| Background and objective:It has been reported that the risk of active pulmonary tuberculosis(PTB)in diabetic(DM)patients is 3.59 times higher than that in nondiabetic patients.Compared with patients with simple tuberculosis,diabetic patients complicated with tuberculosis(DM-PTB)had more serious clinical symptoms such as cough,night sweats and hemoptysis.During the treatment,the body weight returned slowly and the course of the disease would be longer.In terms of outcome,it is more likely to be developed into multi-drug resistant tuberculosis and there is a higher risk of treatment failure,recurrence and death.Blood glucose management is very important for progression and prognosis,which can be divided into two aspects:blood glucose control level and blood glucose variability level.As an infectious disease,tuberculosis can cause stress hyperglycemia,weaken the effect of hypoglycemic drugs and increase the demand of insulin,which can lead to the poor management of blood glucose in diabetic patients complicated with tuberculosis,and even the exacerbation of diabetes.At present,some studies have found that poor blood glucose control is positively related to the severity of symptoms and pulmonary cavity in diabetic patients complicated with tuberculosis,however,there are few reports on the effect of blood glucose control on treatment outcome and prognosis.At the same time,most TB patients are malnourished,and there is a significant correlation between nutritional status and disease outcome.At present,studies have confirmed that malnutrition is related to the risk of slow weight recovery of tuberculosis patients in the first two months of treatment,and the risk of retreatment and death of malnourished patients is significantly increased.The nutritional status of patients with diabetes mellitus complicated with tuberculosis is more complex,and its effect on the outcome of the disease is rarely reported.Therefore,the main purpose of this study is to explore the influence of baseline blood glucose management and baseline nutritional status on the progression and prognosis of diabetic patients complicated with newly diagnosed tuberculosis,and to explore the influencing factors of the failure of sputum conversion to negative after 2 months of anti-tuberculosis treatment and the final unsatisfactory outcome of this treatment.The purpose of this study is to provide a scientific basis for optimizing the anti-tuberculosis treatment strategy and improving the prognosis of patients with DM-PTB.Methods:This study is divided into two chapters,the first chapter discusses the relationship between blood glucose management and the prognosis of patients with DM-PTB.Blood glucose management includes blood glucose control level based on glycosylated hemoglobin(HbA1c)index and blood glucose fluctuation based on fingertip blood glucose variation and fluctuation.In the first chapter,the effect of blood glucose control on the prognosis of patients with DM-PTB was studied in a prospective cohort study.According to the baseline HbA1c level,the patients were divided into two groups,good blood glucose control group(HbA1c lower than 8.0%)and poor blood glucose control group(HbA1c higher than or equal to 8.0%).The general demographic characteristics,living habits and the changes of tuberculosis symptoms,sputum bacteriology and imaging results in the course of anti-tuberculosis treatment were compared between the two groups.The fluctuation of blood sugar adopts the method of longitudinal study.According to the range of blood glucose fluctuation,the patients were divided into normal blood glucose fluctuation group and abnormal blood glucose fluctuation group,and according to the coefficient of variation of blood glucose,the patients were divided into two groups:low blood glucose variation and high blood glucose variation.The correlation between the average fluctuation range of blood glucose,the coefficient of variation of blood glucose and the characteristic symptoms of tuberculosis,the negative conversion of sputum bacteria and the imaging features of lung were observed and analyzed at baseline and one month.The patients included in the first chapter sought medical consultation in Qingdao Chest Hospital from December 2017 to December 2019,who were diagnosed as type 2 diabetes complicated with pulmonary tuberculosis.At the same time,they met the requirements of measuring HbA1c at admission or measuring fingertip blood glucose value at least three days after admission(at least three times a day)during different periods of the day.In the second chapter,a prospective cohort study was conducted to explore the effect of nutritional status on the prognosis of patients with DM-PTB.The patients were divided into two groups according to their nutritional status at baseline,and the general demographic characteristics,living habits,tuberculosis symptoms,sputum bacteriological results and imaging results were compared between the two groups.The patients included in Chapter II were hospitalized in Qingdao Chest Hospital from March 2018 to March2019 and were clinically diagnosed as type 2 diabetes complicated with pulmonary tuberculosis,and blood samples were collected at the beginning of anti-tuberculosis treatment(i.e.baseline).Patients were divided into groups according to whether there is hypoalbuminemia,lymphocytopenia,and anemia and whether BMI is higher than or equal to 24.0 kg/m~2.Single factor and multi factor Cox regression analysis were used to determine the risk factors related to the failure of sputum conversion to negative in 2 months and the final adverse outcome after anti-tuberculous treatment.Hazard ratio(HR)was used to evaluate the correlation between the influencing factors and progression and prognosis,and 95%confidence interval(95%CI)was used to estimate the range of the overall parameters.Results:In the analysis of the relationship between blood glucose management and the outcome of DM-PTB patients(Chapter 1),a total of 404 patients with diabetes mellitus complicated with pulmonary tuberculosis were included at baseline.It was found that54.70%of the diabetic patients complicated with pulmonary tuberculosis had poor baseline blood glucose control,52.17%had abnormal blood glucose fluctuation and55.28%had hyperglycemia variation.Poor blood glucose management is associated with baseline symptoms and indications of tuberculosis,and patients with poor blood glucose control have a lower sputum negative rate after 2 months,but no difference in the final treatment outcome was found.After adjusting the confounding factors such as gender,age and the course of diabetes,we found that poor baseline glycemic control(HR=2.01,95%CI:1.10 to 3.67),smokers(HR=2.29,95%CI:1.07-4.02),and baseline lymphocytopenia(HR=1.80,95%CI:1.01 to 3.19)increased the risk of sputum conversion failure after 2 months.After adjusting for confounding factors such as age,course of diabetes,positive sputum bacteriological examination and baseline HbA1c level,it was found that smokers(HR=2.11,95%CI:1.02 to 4.37)and baseline hypoproteinemia(HR=2.34,95%CI:1.18 to 4.61)were the independent risk factors for poor outcome after receiving anti-tuberculosis treatment.In the study of the effect of nutritional status on the prognosis of patients with DM-PTB(Chapter 2),a total of 245 patients with DM-PTB were included at baseline.It was found among them that the proportion of patients with hypoalbuminemia was 24.49%at baseline,23.27%with lymphocytopenia,25.71%with anemia and 34.04%with BMI higher than or equal to 24.0 kg/m~2.The sputum negative rate of patients with hypoproteinemia decreased in both intensive and consolidation stages of anti-tuberculosis treatment,and the possibility of poor outcome was increased after receiving anti-tuberculosis treatment.After adjusting the confounding factors such as gender,age,course of diabetes and smoking,it is found that the baseline with hypoproteinemia(HR=1.86,95%CI:1.08 to 3.20)was an independent risk factor for the failure of sputum conversion to negative in two months.And after adjusting the confounding factors such as gender,age and the course of diabetes,it is found that hypoproteinemia(HR=1.85,95%CI:1.08 to 3.15)also increased the risk of unsatisfactory outcome after anti-tuberculosis treatment.Conclusion:The time of sputum converting to negative during anti-tuberculosis treatment was prolonged in diabetic patients complicated with tuberculosis with malnutrition and poor blood glucose management at baseline,and patients with baseline malnutrition were more likely to end up with poor outcomes after anti-tuberculous treatment.The risk of sputum converting to negative failure for patients with poor baseline blood glucose control,lymphocytopenia,hypoproteinemia,and smokers treated with anti-tuberculosis in 2months was increased,and the risk of poor outcome after treatment for patients has baseline complicated with hypoproteinemia and smokers is also increased.Therefore,it is necessary to strengthen the blood glucose management of diabetic patients complicated with tuberculosis,since strict blood glucose management may change the influence of poor baseline blood glucose management on the final treatment outcome to some extent.At the same time,strengthening the control of tobacco,improving the health status of patients,and reversing malnutrition,which can improve the process of tuberculosis prognosis,reduce the risk of poor outcome of anti-tuberculosis treatment in diabetic patients complicated with tuberculosis. |
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