reference lists were reviewed and expert consultations were held to identify studies. Cohort and case-control studies were included if there were no temporal violations of exposure and outcome. Risk relations (RRs) were pooled by using categorical and dose-response meta-analyses. The alcohol-attributable tuberculosis burden of disease was estimated by using alcohol-attributable fractions.36 of 1108 studies were included. RRs for alcohol use and alcohol-related problems were 1.35 (95% CI 1.09-1.68; I2: 83%) and 3.33 (95% CI 2.14-5.19; 87%), respectively. Concerning alcohol dosage, tuberculosis risk rose as ethanol intake increased, with evidence of a threshold effect. Alcohol consumption caused 22.02 incident cases (95% CI 19.70-40.77) and 2.35 deaths (95% CI 2.05-4.79) per 100 000 people from tuberculosis in 2014. Alcohol-attributable tuberculosis incidence increased between 2000 and 2014 in most high tuberculosis burden countries, whereas mortality decreased.Alcohol consumption was associated with an increased risk of tuberculosis in all meta-analyses. It was consequently a major contributor to the tuberculosis burden of disease.

Protective effect of metformin against tuberculosis infections in diabetic patients: an observational study of south Indian tertiary healthcare facility

Background

World Health Organization estimated that people with diabetes (DM) are at 2–3 times higher risk for tuberculosis (TB). Studies have shown that DM not only increases the risk of active TB, but also puts co-affected persons at increased risk of poor outcomes.

Objectives

To determine the protective effect of metformin against TB in DM patients and also, to investigate the relationship between poor glycemic control and TB.

Methods

A case–control study was conducted over 8 months, where cases and controls were selected based on the inclusion and exclusion criteria of the study. The diabetics diagnosed with TB were selected as study group (SG = 152) and without TB were as control group (CG = 299). Exposure status of metformin in both groups were analyzed.

Results

The mean (SD) age of both CG and SG were 55.54 ± 11.82 and 52.80 ± 11.75, respectively. Majority of the subjects in the study were males. The mean hospital stay of SG and CG were 7 days and 6 days, respectively. Poor glycemic control (HbA1c > 8) observed in SG (51.7%) vs CG (31.4%). HbA1c value <7 is associated protective factor for TB occurrence [OR = 0.52 (95% CI 0.29–0.93)]. The protective effect of metformin against TB was 3.9-fold in diabetics (OR = 0.256, 0.16–0.40).

Conclusion

Poor glycemic control among diabetics is a risk factor for TB occurrence. The result shows metformin use is a protective agent against TB infection in diabetics. Hence, incorporation of metformin into standard clinical care would offer a therapeutic option for the prevention of TB.

Increased risk of active tuberculosis after cancer diagnosis

BACKGROUND

Cancer may increase risk of active tuberculosis but evidence is sparse. We therefore examined tuberculosis risk in patients with incident cancer using Danish nationwide medical databases.

METHODS

We conducted a matched follow-up study comparing risk of active tuberculosis in cancer-exposed individuals to that in a general population comparison cohort, matched on gender, age, and country of origin, in different follow-up intervals using Cox regression.

FINDINGS

We identified 290,944 patients with incident cancer and 871,147 matched comparison cohort members during 1 January, 2004-30 November, 2013. After adjusting for comorbidities, the overall adjusted hazard ratio (aHR) for tuberculosis among cancer patients was 2.48 (95% confidence interval [CI]: 1.99-3.10). The highest tuberculosis risks were observed following cancers of the aerodigestive tract (aHR = 8.12; 95% CI: 4.33-15.22), tobacco-related cancers (aHR = 5.01; 95% CI: 3.37-7.44), and hematological cancers (aHR = 4.88; 95% CI: 2.27-10.48). Tuberculosis risk was highly elevated within the first year after cancer diagnosis (aHR = 4.14; 95% CI: 2.88-5.96), with a 6.78-fold increased aHR for cancer patients receiving cytostatics or radiotherapy. Beyond five years of observation, the overall aHR for tuberculosis remained at 2.66 (95% CI: 1.22-5.81).

INTERPRETATION

Cancer is a clinical predictor for increased risk of active tuberculosis, probably related to decreased infection barriers, immunosuppression, and shared risk factors.

Effectiveness of intensification therapies in Danes with Type 2 diabetes who use basal insulin: a population-based study

AIMS

To examine the usage and real-life effectiveness of intensification therapies in people with Type 2 diabetes treated with basal insulin.

METHODS

We used population-based healthcare databases in Denmark during 2000-2012 to identify all individuals with a first basal insulin prescription (with or without oral drugs), and evaluated subsequent intensification therapy with bolus insulin, premixed insulin or glucagon-like peptide-1 (GLP-1) receptor agonists. Poisson regression was used to compute the adjusted relative risks of reaching glycaemic control targets.

RESULTS

We included 7034 initiators of basal insulin (median age 64 years, diabetes duration 5.3 years, 84% with oral co-medication and median (interquartile range) pre-insulin HbA_1c level 77 (65-92) mmol/mol [9.2% (8.1-10.6%)]. Of these, 3076 (43.7%) received intensification therapy after a median of 11 months: 58.5% with premixed insulin, 29.0% with bolus insulin, 10.6% with GLP-1 receptor agonists, and 1.9% with more than one add-on. Overall, 22% had attained an HbA_1c level of < 53 mmol/mol (< 7%) by 3-6 months after intensification, while 38% attained an HbA_1c < 58 mmol/mol (< 7.5%). Compared with premixed insulin intensification, attainment of HbA_1c < 53 and < 58 mmol/mol was similar with bolus insulin add-on [adjusted relative risk 1.03 (95% CI 0.86-1.24) and 1.02 (95% CI 0.91-1.15), and higher for GLP-1 receptor agonist add-on [adjusted relative risk 1.56 (95% CI 1.27-1.92) and 1.27 (1.10-1.47)].

CONCLUSIONS

Among people with Type 2 diabetes, 22 and 38% reached a target HbA_1c < 53 mmol/mol (< 7%) or < 58 mmol/mol (< 7.5%), respectively, after intensification of their basal insulin therapy. Compared with premixed insulin, target attainment was similar with bolus insulin and higher with GLP-1 receptor agonists.

The global dynamics of diabetes and tuberculosis: the impact of migration and policy implications

The convergence between tuberculosis (TB) and diabetes mellitus (DM) will represent a major public health challenge in the near future. DM increases the risk of developing TB by two to three times and also increases the risk of TB treatment failure, relapse, and death. The global prevalence of DM is predicted to rise significantly in the next two decades, particularly in some of the low- and middle-income countries with the highest TB burden. Migration may add further complexity to the effort to control the impact on TB of the growing DM pandemic. Migration may increase the risk of DM, although the magnitude of this association varies according to country of origin and ethnic group, due to genetic factors and lifestyle differences. Migrants with TB may have an increased prevalence of DM compared to the native population, and the risk of TB among persons with DM may be higher in migrants than in autochthonous populations. Screening for DM among migrants, screening migrants with DM for active and latent TB, and improving access to DM care, could contribute to mitigate the effects of DM on TB.

Diabetes and pulmonary tuberculosis: a global overview with special focus on the situation in Asian countries with high TB-DM burden

BACKGROUND

The double burden of tuberculosis (TB) and diabetes mellitus (DM) is hitting certain Asian countries harder than other areas. In a global estimate, 15% of all TB cases could be attributable to DM, with 40% of those cases coming from India and China. Many other countries of South, East, and South-East Asia are of particular concern given their TB burdens, large projected increases in DM prevalence, and population size.

OBJECTIVE

In this narrative review, we aimed to: (i) give an overall insight into the evidence on TB-DM epidemiology from high double burden Asian countries, (ii) present the evidence on bi-directional screening implementation in this region, (iii) discuss possible factors related to higher TB susceptibility of Asian diabetic patients, and (iv) identify TB-DM comorbidity treatment challenges.

METHODS

The PubMed and Google Scholar databases were searched for all studies addressing DM/TB epidemiology, bi-directional screening and management in South, East and South-East Asia.

RESULTS

We identified the DM prevalences among TB patients as ranging from approximately 5% to more than 50%, whereas TB prevalences among diabetic patients were 1.8-9.5 times higher than in the general population in developing Asian countries. Evidence from studies designed to address diagnosis and treatment of the dual disease in these critical regions is scarce as well as the evidence related to possible DM patients' genetic and acquired predisposition for TB.

CONCLUSION

More prospective studies specifically designed to address adequate screening techniques, identify patients at risk, and define an adequate treatment of dual disease in this region are needed without delay.

Risk for latent and active tuberculosis in Germany

Purpose

Few individuals that are latently infected with M. tuberculosis latent tuberculosis infection(LTBI) progress to active disease. We investigated risk factors for LTBI and active pulmonary tuberculosis (PTB) in Germany.

Methods

Healthy household contacts (HHCs), health care workers (HCWs) exposed to M. tuberculosis and PTB patients were recruited at 18 German centres. Interferon-γ release assay (IGRA) testing was performed. LTBI risk factors were evaluated by comparing IGRA-positive with IGRA-negative contacts. Risk factors for tuberculosis were evaluated by comparing PTB patients with HHCs.

Results

From 2008–2014, 603 HHCs, 295 HCWs and 856 PTBs were recruited. LTBI was found in 34.5% of HHCs and in 38.9% of HCWs. In HCWs, care for coughing patients (p = 0.02) and longstanding nursing occupation (p = 0.04) were associated with LTBI. In HHCs, predictors for LTBI were a diseased partner (odds ratio 4.39), sexual contact to a diseased partner and substance dependency (all p < 0.001). PTB was associated with male sex, low body weight (p < 0.0001), alcoholism (15.0 vs 5.9%; p < 0.0001), glucocorticoid therapy (7.2 vs 2.0%; p = 0.004) and diabetes (7.8 vs. 4.0%; p = 0.04). No contact developed active tuberculosis within 2 years follow-up.

Conclusions

Positive IGRA responses are frequent among exposed HHCs and HCWs in Germany and are poor predictors for the development of active tuberculosis.

Electronic supplementary material

The online version of this article (doi:10.1007/s15010-016-0963-2) contains supplementary material, which is available to authorized users.

Profile of glycated-hemoglobin, antioxidant vitamin and cytokine levels in pulmonary tuberculosis patients: A cross sectional study at Pulmonary Diseases Center Semarang City, Indonesia

Background

Uncontrolled blood glucose, which marked by high level of HbA1c, increases risk of pulmonary TB because of cellular immunity dysfunction. This study aimed to analyze profile of glycated hemoglobin, antioxidant vitamins status and cytokines levels in active pulmonary TB patients.

Methods

This was a cross sectional study, conducted at Pulmonary Diseases Center Semarang City, Indonesia. Study subject consisted of 62 pulmonary TB patients, diagnosed with positive acid fast bacilli and chest X-ray. ELISA was used to measure IFN-γ and IL-12. Status of antioxidant vitamins was determined by concentration of vitamin A and E using HPLC. Blood glucose control was determined by HbA1c concentration (HbA1c ≥7% is considered as uncontrolled).

Results

A significant difference of age between pulmonary tuberculosis patients with normal and uncontrolled blood glucose (p = 0.000) was showed, while all other characteristics (sex, education, occupation) did not differ with p = 0.050, 0.280, 0.380 respectively. Mean HbA1c was 7.25 ± 2.70%. Prevalence of uncontrolled glucose among pulmonary TB patients was 29%. Levels of IFN-γ and IL-12 did not differ according to HbA1c concentration (p = 0.159 and p = 0.965 respectively). Pulmonary tuberculosis patients with uncontrolled blood glucose has higher vitamin E (p = 0.006), while vitamin A did not differ significantly (p = 0.478).

Conclusions

This study supports the importance of performing diabetes screening among pulmonary TB patients. Further study needs to be done to determine the feasibility of TB-DM co-management.

Glycemic Control and the Risk of Tuberculosis: A Cohort Study

BACKGROUND

Diabetes is a well-known risk factor for tuberculosis (TB) and is increasingly prevalent in low- and middle-income countries, where the burden of TB is high. Glycemic control has the potential to modify the risk of TB. However, there are few studies on the association between glycemic control and TB risk, and the results are inconsistent.

METHODS AND FINDINGS

We assembled a cohort using 123,546 individuals who participated in a community-based health screening service in northern Taiwan from 5 March 2005 to 27 July 2008. Glycemic control was measured using fasting plasma glucose (FPG) at the time of screening. The cohort was followed up to 31 December 2012 for the occurrence of TB by cross-matching the screening database to the national health insurance database. Multiple imputation was used to handle missing information. During a median follow-up of 4.6 y, 327 cases of TB occurred. In the multivariable Cox regression model, diabetic patients with poor glycemic control (FPG > 130 mg/dl) had a significantly higher hazard of TB (adjusted hazard ratio [aHR] 2.21, 95% CI 1.63-2.99, p < 0.001) compared to those without diabetes. The hazard of TB in diabetic patients with good glycemic control (FPG ≤ 130 mg/dl) did not differ significantly from that in nondiabetic individuals (aHR 0.69, 95% CI 0.35-1.36, p = 0.281). In the linear dose-response analysis, the hazard of TB increased with FPG (aHR 1.06 per 10-mg/dl increase in FPG, 95% CI 1.03-1.08, p < 0.001). Assuming the observed association between glycemic control and TB was causal, an estimated 7.5% (95% CI 4.1%-11.5%) of incident TB in the study population could be attributed to poor glycemic control. Limitations of the study include one-time measurement of fasting glucose at baseline and voluntary participation in the health screening service.

CONCLUSIONS

Good glycemic control could potentially modify the risk of TB among diabetic patients and may contribute to the control of TB in settings where diabetes and TB are prevalent.

Hyperglycemia Impairs Neutrophil-Mediated Bacterial Clearance in Mice Infected with the Lyme Disease Pathogen

Insulin-insufficient type 1 diabetes is associated with attenuated bactericidal function of neutrophils, which are key mediators of innate immune responses to microbes as well as pathological inflammatory processes. Neutrophils are central to immune responses to the Lyme pathogen Borrelia burgdorferi. The effect of hyperglycemia on host susceptibility to and outcomes of B. burgdorferi infection has not been examined. The present study investigated the impact of sustained obesity-independent hyperglycemia in mice on bacterial clearance, inflammatory pathology and neutrophil responses to B. burgdorferi. Hyperglycemia was associated with reduced arthritis incidence but more widespread tissue colonization and reduced clearance of bacterial DNA in multiple tissues including brain, heart, liver, lung and knee joint. B. burgdorferi uptake and killing were impaired in neutrophils isolated from hyperglycemic mice. Thus, attenuated neutrophil function in insulin-insufficient hyperglycemia was associated with reduced B. burgdorferi clearance in target organs. These data suggest that investigating the effects of comorbid conditions such as diabetes on outcomes of B. burgdorferi infections in humans may be warranted.

Diabetes mellitus and tuberculosis: programmatic management issues

In August 2011, the World Health Organization and the International Union Against Tuberculosis and Lung Disease launched the Collaborative Framework for Care and Control of Tuberculosis (TB) and diabetes mellitus (DM) to guide policy makers and implementers in combatting the epidemics of both diseases. Progress has been made, and includes identifying how best to undertake bidirectional screening for both diseases, how to provide optimal treatment and care for patients with dual disease and the most suitable framework for monitoring and evaluation. Key programmatic challenges include the following: whether screening should be directed at all patients or targeted at those with high-risk characteristics; the most suitable technologies for diagnosing TB and diabetes in routine settings; the best time to screen TB patients for DM; how to provide an integrated, coordinated approach to case management; and finally, how to persuade non-communicable disease programmes to adopt a cohort analysis approach, preferably using electronic medical records, for monitoring and evaluation. The link between DM and TB and the implementation of the collaborative framework for care and control have the potential to stimulate and strengthen the scale-up of non-communicable disease care and prevention programmes, which may help in reducing not only the global burden of DM but also the global burden of TB.

The economic burden of tuberculosis in Denmark 1998-2010. Cost analysis in patients and their spouses

OBJECTIVE

To evaluate the economic burden of tuberculosis (TB) in Denmark,

METHODS

8,433 Danish TB-patients (1998-2010) were matched with 33,707 controls by age, gender, civil status and geography. Health-related costs (health system contacts and -procedures, medications) and socio-economic parameters (foregone earnings and social transfer expenses) were calculated on data from national databases. The same information was obtained for 3,485 spouses of TB-patients, and 17,403 controls.

RESULTS

Health-related costs were higher for cases throughout the period. Before diagnosis, cases posed € 1,180 more health costs per year than controls. Excess health costs in the 2 years around diagnosing and treating TB were € 10,509. Cases received an average excess public transfer income of € 3,345 before vs. € 3,121 after diagnosis. Average employment income deficiency was € 11,635 before vs. € 13,885 after diagnosis, but the increasing difference showed a linear shape throughout the period. Spouses also had lower income, more social transfer, and posed higher health-related costs than matched controls.

CONCLUSION

We estimate the direct costs per TB patient to be €10,509. TB patients and their households are characterized by increasingly lower employment income, lower employment rate, and higher dependency on public transfer, but the socio/economic deterioration is rather a risk factor for TB than a direct consequence of the disease.

Early glycaemic control among patients with type 2 diabetes and initial glucose-lowering treatment: a 13-year population-based cohort study

AIM

To examine real-life time trends in early glycaemic control in patients with type 2 diabetes between 2000 and 2012.

METHODS

We used population-based medical databases to ascertain the association between achievement of glycaemic control with initial glucose-lowering treatment in patients with incident type 2 diabetes in Northern Denmark. Success in reaching glycated haemoglobin (HbA1c) goals within 3-6 months was examined using regression analysis.

RESULTS

Of 38 418 patients, 91% started with oral glucose-lowering drugs in monotherapy. Metformin initiation increased from 32% in 2000-2003 to 90% of all patients in 2010-2012. Pretreatment (interquartile range) HbA1c levels decreased from 8.9 (7.6-10.7)% in 2000-2003 to 7.0 (6.5-8.1)% in 2010-2012. More patients achieved an HbA1c target of <7% (<53 mmol/mol) in 2010-2012 than in 2000-2003 [80 vs 60%, adjusted relative risk (aRR) 1.10, 95% confidence interval (CI) 1.08-1.13], and more achieved an HbA1c target of <6.5% [(<48 mmol/mol) 53 vs 37%, aRR 1.07 95% CI 1.03-1.11)], with similar success rates observed among patients aged <65 years without comorbidities. Achieved HbA1c levels were similar for different initiation therapies, with reductions of 0.8% (from 7.3 to 6.5%) on metformin, 1.5% (from 8.1 to 6.6%) on sulphonylurea, 4.0% (from 10.4 to 6.4%) on non-insulin combination therapies, and 3.8% (from 10.3 to 6.5%) on insulin monotherapy.

CONCLUSIONS

Pretreatment HbA1c levels in patients with incident type 2 diabetes have decreased substantially, which is probably related to earlier detection and treatment in accordance with changing guidelines. Achievement of glycaemic control has improved, but 20% of patients still do not attain an HbA1c level of <7% within the first 6 months of initial treatment.

Diabetes Mellitus is Associated With Low Secretion Rates of Immunoglobulin A in Saliva

BACKGROUND

The association between diabetes mellitus (DM) and low secretory immunoglobulin A (s-IgA) secretion rates is one mechanism suspected of influencing susceptibility to infections among DM patients. However, several studies have shown contradictory results. We examined these two factors to seek evidence of an association among older people.

METHODS

We analyzed a prospective cohort of 2306 subjects (1209 men and 1097 women) around 64 years old from the New Integrated Suburban Seniority Investigation (NISSIN) Project in Nisshin, Japan. DM statuses were ascertained from levels of fasting plasma glucose and HbA1c, and s-IgA secretion rates were obtained from 5-min saliva samples. We used an analysis of covariance adjusted for possible confounders to compare s-IgA secretion rates according to DM status.

RESULTS

s-IgA secretion rates in DM participants were lower than in those classified as normal (18.6 µg/min vs 15.0 µg/min, P = 0.03), even after elimination of the effects of possible confounders.

CONCLUSIONS

DM was associated with lower s-IgA secretion rates. This suggests that lower s-IgA levels may be a mechanism of susceptibility to infection in individuals with DM.

Diabetes: A Contributor to Tuberculosis in Tropical Australia

In countries with a high-burden of tuberculosis (TB), it has been well established that there is an increased incidence of TB among patients with diabetes. However, in countries with a low burden of TB there are conflicting reports. This study aimed to determine if diabetes was associated with TB in patients admitted to a teaching hospital in tropical Australia. A 20-year retrospective study found patients with comorbid diabetes were seven times overrepresented in the TB patient population when compared with the general population. This study demonstrates a strong association between TB and diabetes regardless of TB endemicity.

Risk of tuberculosis in patients with diabetes: population based cohort study using the UK Clinical Practice Research Datalink

BACKGROUND

Previous cohort studies demonstrate diabetes as a risk factor for tuberculosis (TB) disease. Public Health England has identified improved TB control as a priority area and has proposed a primary care-based screening program for latent TB. We investigated the association between diabetes and risk of tuberculosis in a UK General Practice cohort in order to identify potential high-risk groups appropriate for latent TB screening.

METHODS

Using data from the UK Clinical Practice Research Datalink we constructed a cohort of patients with incident diabetes. We included 222,731 patients with diabetes diagnosed from 1990-2013 and 1,218,616 controls without diabetes at index date who were matched for age, sex and general practice. The effect of diabetes was explored using a Poisson analysis adjusted for age, ethnicity, body mass index, socioeconomic status, alcohol intake and smoking. We explored the effects of age, diabetes duration and severity. The effects of diabetes on risk of incident TB were explored across strata of chronic disease care defined by cholesterol and blood pressure measurement and influenza vaccination rates.

RESULTS

During just under 7 million person-years of follow-up, 969 cases of TB were identified. The incidence of TB was higher amongst patients with diabetes compared with the unexposed group: 16.2 and 13.5 cases per 100,000 person-years, respectively. After adjustment for potential confounders the association between diabetes and TB remained (adjusted RR 1.30, 95 % CI 1.01 to 1.67, P = 0.04). There was no evidence that age, time since diagnosis and severity of diabetes affected the association between diabetes and TB. Diabetes patients with the lowest and highest rates of chronic disease management had a higher risk of TB (P <0.001 for all comparisons).

CONCLUSIONS

Diabetes as an independent risk factor is associated with only a modest overall increased risk of TB in our UK General Practice cohort and is unlikely to be sufficient cause to screen for latent TB. Across different consulting patterns, diabetes patients accessing the least amount of chronic disease care are at highest risk for TB.

Incretin-based therapy and risk of acute pancreatitis: a nationwide population-based case-control study

OBJECTIVE

To investigate whether the use of incretin-based drugs (GLP-1 receptor agonists and dipeptidyl peptidase 4 [DPP4] inhibitors) is associated with acute pancreatitis.

RESEARCH DESIGN AND METHODS

The study was a nationwide population-based case-control study using medical databases in Denmark. Participants were 12,868 patients with a first-time hospitalization for acute pancreatitis between 2005 and 2012 and a population of 128,680 matched control subjects. The main outcome measure was the odds ratio (OR) for acute pancreatitis associated with different antihyperglycemic drugs. We adjusted for history of gallstones, alcoholism, obesity, and other pancreatitis-associated comorbidities and medications.

RESULTS

A total of 89 pancreatitis patients (0.69%) and 684 control subjects (0.53%) were ever users of incretins. The crude OR for acute pancreatitis among incretin users was 1.36 (95% CI 1.08-1.69), while it was 1.44 (95% CI 1.34-1.54) among users of other antihyperglycemic drugs. After confounder adjustment, the risk of acute pancreatitis was not increased among incretin users (OR 0.95 [95% CI 0.75-1.21]), including DPP4 inhibitor users (OR 1.04 [95% CI 0.80-1.37]) or GLP-1 receptor agonist users (OR 0.82 [95% CI 0.54-1.23]), or among nonincretin antihyperglycemic drug users (OR 1.05 [95% CI 0.98-1.13]), compared with nonusers of any antihyperglycemic drugs. Findings were similar in current versus ever drug users and in patients with pancreatitis risk factors. The adjusted OR comparing incretin-based therapy with other antihyperglycemic therapy internally while also adjusting for diabetes duration and complications was 0.97 (95% CI 0.76-1.23).

CONCLUSIONS

Our findings suggest that the use of incretin-based drugs appears not to be associated with an increased risk of acute pancreatitis.

Diabetes mellitus prevalence in tuberculosis patients and the background population in Guinea-Bissau: a disease burden study from the capital Bissau

BACKGROUND

Data regarding the association between diabetes mellitus (DM) and tuberculosis (TB) in Africa are scare. We did a DM screening survey among TB patients and non-TB controls in Guinea-Bissau.

METHODS

The study was conducted at the Bandim Health Project (BHP) in the capital Bissau. From July 2010 to July 2011, newly diagnosed TB cases were identified through a TB notification system. Concurrently, non-TB controls were selected randomly from the BHP's demographic surveillance database and visited at home. Participants were tested using fasting blood glucose (FBG) measurements. DM was diagnosed as FBG ≥ 7 mmol/l. Our survey was linked to the patient database at the only existing Diabetes Clinic in Bissau.

RESULTS

TB patients (n=110) were older than the controls (n=572) (35 vs 31 years; p=0.02), more often male (55% vs 37%; p<0.001) and had a lower body mass index (18.7 vs 24.2 kg/m(2); p<0.001). The prevalence of DM was 2.8% (3/107) for TB patients and 2.1% (11/531) for controls (p=0.64). Excluding two controls already receiving anti-diabetic treatment, the prevalence of DM was 2.8% (3/107) vs 1.7% (9/529) (p=0.44).

CONCLUSIONS

The prevalence of DM was low, also among TB patients. No association between DM and TB was found.

Lifestyle factors associated with type 2 diabetes and use of different glucose-lowering drugs: cross-sectional study

Aims

To examine the lifestyle profile among persons with and without Type 2 diabetes mellitus (DM) and among users of different glucose-lowering drugs.

Methods

We used questionnaire data from a Danish health survey and identified presence of Type 2 DM and use of medications through medical databases. We calculated age- and gender-standardized prevalence ratios (PRs) of lifestyle factors according to Type 2 DM and different glucose-lowering drugs.

Results

Of 21,637 survey participants aged 25–79 years, 680 (3%) had Type 2 DM (median age 63 years) with a median diabetes duration of 5 years. Participants with Type 2 DM had a substantially higher prevalence of obesity (36% vs. 13%, PR: 3.1, 95% confidence interval (CI): 2.8–3.6), yet more reported to eat a very healthy diet (25% vs. 21%, PR: 1.2, 95% CI: 1.0–1.4) and to exercise regularly (67% vs. 53%, PR: 1.3, 95% CI: 1.2–1.4). Also, fewer were current smokers or had high alcohol intake. When compared with metformin users, obesity was substantially less prevalent in users of sulfonylurea (PR: 0.5, 95% CI: 0.4–0-8), and insulin and analogues (PR: 0.4, 95% CI: 0.3–0.7). Tobacco smoking was more prevalent in sulfonylurea users (PR: 1.4, 95% CI: 0.9–2.1) compared with metformin users. We found no material differences in physical exercise, diet or alcohol intake according to type of glucose-lowering drug.

Conclusions

Type 2 DM patients are substantially more obese than other individuals, but otherwise report to have a healthier lifestyle. Metformin use is strongly associated with obesity, whereas sulfonylurea use tends to be associated with tobacco smoking.

Impact of diabetes on the natural history of tuberculosis

Tuberculosis (TB) is the number one bacterial killer worldwide and the current increase in type 2 diabetes mellitus patients (DM), particularly in countries where TB is also endemic, has led to the re-emerging importance of DM2 as a risk factor for TB. There is an urgent need to implement strategies for TB prevention among the millions of DM patients exposed to Mycobacterium tuberculosis (Mtb) worldwide, but knowledge is limited on how and when DM2 alters the natural history of this infection. In this review we summarize the current epidemiological, clinical and immunologic studies on TB and DM and discuss the clinical and public health implications of these findings. Specifically, we evaluate the mechanisms by which DM patients have a higher risk of Mtb infection and TB development, present with signs and symptoms indicative of a more infectious TB infection, and are more likely to have adverse TB treatment outcomes, including death. Emphasis is placed on type 2 DM given its higher prevalence in contemporary times, but the underlying role of hyperglycemia and of type 1 DM is also discussed.

Tuberculosis and diabetes mellitus - an underappreciated association

The current review presents up-to-date knowledge on tuberculosis (TB) in diabetic patients. On the basis of available literature, there is little doubt about the close relationship between these two conditions. Diabetes mellitus in this association may still contribute substantially to the burden of TB and negatively affect control of the latter. Chronic hyperglycemia at least to some extent may alter the clinical manifestation, radiological appearance, treatment outcome and prognosis of TB. Although the pathogenesis is not clear, diabetes may impair both innate and adaptive immune responses to Mycobacterium tuberculosis. Eventually, effective screening and dual management of the diseases have to be addressed both in low- and high-income countries in order to limit the negative effects of the forthcoming global diabetes epidemic.

The double burden: a new-age pandemic meets an ancient infection

Tuberculosis is responsible for significant morbidity and mortality in the tropics. Active TB develops when host defences are impaired. Epidemiological evidence and studies addressing the double burden of communicable and non-communicable diseases demonstrate a clear association between diabetes and susceptibility to TB, treatment failure and complications. The immune mechanisms involved in host-pathogen interactions in co-morbid TB-diabetes are not well defined and require further investigation. This combined with the increase in diabetes predominately in low- and middle-income countries where TB is prevalent has major health implications.