Andre-Pascal Kengne

Hypertension, diabetes mellitus and task shifting in their management in sub-Saharan Africa

Chronic diseases are becoming increasingly important in sub-Saharan Africa (SSA). The current density and distribution of health workforce suggest that SSA cannot respond to the growing demand for chronic disease care, together with the frequent infectious diseases. Innovative approaches are therefore needed to rapidly expand the health workforce. In this article, we discuss the evidences in support of nurse-led strategies for chronic disease management in SSA, with a focus on hypertension and diabetes mellitus.

Effects of the endpoint adjudication process on the results of a randomised controlled trial: the ADVANCE trial

Background Endpoint adjudication committees (EPAC) are widely used in clinical trials. The aim of the present analysis is to assess the effects of the endpoint adjudication process on the main findings of the ADVANCE trial (Trial registration: ClinicalTrials.gov NCT00145925). Methods and Findings The ADVANCE trial was a multicentre, 2×2 factorial randomised controlled trial of blood pressure lowering and intensive blood glucose control in 11140 patients with type 2 diabetes. Primary outcomes were major macrovascular (nonfatal myocardial infarction, nonfatal stroke and cardiovascular death) and microvascular (new or worsening nephropathy and retinopathy) events. Suspected primary outcomes were initially reported by the investigators at the 215 sites with subsequent adjudication by the EPAC. The EPAC also adjudicated upon potential events identified directly by ongoing screening of all reported events. Over a median follow-up of 5 years, the site investigators reported one or more primary outcomes among 2443 participants. After adjudication these events were confirmed for 2077 (85%) with 48 further events added through the EPAC-led database screening process. The estimated relative risk reductions (95% confidence intervals) in the primary outcome for the blood pressure lowering comparison were 8% (−1 to 15%) based on the investigator-reported events and 9% (0 to 17%) based on the EPAC-based events (P for homogeneityu200a=u200a0.70). The corresponding findings for the glucose comparison were 8% (1 to 15%) and 10% (2% to 18%) (P for homogeneityu200a=u200a0.60). The effect estimates were also highly comparable when studied separately for macrovascular events and microvascular events for both comparisons (all P for homogeneity>0.6). Conclusions The endpoint adjudication process had no discernible impact on the main findings in ADVANCE. These data highlight the need for careful consideration of the likely impact of an EPAC on the findings and conclusions of clinical trials prior to their establishment.

Ten-year Changes in Central Obesity and BMI in Rural and Urban Cameroon

Objective: To compare the 10‐year changes in the distribution of adiposity in rural and urban Cameroonian populations.

Waist circumference and obesity-related abnormalities in French and Cameroonian adults: the role of urbanization and ethnicity

Objectives:To evaluate the effect of urbanization and ethnicity on correlations between waist circumference (WC) and obesity-related cardiovascular risk factors.Methods:1471 rural and urban Cameroonians, and 4185 French, from community-based studies, aged ⩾25 years, not treated for hypertension, diabetes and dyslipidemia participated in this study. Slopes of obesity-related abnormalities with WC were compared using an interaction term between place of residence and WC.Results:Women in urban Cameroon and men in France had significantly higher WC and BMI relative to their gender counterparts. Urban Cameroonians had higher abdominal adiposity, but lower BP and better metabolic profile than the French. WC was positively associated to all the obesity-related abnormalities in the three sites except to FPG (both genders) and blood lipids (women) in rural Cameroon. A 5u2009cm larger WC was associated with a higher increment among urban than rural Cameroonians for diastolic blood pressure (DBP) (women, 1.95/0.63u2009mmu2009Hg; men, 2.56/1.44u2009mmu2009Hg), HOMA-IR (women, 0.11/0.05), fasting plasma glucose (FPG) (men, 0.09/−0.01u2009mmol/l) and triglycerides (women, 0.06/0.01u2009mmol/l; men, 0.09/0.03u2009mmol/l), all P<0.05. A 5u2009cm larger WC was associated with a higher increment among urban Cameroon than French people for DBP (women, 1.95/1.28u2009mmu2009Hg, P<0.01; men, 2.56/1.49u2009mmu2009Hg, P<0.01), but with a lower increment for HOMA-IR (women, 0.11/0.14, P<0.05), FPG (women, 0.05/0.09u2009mmol/l), total cholesterol (women, 0.07/0.11u2009mmol/l; men, 0.10/0.13u2009mmol/l) and triglycerides (women, 0.06/0.11u2009mmol/l; men, 0.09/0.13u2009mmol/l) all P<0.05.Conclusion:Ethnicity and urbanization modify the association of WC with obesity-related metabolic abnormalities. WC cutoff points derived from Caucasians may not be appropriate for black Sub-Saharan Africans.

The efficacy of lowering glycated haemoglobin with a gliclazide modified release-based intensive glucose lowering regimen in the ADVANCE trial

The aim of these analyses was to examine the efficacy of the intensive gliclazide MR-based glucose lowering regimen used in the ADVANCE trial in lowering the level of glycated haemoglobin (HbA1c). All 11,140 randomised patients were included in analyses of treatment efficacy. Treatment efficacy was also examined in subgroups defined by baseline characteristics and treatments. At the end of 5 years follow-up, the mean HbA1c was reduced from 7.5% at baseline to 6.5% in those on intensive glucose control and to 7.3% in those on standard glucose control. With intensive glucose lowering greater proportions achieved HbA1c levels of < or =7.0%, < or =6.5% and < or =6.0%. With intensive glucose lowering substantial reductions in HbA1c were observed across subgroups defined by baseline age, sex, duration of diabetes, BMI, HbA1c or treatment regimen (p<0.0001). The main independent predictors of reduction in HbA1c during follow-up were baseline HbA1c, duration of diabetes and BMI. There was no weight gain in the intensive glucose control group and severe hypoglycaemia was uncommon, though more frequent than in the standard control group. Intensive glucose control with a gliclazide MR-based regimen was well tolerated and consistently effective in lowering HbA1c across a broad range of patient with type 2 diabetes.

Effects of blood pressure lowering on cardiovascular outcomes in different cardiovascular risk groups among participants with type 2 diabetes

AIMSnTo asses differences in treatment effects of a fixed combination of perindopril-indapamide on major clinical outcomes in patients with type 2 diabetes across subgroups of cardiovascular risk.nnnMETHODSn11,140 participants with type 2 diabetes, from the ADVANCE trial, were randomized to perindopril-indapamide or matching placebo. The Framingham equation was used to calculate 5-year CVD risk and to divide participants into two risk groups, moderate-high risk (<25% and no history of macrovascular disease), very high risk (>25% and/or history of macrovascular disease). Endpoints were macrovascular and microvascular events.nnnRESULTSnThe mean age of participants was 66 years (42.5% female). 1000 macrovascular and 916 microvascular events were recorded over follow-up of 4.3 years. Relative treatment effects were similar across risk groups, (all P-values for heterogeneity ≥0.38). Hazard ratios for combined macro- and microvascular events were 0.89 (0.77-1.03) for the moderate-high risk and 0.92 (0.81-1.03) for the very high risk. Absolute treatment effects tended to be greater in the high risk groups although differences were not statistically significant (P>0.05).nnnCONCLUSIONSnRelative effects of blood pressure lowering with perindopril-indapamide on cardiovascular outcomes were similar across risk groups whilst absolute effects trended to be greater in the high risk group.

Prediction of 10-year vascular risk in patients with diabetes: the AD-ON risk score.

To formulate a combined cardiovascular risk score in diabetes that could be useful both to physicians and healthcare funders.

Influence of migration on characteristics of type 2 diabetes in sub-Saharan Africans

AIMnThis study compared the clinical and biochemical characteristics and microvascular complications found in three groups of type 2 diabetes (T2D) patients: Africans living in Africa; African immigrants living in France; and Caucasians living in France.nnnMETHODSnDiagnosed T2D Africans living in Cameroon (n=100) were compared with 98 African migrants diagnosed with T2D after having moved to France, and a group of 199 T2D Caucasian patients living in France. All underwent clinical and biochemical evaluations, and all were assessed for microvascular complications.nnnRESULTSnThe median duration of stay of the migrants in France was 15years before being diagnosed with diabetes. Despite similar durations of diagnosis, they were 8.9years younger at the time of diagnosis than Africans living in Cameroon (P<0.001). Caucasians and African immigrants in France had lower HbA1c values than Africans in Cameroon (P<0.001); they were also more aggressively treated for hypertension and dyslipidaemia and, therefore, had significantly lower blood pressure levels and better lipid profiles. Diabetic nephropathy and retinopathy rates were higher in Cameroon than in the two other groups. After adjusting for age, diabetes duration, HbA1c, hypertension and other covariates, only the prevalence of diabetic nephropathy (OR: 5.61, 95% CI: 2.32-13.53; P<0.0001) was higher in Cameroon compared with those living in France.nnnCONCLUSIONnOur results suggest that Africans who emigrate to France may develop diabetes earlier than those staying in their home country. However, the latter may be a reflection of late diagnosis of diabetes. Also, the less adequate diabetes and hypertension control in the latter would explain their higher rates of nephropathy. Large-scale cohorts are now warranted to substantiate these observations.

Fasting insulin sensitivity indices are not better than routine clinical variables at predicting insulin sensitivity among Black Africans: a clamp study in sub-Saharan Africans

BackgroundWe aimed to evaluate the predictive utility of common fasting insulin sensitivity indices, and non-laboratory surrogates [BMI, waist circumference (WC) and waist-to-height ratio (WHtR)] in sub-Saharan Africans without diabetes.MethodsWe measured fasting glucose and insulin, and glucose uptake during 80/mU/m2/min euglycemic clamp in 87 Cameroonians (51 men) aged (SD) 34.6 (11.4) years. We derived insulin sensitivity indices including HOMA-IR, quantitative insulin sensitivity check index (QUICKI), fasting insulin resistance index (FIRI) and glucose-to-insulin ratio (GIR). Indices and clinical predictors were compared to clamp using correlation tests, robust linear regressions and agreement of classification by sex-specific thirds.ResultsThe mean insulin sensitivity was M =u200910.5u2009±u20093.2xa0mg/kg/min. Classification across thirds of insulin sensitivity by clamp matched with non-laboratory surrogates in 30-48% of participants, and with fasting indices in 27-51%, with kappa statistics ranging from −0.10 to 0.26. Fasting indices correlated significantly with clamp (/r/=0.23-0.30), with GIR performing less well than fasting insulin and HOMA-IR (both p <u20090.02). BMI, WC and WHtR were equal or superior to fasting indices (/r/=0.38-0.43). Combinations of fasting indices and clinical predictors explained 25-27% of variation in clamp values.ConclusionFasting insulin sensitivity indices are modest predictors of insulin sensitivity measured by euglycemic clamp, and do not perform better than clinical surrogates in this population.

The spectrum of coma among people with diabetes in Cameroon: an appraisal of the implications and challenges at the Yaounde Central Hospital.

Abstract The present study was undertaken to assess the prevalence and prognosis of comas, the most serious acute complications of diabetes, among people with diabetes in Cameroon. The medical records of diabetic patients admitted to the endocrinolgy service of the Yaounde Central Hospital between November 1999 and October 2002 were reviewed. For each patient, data were collected on past medical history, clinical parameters, results of laboratory investigations, treatment received, and outcome. Coma was found to account for 10.2% (52) of the 509 admissions of diabetic patients, and to be responsible for a diagnosis of diabetes in 11 patients. The underlying causes of the comas were hypoglycaemia (28.8%), ketoacidosis (25%), hyperosmolar syndrome (25%), stroke (5.8%), uraemic syndrome (5.8%) and meningitis (5.8%). Hypoglycaemia was treated with intravenous (10%) glucose. Careful rehydration and subcutaneous injections of low doses of regular insulin were used to manage the hyperglycaemic crises, and broad-spectrum antibiotics were used to treat the infections. Despite the treatments, 11 of the coma cases died in hospital, six (55%) of the deaths being ultimately attributed to infection. Diabetic comas are relatively frequent in Yaounde and sometimes the first indication that an individual is diabetic. Associated deaths are regularly the result of infection. The management of the comas, using techniques that are not particularly aggressive, generates outcomes similar to those reported elsewhere.