Asymptomatic peripheral arterial disease in HIV patients in Ghana: A case-control study

BACKGROUND

Peripheral arterial disease (PAD) is common in HIV patients and can be diagnosed noninvasively using the ankle-brachial index (ABI). The burden of PAD has not been investigated in Ghanaian HIV patients. We investigated the prevalence and risk factors associated with PAD in HIV patients at a periurban hospital in Ghana.

METHODS

In a case-control design, ABI was measured in 158 cART-treated HIV patients, 150 cART-naïve HIV patients and 156 non-HIV controls with no clinical symptoms of CVDs. PAD was defined as ABI ≤ 0.9. A structured questionnaire was used to collect socio-demographic and clinical data. Fasting venous blood samples were collected to measure plasma levels of glucose, lipid profile, and CD4+ lymphocytes.

RESULTS

The prevalence of PAD was 13.9% among cART-treated HIV patients, 21.3% among cART-naïve HIV patients, and 15.4% among non-HIV controls. Patients with PAD had increased odds of having low CD4+ cell counts [OR (95% CI) = 3.68 (1.41-12.85)]. In cART-treated HIV patients, those on TDF-based [5.76 (1.1-30.01), p = 0.038] and EFV-based [9.28 (1.51-57.12), p = 0.016] regimens had increased odds of having PAD.

CONCLUSION

In our study population, there was no difference in the prevalence of PAD between cART-treated HIV patients compared to cART-naïve HIV patients or non-HIV controls. Having a low CD4 cell count and being on TDF- or EFV-based regimens were associated with an increased likelihood of having PAD.

Associations between spirometric impairments and microvascular complications in type 2 diabetes: a cross-sectional study

OBJECTIVE

Evidence shows that the conventional cardiometabolic risk factors do not fully explain the burden of microvascular complications in type 2 diabetes (T2D). One potential factor is the impact of pulmonary dysfunction on systemic microvascular injury. We assessed the associations between spirometric impairments and systemic microvascular complications in T2D.

DESIGN

Cross-sectional study.

SETTING

National Diabetes Management and Research Centre in Ghana.

PARTICIPANTS

The study included 464 Ghanaians aged ≥35 years with established diagnosis of T2D without primary myocardial disease or previous/current heart failure. Participants were excluded if they had primary lung disease including asthma or chronic obstructive pulmonary disease.

PRIMARY AND SECONDARY OUTCOME MEASURES

The associations of spirometric measures (forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC) and FEV1/FVC ratio) with microvascular complications (nephropathy (albumin-creatinine ratio ≥3 mg/g), neuropathy (vibration perception threshold ≥25 V and/or Diabetic Neuropathy Symptom score >1) and retinopathy (based on retinal photography)) were assessed using multivariable logistic regression models with adjustments for age, sex, diabetes duration, glycated haemoglobin concentration, suboptimal blood pressure control, smoking pack years and body mass index.

RESULTS

In age and sex-adjusted models, lower Z-score FEV1 was associated with higher odds of nephropathy (OR 1.55, 95% CI 1.19-2.02, p=0.001) and neuropathy (1.27 (1.01-1.65), 0.038) but not retinopathy (1.22 (0.87-1.70), 0.246). Similar observations were made for the associations of lower Z-score FVC with nephropathy (1.54 (1.19-2.01), 0.001), neuropathy (1.25 (1.01-1.54), 0.037) and retinopathy (1.19 (0.85-1.68), 0.318). In the fully adjusted model, the associations remained significant for only lower Z-score FEV1 with nephropathy (1.43 (1.09-1.87), 0.011) and neuropathy (1.34 (1.04-1.73), 0.024) and for lower Z-score FVC with nephropathy (1.45 (1.11-1.91), 0.007) and neuropathy (1.32 (1.03-1.69), 0.029). Lower Z-score FEV1/FVC ratio was not significantly associated with microvascular complications in age and sex and fully adjusted models.

CONCLUSION

Our study shows positive but varying strengths of associations between pulmonary dysfunction and microvascular complications in different circulations. Future studies could explore the mechanisms linking pulmonary dysfunction to microvascular complications in T2D.

Associations between spirometric measures and exercise capacity in type 2 diabetes

BACKGROUND

Physical exercise aids glycemic control and the prevention of diabetes-related complications. However, exercise beyond an individual's pulmonary functional capacity may be detrimental. To date, little is known about the relationship between pulmonary function and exercise capacity in people with type 2 diabetes (T2D). We investigated the relationship between pulmonary function and exercise capacity in T2D.

METHODS

Spirometry and 6-min walk test (6MWT) were conducted for 263 systematically sampled adults with T2D without primary heart/lung disease. The primary measure of exercise capacity was the 6-min walk distance (6MWD); impaired exercise capacity was defined as 6MWD<400 m. Logistic regression analyses were used to assess the associations between spirometric measures and exercise capacity with adjustments for age, sex, height, body mass index, diabetes duration, glycated hemoglobin concentration, smoking, suboptimum blood pressure control, and total cholesterol concentration.

RESULTS

Compared with individuals with normal spirometry, those with pulmonary restriction/obstruction had significantly lower 6MWD (404.67 m vs. 451.70),p < 0.001). The proportion of individuals with impaired exercise capacity was higher in individuals with impaired pulmonary function compared with those with normal pulmonary function (39.8% vs. 20.7%,p = 0.001). In the unadjusted models, decreasing Z-score FEV1 [odds ratio 1.40, 95% confidence interval (1.07-1.83),p = 0.013] and Z-score FVC [1.37 (1.06-1.76),0.016], but not Z-score FEV1/FVC ratio [1.00 (0.78-1.27),0.972] were significantly associated with impaired exercise capacity. In the fully adjusted model, the strength of association remained statistically significant for Z-score FEV1 [1.60 (1.06-2.41),0.025] but not Z-score FVC [1.48 (0.98-2.23),0.065].

CONCLUSIONS

Our study shows inverse associations between FEV1 and impaired exercise capacity in T2D, Future research could characterize optimal exercise levels based on a patient's FEV1.

Multidisciplinary care results in similar maternal and perinatal mortality rates for women with and without SCD in a low-resource setting

In Africa, the maternal mortality rate in sickle cell disease (SCD) is ~10%. Our team previously demonstrated an 89% decrease in mortality rate in a before-and-after feasibility study among women with SCD living in low-resource setting in Ghana. In the same cohort including additional participants with and without SCD, we used a prospective cohort design to test the hypothesis that implementing a multidisciplinary care team for pregnant women with SCD in low-resource setting will result in similar maternal and perinatal mortality rates compared to women without SCD. We prospectively enrolled pregnant women with and without SCD or trait and followed them up for 6-week postpartum. We tested the newborns of mothers with SCD for SCD. We recruited age and parity matched pregnant women without SCD or trait as the comparison group. Maternal and perinatal mortality rates were the primary outcomes. A total of 149 pregnant women with SCD (HbSS, 54; HbSC, 95) and 117 pregnant women without SCD or trait were included in the analysis. Post-intervention, maternal mortality rates were 1.3% and 0.9% in women with and without SCD, respectively (P = 1.00); the perinatal mortality rates were 7.4% and 3.4% for women with and without SCD, respectively (P = 0.164). Among the mothers with SCD, ~15% of newborns had SCD. Multidisciplinary care of pregnant women with SCD may reduce maternal and perinatal mortality rates to similar levels in pregnant women without SCD in low-resource settings. Newborns of mothers with SCD have a high rate of SCD.

Implementation of multidisciplinary care reduces maternal mortality in women with sickle cell disease living in low-resource setting

Sickle cell disease (SCD) is associated with adverse pregnancy outcome. In women with SCD living in low-resource settings, pregnancy is associated with significantly increased maternal and perinatal mortality rates. We tested the hypothesis that implementing a multidisciplinary obstetric and hematology care team in a low-resource setting would significantly reduce maternal and perinatal mortality rates. We conducted a before-and-after study, at the Korle-Bu Teaching Hospital in Accra, Ghana, to evaluate the effect of a multidisciplinary obstetric-hematology care team for women with SCD in a combined SCD-Obstetric Clinic. The pre-intervention period was assessed through a retrospective chart review to identify every death and the post-intervention period was assessed prospectively. Interventions consisted of joint obstetrician and hematologist outpatient and acute inpatient reviews, close maternal and fetal surveillance, and simple protocols for management of acute chest syndrome and acute pain episodes. Primary outcomes included maternal and perinatal mortality rates before and after the study period. A total of 158 and 90 pregnant women with SCD were evaluated in the pre- and post- intervention periods, respectively. The maternal mortality rate decreased from 10 791 per 100 000 live births at pre-intervention to 1176 per 100 000 at post-intervention, representing a risk reduction of 89.1% (P = 0.007). Perinatal mortality decreased from 60.8 per 1000 total births at pre-intervention to 23.0 per 1000 at post-intervention, representing a risk reduction of 62.2% (P = 0.20). A multidisciplinary obstetric and hematology team approach can dramatically reduce maternal and perinatal mortality in a low-resource setting.