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Dr C. Kamotho MBChB, MMed, Cert Cardio KAP Scientific Conference
Kisumu March 2011
Research QUESTION
What is the prevalence of Newly‐Diagnosed Diabetes Mellitus in Newly‐Admitted Patients at the Thika Level 5 Hospital?
OBJECTIVE To determine the prevalence of previously undiagnosed diabetes mellitus in patients newly admitted to the Thika District Hospital, now called the TL5H
TYPE: A prospective descriptive hospital‐based study of disease prevalence.
Background High prevalence and predicted incidence of Diabetes Mellitus
WHO: diabetes would increase by 161% by the year 2030 in Sub‐Sahara Africa, as compared with 54% in the established market economies of the West. Diabetes Care 27: 1047‐1053, 2004
Background Diabetes is associated with increased cardiovascular risk.
A study of Black Africans with angiographically evident coronary artery disease showed that diabetes was significantly more prevalent in such individuals (38.5%) than in those with normal coronary arteries (12%, P=0.0002). Kamotho C, Ogola E, Joshi M, Gikonyo D: Cardiovascular risk factor profiles of Black Africans undergoing coronary angiography. East African Medical Journal 81:82‐86,2004)
Background The INTERHEART Africa:
the OR of diabetes leading to a new myocardial infarction in African INTERHEART was 3.55 (2.53, 4.99)
Higher than in the Overall INTERHEART Study 3.07 (2.84, 3.33)
Black Africans had highest OR among the three races in Africa 5.79 (2.91, 11.53).
Steyn K, Sliwa K, Hawken S, Commerford P, Onen C, Damasceno A, Ounpuu S, Yusuf S for the INTERHEART Investigators in Africa. Risk Factors Associated With Myocardial Infarction in Africa: The INTERHEART Africa Study. Circulation 2005;112;3554‐3561
Rationale Despite the evidence:
There is paucity of local data Poor screening especially in Government Hospitals Low levels of awareness
Research Methodology Pilot study: Female Amenity wing of the hospital on seven consecutive patients (six adults and one child) admitted on the 16th September 2009.
RBS on admission, and FBS next morning. 5 of the 7 patients had elevated FBS in the Diabetes range , and of these only one was a known diabetic. The remaining two patients had IFG.
Therefore 57.1% in this small pilot study had newly‐diagnosed diabetes, and two (28.6%) had newly‐diagnosed impaired fasting glucose. All patients (100%) had abnormal glucose metabolism. These findings prompted the main study.
Methodology 145 patients, between 5th January and 31st January 2010. On admission:
clerkship usual baseline investigations done random blood sugar was done (RBS) at no extra cost to the patient.
The medical officers and interns in the four major departments of the hospital were trained on the measurement of blood sugar using capillary blood glucometers, values of fasting venous and capillary blood sugar being the same.
The RBS was done by the admitting doctor and the FBS done also by the admitting doctor or by one of the clinical officers or nurses designated and trained beforehand.
WHO Criteria DM: FBS 7.0 and above. Impaired fasting glucose: FBS 6.1 to 6.9 mmol
(Definition and diagnosis of diabetes mellitus and intermediate hyperglycemia: report of a WHO/IDF consultation. World Health Organization 2006)
Results 145 screened:
141 studied
FBS<7: 95 (67.4%)
FBS >/=7 46 (32.6%)
1 absconded, 1 transferred, 1 died, 1 no data
Results FBS<7 95
Normal: 76 (53.9%)
IFGL: 19 (13.5%)
Known 1
New 18
Results FBS >/=7 46 (32.6%)
Known DM 13 (9.2%)
Poor Control Infection
Newly DM 33 (23.4%)
ALARM BELLS!
Results Abnormal glucose metabolism: 65 (46.1%) Diabetes: 46 (32.6%) Newly‐diagnosed diabetics: 33 (23.4%). Newly diagnosed hyperglycemia (DM+IFG): 51 (36.2%) RBS screen (Medicine): 16/33 (48.5%) vs 9/39 (23%)
Results Diabetes Cases
MedicineSurgeryPaediatricsObs/Gyn
Discussion Newly diagnosed cases: 23.4% Highest among all the data seen so far. Importance of larger studies, also in other locations
Literature Review A British review of otherwise apparently healthy asymptomatic preoperative patients revealed that in routine preoperative tests of serum biochemistry, abnormal levels of glucose are found in up to 5.2% of patients. (Health Technol Assess. 1997;1(12):i‐iv; 1‐62)
Literature Review A more recent American study of newly admitted patients into ICU revealed that elevations in blood glucose levels were detected in 41% of study patients without previously diagnosed diabetes, suggesting that routine implementation of blood glucose monitoring in an ICU will identify patients at increased risk for hyperglycemia‐associated higher morbidity and mortality. (Endocr Pract. 2007 Nov‐Dec;13(7):705‐10.)
Literature Review Hammersmith Hospital Examined the use of a blood glucose assay, performed on admission in 515 consecutive acute admissions, aged 65 years and over as an initial screening test for diabetes mellitus. Of these, 7.6% were previously known to have diabetes and 4.7% were newly diagnosed on the basis of subsequent fasting blood glucose estimations. Using a random blood glucose level 8.0mmol: 18.5% of those screened needed further investigation. Dr. K Shotliff, MRCP *, A Prasad, MRCP: Random blood glucose estimations on admission as a screening test for diabetes in an elderly population.
Literature Review Kenyan study in 2003 among children newly admitted at the Kilifi District Hospital concluded that while hypoglycaemia was more prevalent than hyperglycaemia, hyperglycemia was present in 2.7% of children and was associated with a higher mortality than normoglycaemia, 14.0% versus 3.8% respectively (p < 0.001). Osier, F.H.A.; Berkley, J.A.; Ross, A.; Sanderson, F.; Mohammed, S.; Newton, C.R.J.C. Abnormal blood glucose concentrations on admission to a rural Kenyan district hospital: prevalence and outcome. Archives of Disease in Childhood. July 01, 2003
Literature Review Coronary Care Unit: Admission hyperglycemia was associated with complications
during hospital stay among 28‐day survivors. The risk for major complications after an incident MI was closely
related to admission RBS near to or within the normal range, and certainly below the diabetic threshold.
Thus, admission hyperglycemia still provides an early marker of bad prognosis after an AMI in an era of modern therapy. C. Meisinger, A. Hörmann, M. Heier, B. Kuch, H. Löwel : Admission
blood glucose and adverse outcomes in non‐diabetic patients with myocardial infarction in the reperfusion era. International Journal of Cardiology, Volume 113, Issue 2, Pages 229‐235
Literature Review US community teaching hospital showed that hyperglycemia was present in 38% of admitted patients; 26% had a known history of diabetes, and 12% had no history of diabetes before the admission.
Newly discovered hyperglycemia was associated with higher in‐hospital mortality rate (16%) compared to those patients with a history of diabetes (3%) and patients with normoglycemia (1.7%).
Patients with new hyperglycemia had a longer average hospital stay and a higher admission rate to the intensive care unit (ICU). They were less also likely to be discharged to home, frequently requiring transfer to a transitional care unit or nursing home facility.
Conclusion High Prevalence of Hyperglycemia High Prevalence of previously undiagnosed Abnormal Glucose Metabolism
Recommendations To carry out RBS Screening from the admission points To carry out FBS as a Baseline test in all patients in all departments
Appreciation: MO Interns
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