Clinical management of concurrent diabetes and tuberculosis and the implications for patient services

Tuberculosis-diabetes comorbidities: Mechanistic insights for clinical considerations and treatment challenges

Tuberculosis (TB) remains a leading cause of death among infectious diseases, particularly in poor countries. Viral infections, multidrug-resistant and ex-tensively drug-resistant TB strains, as well as the coexistence of chronic illnesses such as diabetes mellitus (DM) greatly aggravate TB morbidity and mortality. DM [particularly type 2 DM (T2DM)] and TB have converged making their control even more challenging. Two contemporary global epidemics, TB-DM behaves like a syndemic, a synergistic confluence of two highly prevalent diseases. T2DM is a risk factor for developing more severe forms of multi-drug resistant-TB and TB recurrence after preventive treatment. Since a bidirectional relationship exists between TB and DM, it is necessary to concurrently treat both, and promote recommendations for the joint management of both diseases. There are also some drug-drug interactions resulting in adverse treatment outcomes in TB-DM patients including treatment failure, and reinfection. In addition, autophagy may play a role in these comorbidities. Therefore, the TB-DM comorbidities present several health challenges, requiring a focus on multidisciplinary collaboration and integrated strategies, to effectively deal with this double burden. To effectively manage the comorbidity, further screening in affected countries, more suitable drugs, and better treatment strategies are required.

Global burden of MDR-TB and XDR-TB attributable to high fasting plasma glucose from 1990 to 2019: a retrospective analysis based on the global burden of disease study 2019

PURPOSE

High fasting plasma glucose (HFPG) has been identified as a risk factor for drug-resistant tuberculosis incidence and mortality. However, the epidemic characteristics of HFPG-attributable multidrug-resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB) remain unclear. We aimed to analyze the global spatial patterns and temporal trends of HFPG-attributable MDR-TB and XDR-TB from 1990 to 2019.

METHODS

Utilizing data from the Global Burden of Disease 2019 project, annual deaths and disability-adjusted life years (DALYs) of HFPG-attributable MDR-TB and XDR-TB were conducted from 1990 to 2019. Joinpoint regression was employed to quantify trends over time.

RESULTS

From 1990 to 2019, the deaths and DALYs due to HFPG-attributable MDR-TB and XDR-TB globally showed an overall increasing trend, with a significant increase until 2003 to 2004, followed by a gradual decline or stability thereafter. The low sociodemographic index (SDI) region experienced the most significant increase over the past 30 years. Regionally, Sub-Saharan Africa, Central Asia and Oceania remained the highest burden. Furthermore, there was a sex and age disparity in the burden of HFPG-attributable MDR-TB and XDR-TB, with young males in the 25-34 age group experiencing higher mortality, DALYs burden and a faster increasing trend than females. Interestingly, an increasing trend followed by a stable or decreasing pattern was observed in the ASMR and ASDR of HFPG-attributable MDR-TB and XDR-TB with SDI increasing.

CONCLUSION

The burden of HFPG-attributable MDR-TB and XDR-TB rose worldwide from 1990 to 2019. These findings emphasize the importance of routine bi-directional screening and integrated management for drug-resistant TB and diabetes.

Sarcopenia assessed using a questionnaire can predict in-hospital mortality in older patients with pulmonary tuberculosis

BACKGROUND & AIMS

Pulmonary tuberculosis is a severe disease with a high mortality rate. However, whether sarcopenia is a risk factor for in-hospital mortality remains unclear. The SARC-F (five items: strength, assistance in walking, rising from a chair, climbing stairs, and falls) is a questionnaire developed to screen for sarcopenia. This study aimed to determine whether the high risk of sarcopenia, assessed using the SARC-F questionnaire, affects in-hospital mortality in older patients with pulmonary tuberculosis.

METHODS

This was a retrospective, observational study. We included patients with active pulmonary tuberculosis aged ≥65 years who required inpatient treatment between 30 April 2021 and 30 November 2022. We assessed sarcopenia using SARC-F, and SARC-F ≥ 4 points at admission was defined as a high risk of sarcopenia. The primary outcome was all-cause mortality during hospitalisation. We extracted information on age, sex, body mass index, comorbidities, blood and biochemical tests, modified Glasgow Prognostic Score, calf circumference, geriatric nutritional risk index, physiotherapy, and length of hospital stay from medical records.

RESULTS

We included 147 patients (mean age: 83.0 ± 7.8 years; males: 61.9%). Ninety-three (63.3%) patients had a high risk of developing sarcopenia. Patients with a high risk of sarcopenia were significantly older (mean: 85.0 ± 7.1 years), had a lower body mass index (median: 18.1 kg/m2, range: 16.1-20.5 kg/m2), had a higher modified Glasgow Prognostic Score (median: 2, range: 2-2), and had a lower calf circumference (mean: 26.8 ± 3.6 cm), had a lower geriatric nutritional risk index (mean: 72.2 ± 12.9) than those without high-risk sarcopenia. More patients with a high risk of sarcopenia underwent physiotherapy (93.5%) than those without high-risk sarcopenia (P < 0.01, all). Kaplan-Meier survival curves showed that patients with a high risk of sarcopenia had significantly lower overall survival than those without high-risk sarcopenia (log-rank test, P = 0.001). Logistic regression analysis for in-hospital mortality showed that a high risk of sarcopenia significantly affected in-hospital mortality (odds ratio [OR]: 6.425, 95% confidence interval [CI]: 1.399-47.299). In addition, logistic regression analysis for each item of SARC-F showed that assistance in walking (OR: 3.931, 95% CI: 1.816-9.617) and rising from a chair (OR: 2.458, 95% CI: 1.235-5.330) significantly affected in-hospital mortality.

CONCLUSION

A high risk of sarcopenia, as assessed using SARC-F at admission, was a risk factor for in-hospital mortality in older patients with pulmonary tuberculosis. Among the SARC-F items, assistance in walking and rising from a chair were the risk factors for in-hospital mortality.

Tuberculosis and diabetes mellitus comorbidity in an adult Ugandan population

BACKGROUND

Diabetes mellitus (DM) has a direct impact on the clinical manifestation and prognosis of active tuberculosis disease (TB) and is known to increase the chance of developing the condition. We sought to determine the prevalence of DM in adult Ugandan patients with recently diagnosed TB and the associated sociodemographic, anthropometric, and metabolic characteristics of TB-DM comorbidity.

METHODS

In this cross-sectional study conducted at the adult TB treatment centres of three tertiary healthcare facilities in Uganda, we screened adult participants with recently diagnosed TB (diagnosed in < 2 months) for DM. All participants were screened with five tests; initially with a random blood glucose (RBG) test, and then later with fasting blood glucose (FBG), laboratory-based glycated hemoglobin (HbA1c), point-of-care (POC) HbA1c, and oral glucose tolerance test (OGTT) if the RBG was ≥ 6.1 mmol/l. The WHO guidelines for diagnosing and managing DM were used to support the DM diagnosis. To identify the factors associated with DM-TB comorbidity, logistic regression was used.

RESULTS

A total of 232 participants with recently diagnosed TB were screened for DM. Of these, 160 (69%) were female. The median (IQR) age, body mass index, and RBG of all study participants was 35 (27-42) years, 19.2 (17.6-21.3) kg/m2, and 6.1 (5.5-7.2) mmol/l, respectively. About half of the participants (n = 117, 50.4%) had RBG level ≥ 6.1 mmol/l. Of these, 75 (64.1%) participants returned for re-testing. Diabetes mellitus was diagnosed in 32 participants, corresponding to a prevalence of 13.8% (95% CI 9.9-18.9). A new diagnosis of DM was noted in 29 (90.6%) participants. On logistic regression, age ≥ 40 years was associated with increased odds of TB and DM comorbidity (AOR 3.12, 95% CI 1.35-7.23, p = 0.008) while HIV coinfection was protective (AOR 0.27, 95% CI 0.10-0.74, p = 0.01).

CONCLUSION

TB and DM comorbidity was relatively common in this study population. Routine screening for DM in adult Ugandan patients with recently diagnosed TB especially among those aged ≥ 40 years and HIV-negative patients should be encouraged in clinical practice.

"As a patient I do not belong to the clinic, I belong to the community." Co-developing a multi-level, person-centred tuberculosis stigma intervention in Cape Town, South Africa

Background

Anticipated, internal, and enacted stigma are major barriers to TB care engagement, and directly impact patient well-being. Unfortunately, targeted stigma interventions are lacking. We aimed to co-develop a person-centred stigma intervention with TB-affected community members and health workers in South Africa.

Methods

Using a community-based participatory research approach, we conducted ten group discussions with people diagnosed with TB (past or present), caregivers, and health workers (total n=87) in Khayelitsha, Cape Town. Group discussions were facilitated by TB survivors. Discussion guides explored experiences and drivers of stigma and used human-centred design principles to co-develop solutions. Recordings were transcribed, coded, thematically analysed and then further interpreted using the socio-ecological model.

Results

Intervention components across socio-ecological levels shared common behaviour change strategies, namely education, empowerment, engagement, and innovation. At the individual level, participants recommended counselling to improve TB knowledge and provide ongoing support. TB survivors can guide messaging to nurture stigma resilience by highlighting that TB can affect anyone and is curable, and provide lived experiences of TB to decrease internal stigma. At the interpersonal level, support clubs and family-centred counselling were suggested to dispel TB-related myths and foster support. At the institutional level, health worker stigma reduction training informed by TB survivor perspectives was recommended. Consideration of how integration of TB/HIV care services may exacerbate TB/HIV intersectional stigma and ideas for restructured service delivery models were suggested to decrease anticipated and enacted stigma. At the community level, participants recommended awareness-raising events led by TB survivors, including TB information in school curricula. At the policy level, solutions focused on reducing the visibility generated by a TB diagnosis and resultant stigma in health facilities and shifting tasks to community health workers.

Conclusions

Decreasing TB stigma requires a multi-level approach. Co-developing a person-centred intervention with affected communities is feasible and generates stigma intervention components that are directed and implementable. Such community-informed intervention components should be prioritised by TB programs, including integrated TB/HIV care services.

Severe esophagitis induced by antituberculosis drugs: a case report

Tuberculosis stands as one of humanity's oldest afflictions, intrinsically intertwined with social disparities. This formidable disease spares no age group and remains the prevailing cause of infection-induced mortality worldwide, particularly in developing nations. We present a case of a 56-year-old woman with diabetes who was diagnosed with Pulmonary Tuberculosis. After receiving antituberculosis drugs as part of her treatment, she experienced a range of systemic manifestations and suffered from severe ulcerative esophagitis. This adverse reaction led to uncontrollable gastrointestinal intolerance, tragically resulting in her untimely demise. The incident underscores the potential seriousness of adverse reactions that can arise from tuberculosis treatment medications.

Assessment of Comorbidity in Patients with Drug-Resistant Tuberculosis

A wide range of comorbidities, especially in multidrug-resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB) patients, markedly complicates selecting effective treatment of tuberculosis (TB) and preventing the development of adverse events. At present, it is impossible to assess the severity of comorbid pathologies and develop indications for the administration of accompanying therapy in TB patients. The aim of this study was to identify the difference in the range of comorbidities between patients with MDR-TB and XDR-TB and assess the impact of comorbidities on TB treatment. Materials and Methods: A retrospective, prospective study was conducted where 307 patients with MDR-TB and XDR-TB pulmonary tuberculosis aged 18 to 75 years who received eTB treatment from 2016 to 2021 in St. Petersburg hospitals were analyzed. The analysis showed that the comorbidity level in MDR-TB and XDR-TB patients with TB treatment success and treatment failure was comparable with the use of the Charlson Comorbidity Index (CCI). The CCI demonstrated declining data in terms of TB treatment outcome period in both groups. A slight predominance of CCI score (3 to 4 points) in XDR-TB (22.7%) vs. MDR-TB (15.4%) patients was found. In the case of an TB treatment failure, the CCI level in MDR-TB vs. XDR-TB patients was characterized by a significantly higher rate of low magnitude (ranging from 1 to 2 points) in 21.1% vs. 4.5% (p < 0.05), which was higher in XDR-TB patients (ranging from 4 to 5 points, in 10.0% vs. 0, χ2 = 33.7 (p < 0.01)). Chronic viral hepatitis B and C infection, cardiovascular pathology, chronic obstructive pulmonary disease, and chronic alcoholism were found to be significant comorbidity factors that influenced the TB treatment success. Conclusions: It is evident that XDR-TB patients comprise a cohort with the most severe disease course due to comorbidities impacting TB treatment efficacy. The obtained data pointed to the need to determine comorbidity severity in patients with drug-resistant Mbt prior to administering TB treatment schemes.

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.

Effects of potentilla discolor bunge extracts on oxidative stress and glycolipid metabolism in animal models of diabetes: a systematic review and meta-analysis

Background/aim: Potentilla discolor Bunge (PDB) is an ancient herb of traditional Chinese medicine. Studies have suggested that extracts of PDB may ameliorate diabetes mellitus (DM). This study aimed to systematically assess the efficacy of PDB extracts on glycolipid metabolism and oxidative stress in animal models of diabetes and to provide evidence-based references for the use of PDB extracts. Methods: This study followed the PRISMA 2020 guidelines. Studies were searched from eight databases until January 2023. Statistical analysis was performed using StataSE 15.0 and RevMan 5.3. The standard mean difference (SMD) and 95% confidence intervals (CI) were computed using the random-effects model. SYRCLE's risk of bias tool was used to assess the risk of bias. Results: In total, 32 studies with 574 animals were included. The findings demonstrated that PDB extracts considerably lowered fasting blood glucose (SMD: -3.56, 95%CI: -4.40 to -2.72, p < 0.00001); insulin resistance (SMD: -3.19, 95% CI: -5.46 to -0.92, p = 0.006), total cholesterol (SMD: -2.18, 95%CI: -2.89 to -1.46, p < 0.00001), triglyceride (SMD: -1.48, 95% CI: -2.01 to -0.96, p < 0.00001), low-density lipoprotein cholesterol (SMD: -1.80, 95% CI: -2.58 to -1.02], p < 0.00001), malondialdehyde (SMD: -3.46, 95% CI: -4.64 to -2.29, p < 0.00001) and free fatty acid levels (SMD: -3.25, 95%CI: -5.33 to -1.16, p = 0.002), meanwhile, increased insulin sensitivity index (SMD: 2.51 95% CI: 1.10 to 3.92, p = 0.0005), body weight (SMD:1.20, 95% CI: 0.38 to 2.01, p = 0.004), and the levels of high-density lipoprotein cholesterol (SMD: 1.04, 95% CI: 0.40 to 1.69, p = 0.001), superoxide dismutase (SMD:2.63, 95% CI: 1.53 to 3.73, p < 0.00001), glutathione peroxidase (SMD:1.13, 95%CI: 0.42 to1.83, p = 0.002), and catalase (SMD:0.75, 95% CI: 0.11 to 1.40], p = 0.02). Conclusion: These findings suggest that PDB extracts can ameliorate DM by improving glycolipid metabolism and oxidative stress. PDB may be a promising medication for DM; however, due to significant heterogeneity between studies, these findings should be interpreted with caution. In addition, future well-designed trials should determine which components of the PDB play a major role in ameliorating DM and whether these benefits persist in humans. Systematic Review Registration: https://www.crd.york.ac.uk/prospero, CRD42023379391.

How can tuberculosis services better support patients with a diabetes co-morbidity? A mixed methods study in the Philippines

BACKGROUND

People with diabetes mellitus (DM) have an estimated two- to three-times greater risk of adverse tuberculosis (TB) treatment outcomes compared to those without DM. Blood glucose control is a primary aim of managing DM during TB treatment, yet TB programmes are not generally adapted to provide DM services. The purpose of this study was to understand perceptions and the lived experiences of diabetic patients in TB treatment in the Philippines, with a view to informing the development of disease co-management strategies.

METHODS

This mixed methods study was conducted within a prospective cohort of adults newly-starting treatment for drug-sensitive and drug-resistant TB at 13 public TB clinics in three regions of the Philippines. Within the subset of 189 diabetic persons who self-reported a prior DM diagnosis, or were diagnosed by screenings conducted through the TB clinic, longitudinal blood glucose data were used to ascertain individuals' glycaemic control (controlled or uncontrolled). Univariable logistic regression analyses exploring associations between uncontrolled glycaemia and demographic and clinical factors informed purposive sampling of 31 people to participate in semi-structured interviews. All audio-recorded data were transcribed and thematic analysis performed.

RESULTS

Participants - both with controlled and uncontrolled blood glucose - were knowledgeable about diabetes and its management. However, a minority of participants were aware of the impact of DM on TB treatment and outcomes. Many participants newly-diagnosed with DM at enrolment in TB treatment had not perceived any diabetic symptoms prior and would have likely not sought clinical consult otherwise. Access to free glucose-lowering medications through TB clinics was a key enabling resource. However, participants expressed fear of side effects and interrupted access to glucose-lowering medications, and a preference for phytotherapy. Many participants felt that physical and financial impacts of TB and its treatment were challenges to DM management.

CONCLUSIONS AND RECOMMENDATIONS

Results of this study indicate that public TB clinics can provide diabetic patients with additional health care resources and education to address co-morbidity. TB programmes might consider identifying patients with complicated DM, and offering diabetic monitoring and management, as DM and diabetic complications may compound the burden of TB and its treatment.

Prevalence of Latent Tuberculosis Infection and its Associated Factors Among Diabetic Patients Availing Primary Health Care in Terengganu State, Malaysia

Objectives

Diabetes mellitus (DM) patients are considered to be at high risk for contracting latent tuberculosis infection (LTBI). This study aimed to determine the prevalence of LTBI and its associated factors among diabetic patients attending primary care clinics in Terengganu state, Malaysia.

Methods

This cross-sectional study was conducted among diabetic patients attending 11 health clinics in the Terengganu region from June 2017 to November 2018. The selected participants were administered a tuberculin skin test (TST). Simple and multivariate logistic regressions were applied to evaluate the significant associated factors of LTBI.

Results

The total number of participants were 703 DM patients. The factors found associated with LTBI were poor diabetic control status (odds ratio (OR) = 8.53; p=0.008), being a healthcare worker (OR = 7.91; p=0.001), history of contact with TB patients (OR = 5.69; p < 0.001), bronchial asthma (OR = 5.28; p=0.019), coronary heart disease (OR = 3.45; p=0.026), and nephropathy (OR = 0.34; p=0.040). The presence of LTBI was found in 34 (4.8%) participants.

Conclusions

At 4.8%, the prevalence of LTBI among DM patients in Terengganu is relatively low. Diabetics with poorly controlled blood glucose levels, nephropathy, bronchial asthma, coronary heart disease, history of TB patient contact, or working in the healthcare profession should be periodically tested for LTBI.

Temporal trends in mortality of tuberculosis attributable to high fasting plasma glucose in China from 1990 to 2019: a joinpoint regression and age-period-cohort analysis

Background

Nowadays, high fasting plasma glucose (HFPG) has been identified as the important risk factor contributing to the increased burden of diseases. But there remains a lack of research on tuberculosis (TB) mortality specifically attributable to HFPG. Thus, this study aims to explore the long-term trends in HFPG-related TB mortality in China from 1990 to 2019.

Methods

Data on HFPG-related TB mortality were obtained from the Global Burden of Disease (GBD) Study 2019. Analyzing the data using joinpoint regression and age-period-cohort methods adjusting for age, period, and cohort allowed us to assess the trends in TB mortality due to HFPG.

Results

The age-standardized mortality rates (ASMRs) of TB attributable to HFPG exhibited a downward trend in China from 1990 to 2019, with an average annual percentage change (AAPC) of -7.0 (95% CI, -7.5 to -6.6). Similar trends were found for male (AAPC of -6.5 [95% CI, -7.0 to -6.0]) and female (AAPC of -8.2 [95% CI, -8.5 to -7.9]), respectively. Local drifts curve with a U-shaped pattern reflected the AAPC of TB mortality due to HFPG across age groups. The greatest decline was observed in the age group of 60-64 years. The mortality rates related to HFPG first increased and then decreased with increasing age, peaking in the 55-59 age group. Our analysis of the period and cohort effects found that the rate ratios of TB mortality due to HFPG have decreased over the past three decades, more prominently in women. It is noteworthy that while both genders have seen a decline in HFPG-attributable TB mortality and risk, men have a higher risk and slightly less significant decline than women.

Conclusion

The present study shows that HFPG-related ASMRs and risk of TB in China decreased over the last 30 years, with similar trends observed in both men and women. In order to attain the recommended level set by the WHO, the effective strategies for glycemic control and management still needed to be implemented strictly to further decrease the burden of TB.

Innovative Integrated Motivational Interviewing for Dual Management in Tuberculosis Patients with Diabetes (MID-DOT) in Malaysia

(1) Background: Achieving successful tuberculosis (TB) treatment outcomes among diabetic patients is a real challenge as TB complicates control of diabetes. This study aimed to evaluate the effectiveness of an integrated dual management educational module, MID-DOTS, which uses the mmotivational interviewing (MI) technique implemented within directly observed treatment as part of a short course (DOTS) program in TB patients with diabetes (TB/DM). A randomized controlled trial was conducted in the northeastern state of Malaysia. (2) Methods: One hundred and twenty-four TB patients with diabetes received educational intervention using a MID-DOT module that used the MI technique, which was repetitively applied by TB nurses throughout a 6-month DOTS program while another 122 patients were given standard health education. Study outcomes include the proportion of patients with successful TB treatment, and changes in HbA1c and diabetic self-care scores at 6 months. (3) Results: The successful TB treatment outcome was 88% in the intervention group versus 72% in the control group (RR = 1.24; 95%CI 1.16, 1.58). A significant reduction of HbA1c (mean difference 0.82%; 95%CI 0.66, 0.98) and significantly higher diabetes self-care score (mean difference 8.49; 95%CI 7.38, 9.59) were also shown in the intervention group. (4) Conclusions: A dual TB/DM educational strategy which integrates the MI technique applied repetitively within the DOTS program is effective in increasing successful TB treatment as well as improving diabetic outcomes.

Clinical standards for the management of adverse effects during treatment for TB

BACKGROUND: Adverse effects (AE) to TB treatment cause morbidity, mortality and treatment interruption. The aim of these clinical standards is to encourage best practise for the diagnosis and management of AE.METHODS: 65/81 invited experts participated in a Delphi process using a 5-point Likert scale to score draft standards.RESULTS: We identified eight clinical standards. Each person commencing treatment for TB should: Standard 1, be counselled regarding AE before and during treatment; Standard 2, be evaluated for factors that might increase AE risk with regular review to actively identify and manage these; Standard 3, when AE occur, carefully assessed and possible allergic or hypersensitivity reactions considered; Standard 4, receive appropriate care to minimise morbidity and mortality associated with AE; Standard 5, be restarted on TB drugs after a serious AE according to a standardised protocol that includes active drug safety monitoring. In addition: Standard 6, healthcare workers should be trained on AE including how to counsel people undertaking TB treatment, as well as active AE monitoring and management; Standard 7, there should be active AE monitoring and reporting for all new TB drugs and regimens; and Standard 8, knowledge gaps identified from active AE monitoring should be systematically addressed through clinical research.CONCLUSION: These standards provide a person-centred, consensus-based approach to minimise the impact of AE during TB treatment.

Diabetes mellitus is associated with an increased risk of unsuccessful treatment outcomes among drug-susceptible tuberculosis patients in Ethiopia: A prospective health facility-based study

Background

The impact of diabetes mellitus on tuberculosis (TB) treatment outcomes has not been well investigated in most sub-Saharan countries including Ethiopia. The current study aimed to determine the association between diabetes mellitus and unsuccessful TB treatment outcomes among drug-susceptible TB patients treated at selected health facilities in Addis Ababa, Ethiopia.

Methods

This health facility-based prospective cohort study was conducted at six randomly selected public health centers in Addis Ababa, from August 2020 until November 2021. Clinically diagnosed adult pulmonary and extra pulmonary TB patients were recruited at the time of treatment initiation. A multivariable logistic regression analysis was used to estimate the association between diabetes and unsuccessful TB treatment outcomes.

Results

Among the total 267 enrolled participants, 9.7% of patients with TB were identified to have diabetes comorbidity. Of patients with diabetes and TB, 9 (34.6%) were newly diagnosed based on glucose test results. Despite an overall high TB treatment success rate (94.0%), more than one-fourth (26.9%) of patients with diabetes had a poor TB treatment outcome (26.9%), which was remarkably higher compared to patients without diabetes (3.7%). In multivariable regression, the adjusted odds of poor TB treatment outcome among those with diabetes was 14.8 (95% CI 3.5 - 62.7) times the odds of poor outcome patients without diabetes.

Conclusion

Diabetes was significantly associated with increased odds of poor TB treatment outcomes among patients in Addis Ababa, Ethiopia.

Insight on Infections in Diabetic Setting

The correlation between diabetes mellitus and infectious diseases is widely recognized. DM patients are characterized by the impaired function of the immune system. This translates into the occurrence of a variety of infections, including urinary tract, skin and surgical site infections, pneumonia, tuberculosis, and, more recently, SARS-CoV-2. Hyperglycemia has been identified as a relevant factor contributing to unfavorable outcomes in hospitalized patients including SARS-CoV-2 patients. Several studies have been performed proving that to maintain the proper and stringent monitoring of glycemia, a balanced diet and physical activity is mandatory to reduce the risk of infections and their associated complications. This review is focused on the mechanisms accounting for the increased susceptibility of DM patients to infections, with particular attention to the impact of newly introduced hypoglycemic drugs in sepsis management.

Longitudinal trends in glycated hemoglobin during and after tuberculosis treatment

AIMS

To investigate the impact of pulmonary TB on glycemic status during and after TB treatment, and associations of glycemic trends with antidiabetic therapy and TB outcomes.

METHODS

Data from two prospective cohort studies of adults in Chennai, India, with pulmonary TB were combined for this analysis. Participants were classified by baseline hemoglobin A1_c (A1C) as having normoglycemia (NG; n = 74), prediabetes (pre-DM; n = 110), or diabetes (DM; n = 244). Repeat A1C measurements were performed at TB treatment months 3 and 6, and then 6 and 12 months after TB treatment completion.

RESULTS

Median A1C at baseline declined after TB treatment initiation in all groups. No baseline NG or pre-DM participants progressed to DM by end of study, while 16.7% of baseline DM participants shifted to pre-DM or NG levels of A1C. In the baseline DM group, rising A1C after the intensive phase of TB treatment was significantly associated with adverse TB outcomes.

CONCLUSIONS

Incident TB promotes transient glucose elevation but was not conclusively shown to promote chronic dysglycemia. Rising A1C during and after TB treatment may predict unfavorable treatment response in persons presenting with A1C ≥ 6.5 % at the time of TB diagnosis.

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

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

A sequential explanatory mixed-methods study on costs incurred by patients with tuberculosis comorbid with diabetes in Bhavnagar, western India

Diabetes is one of the commonest morbidity among patients with tuberculosis (TB). We conducted this study to estimate the costs incurred by patients with TB comorbid with diabetes and to explore the perspectives of program managers as well as patients on the reasons and solutions for the costs incurred due to TB-diabetes. We conducted a descriptive cross-sectional study to estimate costs among 304 patients with TB-diabetes comorbidity registered in the public health system during 2017-2020 in the Bhavnagar region of western India, which was followed by in-depth interviews among program functionaries and patients to explore solutions for reducing the costs. Costs, when exceeded 20% of annual household income, were defined as catastrophic as this cut-off was most significantly related to adverse TB outcomes. Among the 304 patients with TB-diabetes comorbidity, 72% were male and the median (interquartile IQR) monthly family income was Indian rupees (INR) 9000 (8000-11,000) [~ US$ 132 (118-162)]. The median (IQR) total costs due to combined TB-diabetes were INR 1314 (788-3170) [~ US$ 19 (12-47)], while that due to TB were INR 618 (378-1933) [~ US$ 9 (6-28)]. Catastrophic costs due to TB were 4%, which increased to 5% on adding the costs due to diabetes. Health system strengthening, an increase in cash assistance, and other benefits such as a nutritious food kit were suggested for reducing the costs incurred. We conclude that, in addition to a marginal increase in the percentage of catastrophic costs, co-existent diabetes nearly doubled the median total costs incurred among patients with TB. Strengthening the TB-diabetes bi-directional activities, tailoring the cash transfer scheme for comorbid patients, and making the common two-drug combination diabetes tablets available at government drug stores would help TB-diabetes comorbid patients cope with the costs of care.

Diagnostic accuracy of two confirmatory tests for diabetes mellitus in adult Ugandans with recently diagnosed tuberculosis

Objective

The optimal confirmatory tests for diabetes mellitus (DM) in patients with tuberculosis (TB) vary across populations. This study aimed to evaluate the performance of two confirmatory tests for DM against the oral glucose tolerance test (OGTT) as the reference test in adult Ugandans with recently diagnosed TB.

Methods

A total of 232 adult participants receiving TB treatment underwent initial screening for DM with random blood glucose (RBG) measurement. Participants with a RBG level ⩾6.1 mmol/l received additional screening with fasting blood glucose (FBG), laboratory-measured glycated haemoglobin (HbA1c) and an OGTT. Using the latter as the gold standard and reference test, we evaluated the diagnostic accuracy of laboratory-measured HbA1c and FBG.

Results

Of the 232 participants initially screened for DM using RBG measurement, 117 participants (50.4%) had RBG level ⩾6.1 mmol/l and were scheduled to return for additional blood glucose testing. Of these, 75 (64.1%) participants returned for FBG and HbA1c measurements. A diagnosis of DM was made in 32 participants, corresponding to a prevalence of 13.8% [95% CI 9.9-18.9].The areas under the curve (AUC) for FBG and laboratory-measured HbA1c were 0.69 [95% CI 0.47-0.90] and 0.65 [95% CI 0.43-0.87], respectively. The sensitivity and specificity of a FBG level of ⩾7 mmol/l were 57.1% [95% CI 18.4-90.1] and 74.6% [95% CI 62.5-84.5], respectively, whereas the sensitivity and specificity for laboratory-measured HbA1c of ⩾6.5 mmol/l (48 mmol/mol) were 14.3% [95% CI 0.40-57.9] and 95.3% (86.9-99.0%), respectively.

Conclusion

FBG may be better than laboratory-measured HbA1c in confirming DM in adult Ugandans with recently diagnosed TB. However, because of the small study sample size, larger studies evaluating the diagnostic utility of these diabetes screening tests in adult Ugandans with TB are needed to confirm these findings.

dos Santos Lara1,3 C, Amorim4 G, C. Silva1,5,6,7 E, Lineu Kritski1 A, Cristina C. Carvalho1,2 A. Clinical, laboratory, and radiographic aspects of patients with pulmonary tuberculosis and dysglycemia and tuberculosis treatment outcomes

Objective: To analyze the association of dysglycemia with clinical, laboratory, and radiographic characteristics of patients with pulmonary tuberculosis (PTB), as well as with their tuberculo-sis treatment outcomes. Methods: This was a longitudinal study involving 140 patients diag-nosed with PTB (positive cultures for Mycobacterium tuberculosis or positive Xpert MTB/RIF results from sputum samples). Patients were evaluated at diagnosis (M0), after completing the second month of treatment (M2), and at the end of treatment (MEND). At M0, the pati-ents were classified into three groups: normoglycemia+PTB (NGTB); pre-diabetes melli-tus+PTB (PDMTB), and diabetes mellitus+PTB (DMTB), in accordance with glycated hemoglo-bin levels (< 5.7%, 5.7%-6.4%, and = 6.5%, respectively). Treatment outcomes were classified as favorable (cure or treatment completion) and unfavorable (death, loss to follow-up, or treatment failure). Results: In our sample, 76 patients (61.4%) had dysglycemia, 20 of whom (14.3%) had DM at M0. The patients with dysglycemia, in comparison with those in the NGTB group, more frequently presented with positive sputum smear microscopy (94.2% vs. 75.9%; p = 0.003); cavities (80.2% vs. 63.0%; p = 0.03); bilateral lesions (67.4% vs. 46.0%; p = 0.02); and higher median of affected thirds of the lungs (3.0 vs. 2.0; p = 0.03) on chest radiography. No significant differences regarding outcomes were found among the groups, but tuberculosis lethality was higher in the DMTB group than in the PDMTB and NGTB groups (20% vs. 2.2%). Conclusions: PTB patients with dysglycemia had laboratory and radiographic manifestations indicative of more advanced disease, and the risk of death was higher in the DMTB group. These findings reinforce the recommendation for early screening for DM in patients with newly diagnosed tuberculosis in order to reduce the risk of death during treatment.

Clinical standards for the dosing and management of TB drugs

BACKGROUND: Optimal drug dosing is important to ensure adequate response to treatment, prevent development of drug resistance and reduce drug toxicity. The aim of these clinical standards is to provide guidance on 'best practice´ for dosing and management of TB drugs.METHODS: A panel of 57 global experts in the fields of microbiology, pharmacology and TB care were identified; 51 participated in a Delphi process. A 5-point Likert scale was used to score draft standards. The final document represents the broad consensus and was approved by all participants.RESULTS: Six clinical standards were defined: Standard 1, defining the most appropriate initial dose for TB treatment; Standard 2, identifying patients who may be at risk of sub-optimal drug exposure; Standard 3, identifying patients at risk of developing drug-related toxicity and how best to manage this risk; Standard 4, identifying patients who can benefit from therapeutic drug monitoring (TDM); Standard 5, highlighting education and counselling that should be provided to people initiating TB treatment; and Standard 6, providing essential education for healthcare professionals. In addition, consensus research priorities were identified.CONCLUSION: This is the first consensus-based Clinical Standards for the dosing and management of TB drugs to guide clinicians and programme managers in planning and implementation of locally appropriate measures for optimal person-centred treatment to improve patient care.

The co-management of tuberculosis-diabetes co-morbidities in Indonesia under the National Tuberculosis Control Program: results from a cross-sectional study from 2017 to 2019

Background

Indonesia suffers from a high burden of tuberculosis (TB) and diabetes (DM). The government initiated national TB-DM co-management activities under the National TB Control Program in 2017. This study investigates the detection and treatment outcomes of TB-DM in Jakarta after implementing these activities, and identifies the main factors associated with these outcomes.

Methods

A cross-sectional study was conducted using TB registry data in two districts of Jakarta, East Jakarta (low-income) and South Jakarta (high-income). A 5-step cascade analysis was used: diagnosed TB patients; TB patients tested for DM; diagnosed TB-DM patients; and patients received and completed TB treatment/cured. We conducted descriptive analyses to understand the characteristics of TB and TB-DM patients, and used a two-level mixed-effect logistic regression to explore factors associated with having a DM test and completing TB treatment/being cured.

Results

Over the study period (2017–2019) 50.8% of the new pulmonary TB patients aged over 15 were tested for DM. The percentage increased from 41.7% in 2017–2018 to 60.1% in 2019. Of the TB patients tested for DM, 20.8% were diagnosed with DM. Over 90% of the detected TB-DM patients received standard TB treatment, 86.3% of whom completed treatment/were cured. Patients in East Jakarta were more likely to be tested for DM and to complete standard TB treatment/be cured than patients in South Jakarta (P <  0.001). Bacteriologically positive TB patients were more likely to be tested for DM (OR = 1.37, 95% CIs 1.17,1.60). Patients diagnosed in sub-district level healthcare centers had a higher likelihood of being tested for DM than those in government and private hospitals (P <  0.05). Receiving DM treatment was associated with a higher likelihood of completing TB treatment/being cured (OR = 1.82, 95% CIs 1.20, 2.77).

Conclusions

TB-DM case detection significantly improved in 2019 after introducing TB-DM co-management activities in Jakarta, while gaps in TB-DM co-management existed between bacteriologically positive and clinically diagnosed TB patients, and across different types of health facilities. Collaboration between TB and DM departments should be strengthened, and more resources need to be mobilized to further improve the co-management of TB-DM in Indonesia.

Diabetes mellitus and its associated factors among patients with tuberculosis attending directly observed treatment centres in Oyo State, Nigeria: a cross-sectional evaluation

OBJECTIVE

Diabetes mellitus (DM) and tuberculosis (TB) comorbidity is evolving into an emerging epidemic globally. In Nigeria, a high burden of both diseases, respectively, exists with limited information on tuberculosis-diabetes mellitus (TB-DM) comorbidity. We determined the fasting blood glucose (FBG) level among patients with TB and factors associated with TB-DM comorbidity in Oyo State, South-west Nigeria.

METHODS

A cross-sectional study was conducted among patients with TB aged 15 years and above, who were selected using multistage sampling. Data were collected on patients' biodata, anthropometric measurements and FBG levels using a pretested semistructured questionnaire. The FBG test was conducted on patients with confirmed pulmonary TB (old and newly diagnosed patients with TB) at any stage of anti-TB treatment. Background characteristics and FBG level were summarised using descriptive statistics and factors associated with TB-DM comorbidity were examined at bivariate and multivariable analyses.

RESULTS

Of the 404 patients with TB, 30 (7.4%) had impaired fasting glucose and 32 (7.9%) were diagnosed with diabetes. The mean age of the male and female respondents was 41 (±14.2) and 36.8 (±15.0), respectively. Females were more likely than males to have diabetes (10.6% vs 6.3%). Median FBG level for the patients was 88 (IQR: Q1: 99, Q3: 79) mg/dL. Age, marital status and educational level were not associated with TB-DM comorbidity. In the multivariable model, only normal body mass index was independently and significantly associated with diabetes.

CONCLUSION

TB-DM was prevalent among the studied population in South-west Nigeria. We recommend the integration of DM screening within the continuum of care for TB management.

Factors associated with treatment outcome of MDR/RR-TB patients treated with shorter injectable based regimen in West Java Indonesia

Background and aims

Multi drug or rifampicin resistant tuberculosis (MDR/RR-TB) is a major burden to TB prevention and eradication globally. Since 2016, WHO guidelines have included options for treating MDR/RR-TB with a standard regimen of 9 to 11 months duration (the ’shorter regimen’) rather than an individual regimen of at least 20 months. This regimen has been introduced in Indonesia since September 2017. Therefore, we aimed to determine the success rate and factors associated with the treatment outcome of shorter injectable based regimen in West Java province, Indonesia.

Methods

This was a retrospective cohort study of MDR/RR-TB patients aged over 18 years old who received the shorter injectable based regimen between September 2017 and December 2020. We defined successful outcomes as the combined proportion of patients who were cured or had complete treatment. While, unsuccessful outcomes were defined as the combined proportion of patients who died from any causes, failure, and loss to follow-up (LTFU).

Results

A total of 315 patients were included in this study. The success rate was 64.5%. Multivariate analysis showed male gender (aRR = 1.18, 95% CI 1.04 to 1.34) increased the chance of successful outcome, while malnutrition (aRR = 0.78, 95% CI 0.68 to 0.89), history of previous TB treatment (aRR = 0.80%CI 0.68 to 0.94), and time of culture conversion >2 months (aRR = 0.72 (95% CI 0.59 to 0.87) decreased the chance of successful outcome.

Conclusion

History of previous TB treatment, time of culture conversion >2 months, and malnutrition were independent factors that decrease the chance for success rate, while male gender increase the likelihood for success rate of patients treated by the shorter injectable based regimen.

The impact of diabetes mellitus on the pharmacokinetics of rifampicin among tuberculosis patients: A systematic review and meta-analysis study

BACKGROUND AND AIMS

Diabetes mellitus has a negative impact on the treatment outcome of tuberculosis, increasing the incidence of treatment failure and relapse. There is a scarcity of knowledge concerning the impact of diabetes mellitus on the pharmacokinetics of rifampicin. This study was conducted to evaluate the impact of diabetes mellitus on the pharmacokinetics of rifampicin among patients with tuberculosis.

METHODS

We explored the Web of Science, Cochrane Library, PubMed, and Scopus databases for articles that reported the pharmacokinetic parameters of rifampicin in diabetic and nondiabetic patients with tuberculosis published until September 2020. Based on the presence or absence of heterogeneity, pooled estimates were calculated using a random or fixed effect model.

RESULTS

Seven studies were relevant and included in this study. The Tmax of rifampicin increased in diabetic patients with tuberculosis compared with nondiabetic patients with tuberculosis (MD 0.84, 95% CI (0.32, 1.35), p = 0.002). No significant differences were detected in rifampicin Cmax (MD 0.18, 95% CI (-0.52, 0.88), p = 0.61), AUC0-24 (SMD -0.02, 95% CI (-0.34, 0.30), p = 0.90), Vd (MD -3.89, 95% CI (-11.17, 3.38), p = 0.29), CL (MD -0.13, 95%CI (-0.88, 0.61), p = 0.72), and MRT (MD 1.89, 95% CI (-0.03, 3.81), p = 0.05) between diabetic and nondiabetic patients with tuberculosis.

CONCLUSION

Diabetes mellitus increased the Tmax of rifampicin without further impact on other rifampicin pharmacokinetic parameters such as Cmax, AUC0-24, Vd, CL and MRT. Early therapeutic drug monitoring of rifampicin is necessary for diabetic tuberculosis patients.

Yield, NNS and prevalence of screening for DM and hypertension among pulmonary tuberculosis index cases and contacts through single time screening: A contact tracing-based study

INTRODUCTION

Diabetes mellitus (DM), hypertension and pulmonary tuberculosis (PTB) are catastrophic illnesses that collectively lead to increased mortality and premature death. However, the size of the problem and the appropriate approach to deal with the burden is still unclear. We aimed to evaluate the yield, number needed to screen (NNS) to prevent one death or adverse event for screening DM and hypertension and assess the prevalence and contributors to DM and/or hypertension.

METHODS

Based on PTB contact tracing, a cross-sectional study was conducted among 801 PTB index cases and 972 household contacts from April 2019 to October 2020 in Guizhou, China. All the participants were screened for DM and hypertension. The yield was calculated as the proportion of newly detected cases among the study subjects, excluding known cases. The NNS was computed by dividing the number needed to treat for risk factors by the prevalence of the unrecognized diseases. The univariate and multivariate logistic regression analyses were applied to determine the independent predictors of DM and/or hypertension.

RESULTS

Of the 1,773 participants, the prevalence of DM and hypertension was 8.7% (70/801) and 15.2% (122/801) in the PTB patients, 3.2% (31/972) and 14.0% (136/972) in the contacts, respectively. The prevalence of DM and/or hypertension was 21.2% (170/801) among the PTB patients and 15.4% (150/972) among their contacts. The screening yields to detect new cases of DM and hypertension among PTB patients were 1.9% and 5.2%, and that in the contacts were 0.8% and 4.8%, respectively. The NNS for DM was 359 for the PTB cases and 977 for the contacts, 299 for PTB cases and 325 for hypertension, respectively. Older age, under or overweight and obesity, family history hypertension and earlier diagnosis of other chronic conditions were the independent predictors for DM and/or hypertension among both PTB cases and their contacts.

CONCLUSION

Screening for DM and hypertension should be mandated in PTB patients and their household contacts to disclose undetected cases of these two conditions during TB contact tracing, which might reduce the potential cardiovascular disease deaths.

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.

Educational counselling of patients with combined TB and diabetes mellitus: a randomised trial

SETTING

Newly diagnosed pulmonary TB with diabetes mellitus (DM) comorbidity attending clinics in Bandung City, Indonesia.

OBJECTIVE

To describe the effect of educational counselling on patients' knowledge about TB (transmission, treatment, risk factors) and DM (symptoms, treatment, complications, healthy lifestyle), adherence to medication, and to assess characteristics associated with knowledge.

DESIGN

All patients received counselling and were then randomised to either structured education on TB-DM, combined with clinical monitoring and medication adjustment (intervention arm), or routine care (control arm). Knowledge and adherence were assessed using a questionnaire.

RESULTS

Baseline and 6-month questionnaires were available for 108 of 150 patients randomised (60/76 in the intervention arm and 48/74 in the control arm). Patients knew less about DM than about TB. There was no significant difference in the proportion with knowledge improvement at 6 months, both for TB (difference of differences 14%; P = 0.20) or for DM (10%; P = 0.39) between arms. Intervention arm patients were more likely to adhere to taking DM medication, with fewer patients reporting ever missing oral DM drugs than those in the control arm (23% vs. 48%; P = 0.03). Higher education level was associated with good knowledge of both TB and DM.

CONCLUSIONS

Structured education did not clearly improve patients' knowledge. It was associated with better adherence to DM medication, but this could not be attributed to education alone. More efforts are needed to improve patients' knowledge, especially regarding DM.

Randomized trial of Metformin with Anti-tuberculosis drugs For Early Sputum Conversion in Adults with Pulmonary Tuberculosis

Background

Metformin, by reducing intracellular Mycobacterium tuberculosis growth, can be considered an adjunctive therapy to anti-tuberculosis treatment (ATT). We determined whether metformin with standard ATT reduces time to sputum culture conversion and tissue inflammation in adults with pulmonary tuberculosis (PTB).

Methods

In a randomized, 8-week, clinical trial, newly diagnosed, culture-positive PTB patients were randomized to standard ATT (HREZ = control arm) or standard ATT plus daily 1000 mg metformin (MET-HREZ = Metformin with Rifampicin [METRIF] arm) for 8 weeks during 2018–2020 at 5 sites in India. The primary end point was time to sputum culture conversion by liquid culture during 8 weeks of ATT. Plasma inflammatory markers were estimated in a subset. A Cox proportional hazard model was used to estimate time and predictors of culture conversion.

Results

Of the 322 patients randomized, 239 (74%) were male, and 212 (66%) had bilateral disease on chest radiograph with 54 (18%) showing cavitation. The median time to sputum culture conversion by liquid culture was 42 days in the METRIF arm and 41 days in the control arm (hazard ratio, 0.8; 95% confidence interval [CI], .624–1.019). After 8 weeks of ATT, cavitary lesions on X-ray (7, 5.3% vs 18, 12.9%; relative risk, 0.42; 95% CI, .18–.96; P = .041) and inflammatory markers were significantly lower in the METRIF arm. Higher body mass index and lower sputum smear grading were associated with faster sputum culture conversion.

Conclusions

The addition of metformin to standard ATT did not hasten sputum culture conversion but diminished excess inflammation, thus reducing lung tissue damage as seen by faster clearance on X-ray and reduced inflammatory markers.

Clinical Trials Registration

Clinical Trial Registry of India (CTRI/2018/01/011176)

Reactivation of latent tuberculosis through modulation of resuscitation promoting factors by diabetes

The evidence of an association between diabetes and latent tuberculosis infection (LTBI) remains limited and inconsistent. Thus, the study aims to delineate the role of diabetes in activation of latent tuberculosis infection. Murine model of latent tuberculosis and diabetes was developed, bacillary load and gene expression of resuscitation promoting factors (rpfA-E) along with histopathological changes in the lungs and spleen were studied. Treatment for LTBI [Rifampicin (RIF) + Isoniazid (INH)] was also given to latently infected mice with or without diabetes for 4 weeks. Diabetes was found to activate latent tuberculosis as the colony forming unit (CFU) counts were observed to be > 10⁴ in lungs and spleen. The gene expression of hspX was downregulated and that of rpfB and rpfD was observed to be upregulated in latently infected mice with diabetes compared to those without diabetes. However, no significant reduction in the CFU counts was observed after 4 weeks of treatment with RIF and INH. Diabetes helps in the progression of LTBI to active disease mainly through altered expression of resuscitation promoting factors rpfB and rpfD, which can serve as important targets to reduce the shared burden of tuberculosis and diabetes.

Readiness of healthcare facilities with tuberculosis services to manage diabetes mellitus in Tanzania: A nationwide analysis for evidence-informed policy-making in high burden settings

Introduction

Double disease burden such as Tuberculosis and Diabetes mellitus comorbidity is evident and on rising especially in high burden settings such as Tanzania. There is limited information about the availability of tuberculosis/diabetes integrated healthcare services in Tanzania. Therefore, this study explored the availability and examined the readiness of healthcare facilities with tuberculosis services to manage diabetes mellitus in Tanzania.

Methods

We abstracted data from the 2014–2015 Tanzania Service Provision Assessment Survey datasets. The service availability was assessed by calculating the proportion of tuberculosis facilities reported to manage diabetes mellitus. There were four domains; each domain with some indicators for calculating the readiness index. High readiness was considered if the tuberculosis facilities scored at least half (≥50%) of the indicators listed in each of the four domains (staff training and guideline, diagnostics, equipment, and medicines) as is recommended by the World Health Organization-Service Availability and Readiness Assessment manual while low readiness for otherwise.

Results

Out of 341 healthcare facilities with tuberculosis services included in the current study, 238 (70.0%) reported providing management for diabetes mellitus. The majority of the facilities were dispensaries and clinics 48.1%; publicly owned 72.6%; and located in rural 62.6%. Overall, the readiness of tuberculosis facilities to manage diabetes was low (10.8%). Similarly, the readiness was low based on the domain-specific readiness of trained staff and guidelines.

Conclusion

Although the majority of the healthcare facilities with tuberculosis services had diabetes mellitus services the overall readiness was low. This finding provides a piece of evidence to inform the policymakers in high burden and low resource countries to strengthen the co-management of tuberculosis and diabetes.

Screening diabetes mellitus patients for pulmonary tuberculosis: a multisite study in Indonesia, Peru, Romania and South Africa

BACKGROUND

Diabetes mellitus (DM) patients are three times more likely to develop tuberculosis (TB) than the general population. Active TB screening in people with DM is part of a bidirectional approach. The aim of this study was to conduct pragmatic active TB screening among DM patients in four countries to inform policy.

METHODS

DM patients were recruited in Indonesia (n=809), Peru (n=600), Romania (n=603) and South Africa (n=51). TB cases were diagnosed using an algorithm including clinical symptoms and chest X-ray. Presumptive TB patients were examined with sputum smear and culture.

RESULTS

A total of 171 (8.3%) individuals reported ever having had TB (South Africa, 26%; Indonesia, 12%; Peru, 7%; Romania, 4%), 15 of whom were already on TB treatment. Overall, 14 (0.73% [95% confidence interval 0.40 to 1.23]) TB cases were identified from screening. Poor glucose control, smoking, lower body mass index, education and socio-economic status were associated with newly diagnosed/current TB. Thirteen of the 14 TB cases diagnosed from this screening would have been found using a symptom-based approach.

CONCLUSIONS

These data support the World Health Organization recommendation for routine symptom-based screening for TB in known DM patients in high TB-burden countries. DM patients with any symptoms consistent with TB should be investigated and diagnostic tools should be easily accessible.

Nutrition Assessment and Adverse Outcomes in Hospitalized Patients with Tuberculosis

Background: Malnutrition in patients with tuberculosis (TB) is associated with poor outcomes. This study assessed the validity of the patient-generated subjective global assessment (PG-SGA) in adult TB patients and examined the association of the PG-SGA score with adverse outcomes. Methods: This is a retrospective chart review study compared with the well-nourished and malnourished TB patients. The nutritional status was determined using the PG-SGA for adult patients (n = 128). Clinical outcomes included liver injury and mortality. Adverse outcomes included hepatitis during anti-tuberculosis therapy. Results: By comparing nutritional status using global assessment, well-nourished patients had a significantly higher body weight index (p = 0.002), a lower PG-SGA score (p < 0.001), and lower diabetic rate (p = 0.029). Malnourishment was a risk factor (p = 0.022) for liver injury and fatal outcomes (p < 0.001). A higher PG-SGA score was a risk factor for liver injury (p = 0.002) and an independent risk factor for fatal outcomes (p = 0.031). ROC analysis for outcome prediction showed that a PG-SGA score of 5.5 points yielded the most appropriate sensitivity (61.5%) and specificity (64.7%). Conclusion: Both global assessment and the total PG-SGA score were related to tuberculosis outcome and liver injury during anti-TB treatment.

Exploring the mechanisms of collaboration between the Tuberculosis and Diabetes Programs for the control of TB-DM Comorbidity in Ghana

OBJECTIVES

To explore the mechanisms of collaboration between the stakeholders, including National Tuberculosis Control Program (NTP) and the Non-Communicable Disease Control and Prevention Program (NCDCP) at the national, regional, and local (health facility) levels of the health care system in Ghana. This is one of the objectives in a study on the "Barriers and Facilitators to the Implementation of the Collaborative Framework for the Care and Control of Tuberculosis and Diabetes in Ghana" RESULTS: The data analysis revealed 4 key themes. These were (1) Increased support for communicable diseases (CDs) compared to stagnant support for non-communicable diseases (NCDs), (2) Donor support, (3) Poor collaboration between NTP and NCDCP, and (4) Low Tuberculosis-Diabetes Mellitus (TB-DM) case detection.

Application of responsibility-based nursing in patients with both DM and PTB

OBJECTIVE

To evaluate the application value of responsibility-based nursing intervention in the nursing of patients with both diabetes mellitus (DM) and pulmonary tuberculosis (PTB).

METHODS

A total of 180 patients with both DM and PTB admitted to our hospital from April 2019 to April 2020 were enrolled as research objects, of which 86 patients were under routine nursing intervention as a regular group (Reg group) and other 94 patients were under responsibility-based nursing intervention as a responsibility group (Res group). The unhealthy emotion, treatment compliance, self-efficacy, self-care ability, and life quality of both groups were evaluated after nursing intervention, and they were compared in blood glucose level and PTB treatment outcome.

RESULTS

After intervention, the Res group got lower self-rating anxiety scale (SAS) and self-rating depression scale (SDS) scores than the Reg group (both P<0.05). The Res group also got higher scores of self-efficacy, self-care ability, and life quality, and showed significantly higher treatment compliance rate and nursing satisfaction than the Reg group after intervention (all P<0.05). Additionally, after intervention, the Res group got higher scores of life quality than the Reg group (all P<0.05). The levels of fasting blood glucose (FBG), 2 hour postprandial blood glucose (2h PG), and glycosylated hemoglobin (HbA1c) in the Res group were lower than those in the Reg group, and the cavity closure rate, sputum negative conversion rate, and focus absorption rate of the Res group were all significantly higher than those of the Reg group (all P<0.05).

CONCLUSION

Responsibility-based nursing intervention can improve the treatment compliance, self-management ability, self-efficacy, and life quality of patients with both DM and PTB.

Protocol for establishing an Adaptive Diseases control Expert Programme in Tanzania (ADEPT) for integrating care of communicable and non-communicable diseases using tuberculosis and diabetes as a case study

INTRODUCTION

Most sub-Saharan African countries endure a high burden of communicable infections but also face a rise of non-communicable diseases (NCDs). Interventions targeting particular epidemics are often executed within vertical programmes. We establish an Adaptive Diseases control Expert Programme in Tanzania (ADEPT) model with three domains; stepwise training approach, integration of communicable and NCDs and a learning system. The model aims to shift traditional vertical programmes to an adaptive diseases management approach through integrating communicable and NCDs using the tuberculosis (TB) and diabetes mellitus (DM) dual epidemic as a case study. We aim to describe the ADEPT protocol with underpinned implementation and operational research on TB/DM.

METHODS AND ANALYSIS

The model implement a collaborative TB and DM services protocol as endorsed by WHO in Tanzania. Evaluation of the process and outcomes will follow the logic framework. A mixed research design with both qualitative and quantitative approaches will be used in applied research action. Anticipated implementation research outcomes include at the health facilities level for organising TB/DM services, pathways of patients with TB/DM seeking care in different health facilities, factors in service delivery that need deimplementation and the ADEPT model implementation feasibility, acceptability and fidelity. Expected operational research outcomes include additional identified patients with dual TB/DM, the prevalence of comorbidities like hypertension in patients with TB/DM and final treatment outcomes of TB/DM including treatment-related complications. Findings will inform the future policies and practices for integrating communicable and NCDs services.

ETHICS AND DISSEMINATION

Ethical approval was granted by The National Research Health Ethical Committee (Ref-No. NIMR/HQ/R.8a/Vol.IX/2988) and the implementation endorsed by the government authorities. Findings will be proactively disseminated through multiple mechanisms including peer-reviewed journals, and engagement with various stakeholders' example in conferences and social media.

Adjunctive vitamin A and D for the glycaemic control in patients with concurrent type 2 diabetes and tuberculosis: a randomised controlled trial

The objective of this study is to investigate the effects of vitamin A, D and their interaction on the glycaemic control in patients with both diabetes and tuberculosis. Tuberculosis infection and its treatment induce hyperglycaemia and complicate the glycaemic control in patients with diabetes. A randomised controlled trial with a 2 × 2 factorial design was conducted in a tuberculosis-specialised hospital in Qingdao, China. A total of 279 patients who have both diabetes and tuberculosis were included in this analysis. The patients received standard anti-tuberculosis treatment alone (control group), or together with a dose of vitamin A (600 μg RAE/d) or vitamin D (10 μg/d) or a combination of vitamin A (600 μg RAE/d) and vitamin D (10 μg/d) for 2 months. The effects of the intervention on fasting plasma glucose and 2-h postprandial blood glucose were investigated by ANCOVA. The analysis was adjusted for baseline values, age, sex, smoking, drinking and antidiabetic treatment as covariates. No significant effect was observed for vitamin A and D supplementation on fasting plasma glucose, 2-h postprandial blood glucose, BMI and related blood parameters. No interaction was observed between vitamin A and D supplementation for these endpoints. Vitamin A and D supplementation showed a null effect on the glycaemic control for patients with concurrent diabetes and tuberculosis. Future work should evaluate the effect of vitamin A and D supplementation on insulin-related indices for these patients and investigate the effect of vitamin D receptor genotypes.

Artificial neural network to predict the effect of obesity on the risk of tuberculosis infection

BACKGROUND

Body weight has been implicated as a risk factor for latent tuberculosis infection (LTBI) and the active disease.

DESIGN AND METHODS

This study aimed to develop artificial neural network (ANN) models for predicting LTBI from body weight and other host-related disease risk factors. We used datasets from participants of the US-National Health and Nutrition Examination Survey (NHANES; 2012; n=5,156; 514 with LTBI and 4,642 controls) to develop three ANNs employing body mass index (BMI, Network I), BMI and HbA1C (as a proxy for diabetes; Network II) and BMI, HbA1C and education (as a proxy for socioeconomic status; Network III). The models were trained on n=1018 age- and sex-matched subjects equally distributed between the control and LTBI groups. The endpoint was the prediction of LTBI.

RESULTS

When data was adjusted for age, sex, diabetes and level of education, odds ratio (OR) and 95% confidence intervals (CI) for risk of LTBI with increased BMI was 0.85 (95%CI: 0.77 - 0.96, p=0.01). The three ANNs had a predictive accuracy varied from 75 to 80% with sensitivities ranged from 85% to 94% and specificities of approximately 70%. Areas under the receiver operating characteristic curve (AUC) were between 0.82 and 0.87. Optimal ANN performance was noted using BMI as a risk indicator.

CONCLUSION

Body weight can be employed in developing artificial intelligence-based tool to predict LTBI. This can be useful in precise decision making in clinical and public health practices aiming to curb the burden of tuberculosis, e.g., in the management and monitoring of the tuberculosis prevention programs and to evaluate the impact of healthy weight on tuberculosis risk and burden.

Diabetes Mellitus and Tuberculosis Treatment Outcomes in Pune, India

Background

Diabetes mellitus (DM) increases the risk of tuberculosis (TB) disease. Knowledge of the impact of DM on TB treatment outcomes is primarily based on retrospective studies.

Methods

We conducted a prospective cohort study of new pulmonary TB patients with and without DM (TB-DM and TB only) in India. The association of DM with a composite unfavorable TB treatment outcome (failure, recurrence, mortality) over 18 months was determined, and the effect of DM on all-cause mortality and early mortality (death during TB treatment) was assessed.

Results

Of 799 participants, 574 (72%) had TB only and 225 (28%) had TB-DM. The proportion of patients with DM who experienced the composite outcome was 20%, as compared with 21% for TB-only participants (adjusted hazard ratio [aHR], 1.13; 95% CI, 0.75–1.70). Mortality was higher in participants with DM (10% vs 7%), and early mortality was substantially higher among patients with DM (aHR, 4.36; 95% CI, 1.62–11.76).

Conclusions

DM was associated with early mortality in this prospective cohort study, but overall unfavorable outcomes were similar to participants without DM. Interventions to reduce mortality during TB treatment among people with TB-DM are needed.

The effect of a structured clinical algorithm on glycemic control in patients with combined tuberculosis and diabetes in Indonesia: A randomized trial

AIMS

Diabetes mellitus (DM) is associated with worse tuberculosis (TB) treatment outcomes, especially among those with poor glycemic control. We examined whether a structured clinical algorithm could improve glycemic control in TB patients with DM.

METHODS

In an open label randomized trial, TB-DM patients were randomized to scheduled counselling, glucose monitoring, and adjustment of medication using a structured clinical algorithm (intervention arm) or routine DM management (control arm), with glycated hemoglobin (HbA1c) at month 6 as the primary end point.

RESULTS

We randomized 150 pulmonary TB-DM patients (92% culture positive, 51.3% male, mean age 53 years). Baseline mean HbA1c was 11.0% in the intervention arm (n = 76) and 11.6% in the control arm (n = 74). At 6 months, HbA1c had decreased more in the intervention arm compared with the control arm (a difference of 1.82% HbA1c, 95% CI 0.82-2.83, p < 0.001). Five patients were hospitalized in the intervention arm and seven in the control arm. There was more hypoglycemia (35.0% vs 11.8%; p = 0.002) in the intervention arm. Two deaths occurred in the intervention arm, one due to cardiorespiratory failure and one because of suspected septic shock and multiorgan failure.

CONCLUSION

Regular monitoring and algorithmic adjustment of DM treatment led to improved glycemic control.

Obesity and Prevalence of Latent Tuberculosis: A Population-Based Survey

OBJECTIVE

Diminution in body weight is a known risk factor that increases the burden of active tuberculosis (TB). However, conflicting evidence exists for the effect of body weight on the risk of latent tuberculosis infection (LTBI). The objective of the present study is to examine the prevalence of LTBI at different body weights, evaluate the extent of association between body mass index (BMI) and LTBI and identify factors mediating this relationship in an adult population.

METHODS

We conducted a cross-sectional study to estimate the relationship between BMI and LTBI in participants from the US-National Health and Nutrition Examination Survey (NHANES; 2012, n = 5156; 514 with LTBI and 4642 controls).

RESULTS

The association between BMI and levels of cardiometabolic risk markers in both LTBI and control groups had a similar profile. When adjusted for age and sex, BMI was significantly inversely correlated with the prevalence of LTBI (r = -0.147, P < .001). Effect of BMI on the risk of LTBI was evaluated using multivariate logistic regression models adjusted for age, sex, diabetes, and level of education. In this model, increasing BMI was significantly associated with lower risk of LTBI (OR = 0.85; 95%CI: 0.77-0.96, P < .01).

CONCLUSION

This study further establishes an inverse relationship between BMI and prevalence of LTBI. Decreased BMI can be considered as a risk factor in LTBI, the reservoir for active TB cases.

The Interaction of Diabetes and Tuberculosis: Translating Research to Policy and Practice

Diabetes Mellitus increases the risk of developing Tuberculosis (TB) disease by about three times; it also doubles the risk of death during TB treatment and other poor TB treatment outcomes. Diabetes may increase the risk of latent infection with Mycobacterium tuberculosis (LTBI), but the magnitude of this effect is less clear. Whilst this syndemic has received considerable attention, most of the published research has focussed on screening for undiagnosed diabetes in TB patients or observational follow-up of TB treatment outcomes by diabetes status. There are thus substantial research and policy gaps, particularly with regard to prevention of TB disease in people with diabetes and management of patients with TB-diabetes, both during TB treatment and after successful completion of TB treatment, when they likely remain at high risk of TB recurrence, mortality from TB and cardiovascular disease. Potential strategies to prevent development of TB disease might include targeted vaccination programmes, screening for LTBI and preventive therapy among diabetes patients or, perhaps ideally, improved diabetes management and prevention. The cost-effectiveness of each of these, and in particular how each strategy might compare with targeted TB prevention among other population groups at higher risk of developing TB disease, is also unknown. Despite research gaps, clinicians urgently need practical management advice and more research evidence on the choice and dose of different anti-diabetes medication and effective medical therapies to reduce cardiovascular risks (statins, anti-hypertensives and aspirin). Substantial health system strengthening and integration may be needed to prevent these at risk patients being lost to care at the end of TB treatment.

Expression of a novel dual-functional polypeptide and its pharmacological action research

AIMS

To develop a dual-functional medicine for hypoglycemic and anti-thrombus.

MAIN METHODS

The long-acting glucagon like peptide-1 (5×GLP-1) and nattokinase (NK) were cloned by SOE PCR and gained the GLP-1 and NK fusion polypeptide after transformed into E. coli. Use of mice models for the hypoglycemic and anti-thrombus activity of the fusion polypeptide. Balb/C mice were given the carrageenan by intraperitoneal injection to induce tail thrombus models. Type 2 diabetes mellitus mice model was used to research the hypoglycemic function of the fusion polypeptide.

KEY FINDINGS

Results showed that the fusion polypeptide could significantly prevent thrombus formation after oral administration. Continuous administration for 15 days, fasting blood glucose levels of the experimental group decreased to nearly normal levels.

SIGNIFICANCE

The present study investigated the expression, purification and functional activity of the rolGLP-1 and NK fusion polypeptide, which provided a foundation for further studying the detailed pharmaceutical mechanism and drug development.