Quality of glycaemic control in ambulatory diabetics at the out-patient clinic of Kenyatta National Hospital, Nairobi

Background: Treatment of diabetes mellitus is based on the evidence that lowering blood glucose as close to normal range as possible is a primary strategy for reducing or preventing complications or early mortality from diabetes. This suggests poorer glycaemic control would be associated with excess of diabetes-related morbidity and mortality. This presumption is suspected to reach high proportions in developing countries where endemic poverty abets poor glycaemic control. There is no study published on Kenyan patients with diabetes mellitus about their glycaemic control as an audit of diabetes care. Objective: To determine the glycaemic control of ambulatory diabetic patients. Design: Cross-sectional study on each clinic day of a randomly selected sample of both type I and 2 diabetic patients. Setting: Kenyatta National Hospital. Methods: Over a period of six months, January 1998 to June 1998. During routine diabetes care in the clinic, mid morning random blood sugar and glycated haemoglobin (HbAI c)were obtained. Results: A total of 305 diabetic patients were included, 52.8% were females and 47.2% were males. 58.3% were on Oral Hypoglycaemic Agent (OHA) only, 22.3% on insulin only; 9.2% on OHA and insulin and 4.6% on diet only. 39.5% had mean HbAlc £ 8% while 60.5% had HbAlc ³ 8%. Patients on diet-only therapy had the best mean HbAlc=7.04% while patients on OHA-only had the worst mean HbAlc=9.06%. This difference was significant (p=0.01). The former group, likely, had better endogenous insulin production. The influence of age, gender and duration of diabetes on the level of glycaemic control observed did not attain statistically significant proportions. Conclusion: The majority of ambulatory diabetic patients attending the out-patient diabetic clinic had poor glycaemic control. The group with the poorest level of glycaemic control were on OHA-only, while best control was observed amongst patients on diet-only, because of possible fair endogenous insulin production. Poor glycaemic control was presumed to be due to sub-optimal medication and deteriorating diabetes. There is need to empower patients with knowledge and resources to enhance their individual participation in diabetes self-care. Diabetes care providers and facilities also need capacity building to improve care of patients with diabetes. East African Medical Journal Vol.80(8) 2003: 406-41

The determinants of health related quality of life of patients on maintenance haemodialysis at Kenyatta National Hospital, Kenya

Background: Health related quality of life (HRQOL) is increasingly being recognised as a primary outcome measure in the treatment of end stage renal disease. In addition to being an important surrogate marker of quality of care in patients on maintenance haemodialysis, HRQOL measures have being shown to be robust predictors of mortality and morbidity.Objective: To determine the health related quality of life and its determinants in patients on maintenance haemodialysis at the Kenyatta National Hospital.Design: A cross-sectional descriptive study.Setting: Renal unit, Kenyatta National HospitalSubjects: Adult patients with end stage renal disease on maintenance haemodialysis.Results: The mean physical composite summary and mental composite summary scores were 39.09±9.49 and 41.87±10.56 respectively. The burden of kidney disease sub-scale, symptom and problems sub-scale and effect of kidney disease on daily life sub-scale scores were 16.15±21.83, 73.46±18.06 and 67.63±23.45 respectively. No significant correlations were found between the health-related quality of life scores, socio-demographic and clinical factors assessed.Conclusion: The health-related quality of life of patients on maintenance haemodialysis is reduced. The physical quality of life is more affected than the mental quality of life. No independent determinants of health-related quality of life were identified

Socio-demographic and clinical aspects of rheumatoid arthritis

Objective: To determine the socio-demographic profiles and some clinical aspects of patients with rheumatoid arthritis (RA).Design: Prospective, cross-sectional study.Setting: Ambulatory out- patient clinics of Kenyatta National Hospital (KNH), a public national and referral hospital.Subjects: Out of 180 patients interviewed and examined, 60 met American College of Rheumatology (ACR) diagnostic criteria of RA.Results: Of the 60 patients recruited 52 (87%) were females with male: female ratio of 1: 6.5. The mean age of patients was 41.38(± 16.8) years. There were two peaks of age of occurrence, 20-29 and 40-49 years. In 75% of the study patients, one or more of metacarpophalangeal joints of the hand were involved in the disease. Other frequently involved sites were - wrists, elbows, knees, ankles and glenohumeral joints of shoulders in a symmetrical manner. Serum rheumatoid factor was positive in 78.9% while rheumatoid nodules were present in 13.3% of the study patients. A large majority of patients (88%) had active disease with 18% having mild disease, 38% moderate activity and 32% having severe disease. Only 12% of patients had disease in remission. Forty six point seven per cent (46.7%) of the study patients were on at least one Disease Modifying anti Rheumatic Drugs (DMARD) from a selection of methotrexate, sulphasalazine, hydroxychloroquine and leflunamide. The most frequent drug combination was methotrexate plus prednisolone at 30% of the study population; while 66.7% were on oral prednisolone with 25% of the study patients taking only Non-Steroidal anti Inflammatory Drugs (NSAIDS).Conclusion: A large majority of ambulatory patients with RA had active disease. Most of’ them were sub-optimally treated, especially the use of DMARDS. About two thirds were on oral steroids. Sub-optimal therapy in relatively young patients, peak 20-29 and 40-49 years is likely to impact negatively on their disease control and quality of life

Clinical and socio-demographic profile of patients on treatment for osteoporosis in Nairobi, Kenya

Background: Osteoporosis is a chronic, progressive disease of multifactorial aetiology and one of the most common metabolic bone diseases worldwide. There is a paucity of data on osteoporosis in Africa as it’s generally thought not to affect the non-Caucasian population. We sought to describe the population with osteoporosis in a Nairobi rheumatology clinic.Objective: To evaluate the clinical characteristics of patients with osteoporosis seen at a rheumatology clinic in Nairobi.Methods: Clinical, with emphasis on musculoskeletal manifestations, treatment and selected comorbidities in 56 patients diagnosed with osteoporosis were followed up and evaluated in the Nairobi Arthritis Clinic.Results: The age distribution was 31- 95 years with majority being above the age of 60 years at 71.5%. Majority were female (89.3%). The main musculoskeletal manifestations were polyarthralgia (30.4%) followed by lower back pain (19.6%) and pathological fractures (12.5%). The types of osteoporosis were grouped as primary (9%), secondary (44.6%) and post-menopausal (46.4%). The most common clinical association being rheumatoid arthritis (39.3%) followed by steroids therapy (25%). Other comorbidities included osteoarthritis, fibromyalgia, systemic lupus erythromatosus and diabetes. Seven study participants had history of fracture with lumbar spine fractures leading at 42.8%. None of the study participants were smokers. The number of patients on calcium supplements was at 71.4% and bisphosphonates was low at 32%.Conclusion: The findings of this study from age to comorbidities on osteoporosis are in keeping with literature. The number of patients on bisphosphonates was low which differed from Western literature. Persons at increased risk for osteoporosis in this set-up include post-menopausal women with debilitating chronic illness causing reduced mobilization over time and presenting with bone pains.These patients should be investigated for osteoporosis and effective treatment administered early.Keywords: Osteoporosis, Clinical profile, Nairobi, Keny

Evolution of HIV Training for Enhanced Care Provision in Kenya: Challenges and Opportunities

Background: Healthcare worker capacity building efforts over the past decade have resulted in decentralisation of HIV prevention, care and treatment servicesObjective: To provide an overview of the evolution of HIV training in Kenya, from 2003 to dateData sources: Various Government of Kenya publications, policy documents and websites on training for HIV service delivery. Publications and websites of stakeholders, donors and partners as well. Journal articles, published peer reviewed literature, abstracts, websites and programme reports related to training for HIV treatment in Kenya and the region. Personal experiences of the authors who are trainers by mandate.Data selection: Data related to training for HIV treatment in Kenya and the region on websites and publications were scrutinised.Data extraction: All selected articles were read.Data synthesis: All the collected data together with the authors’  experiences were used for this publication.Conclusion: Accelerated in-service capacity building efforts have contributed to the success of decentralisation of HIV services. Pre-service HIV training provides an opportunity for sustaining the gains made so far, in the face of declining donor funds. Implementation of the proposed harmonized HIV curriculum in the setting of devolved healthcare provides an opportunity for partnerships between stakeholders involved in pre-service and in-service HIV training to ensure sustainability

Stratification of persons with diabetes into risk categories for foot ulceration

Background: Patients with diabetes mellitus are at a higher risk of lower extremity complications as compared to their non-diabetic counterparts.Objective: To study risk factors for diabetic foot ulcer disease and stratify patients with diabetes into risk categories for foot ulceration.Design: Cross-sectional descriptive study over five months period.Setting: Diabetic outpatient clinic, at the Kenyatta National Hospital.Subjects: Two hundred and eighteen ambulatory subjects with diabetes mellitus without active foot lesions.Results: The prevalence of previous foot ulceration was 16% while that of previous amputation was 8%. Neuropathy was present in 42% of the study subjects and was significantly associated with age, male gender, duration of diabetes, random blood sugar, systolic blood pressure and the presence of foot deformity. Peripheral arterial disease was present in 12% and showed significant association with male gender. Foot deformities were observed in 46% of study subjects and were significantly associated with age, male gender, and presence of neuropathy. Subsequently 57% were categorised into IWGDF group 0 - no neuropathy, 10% were placed in group 1- neuropathy alone, 16% were put in group 2 - neuropathy plus either peripheral arterial disease or foot deformity and 17% were placed in risk group 3 - previous foot ulceration/amputation.Conclusion: More than one third (33%) of diabetic patients were found to be at high risk for future foot ulceration (lWGDF groups 2 and 3). Published evidence exists that shows improved outcomes with interventions targeting individual patients with diabetes at high-risk of foot ulceration. Long term prospective studies to determine outcomes for the different risk categories should be carried out locally

Morbidity and CD4+ Cell Counts at Initial Presentation of a Cohort of HAART-Naive, HIV Positive Kenyan Patients: Implications to Initiating HAART

Background: Sub-Saharan Africa with under 10% of the worldfs total population accounts for 60-70% of all HIV/AIDS cases. While these patients require HAART to manage the disease, HAART is not universally available. Majority of the patients are in resource-constrained settings, have multiple co- morbidities/infections, opportunistic infections, present late for treatment and are in the advanced stages of the HIV/A}IDSinfection.Objective: To describe the CD4+ cell counts, opportunistic infections and laboratory parameters of a cohort of HIV positive, HAART-naive patients at first presentation.Design: Cross sectional, prospective, descriptive, consecutive entry study.Setting: Kisumu District Hospital wards (medical, surgical) and medical outpatient clinic, Nairobi Rheumatology Clinic, Nairobi West Hospital and the Mater Hospital between January 2001 and December 2008.Main outcome measures: Socio-demographic parameters, opportunistic infections, CD4+ cell counts and complete blood count, biochemistry, HBsAg markers and anti- HCV serostatus.Results: Eight hundred and thirty four (350 males and 484 females) patients were screened. Three hundred and seventy (94 males and 276 females) patients were excluded. Four hundred and sixty four (256 males and 208 females) patients were finally included in the study. The mean age was 37.2 }10.6 years, range (12-78). The M: F ratio was 1.2:1. The mean CD4+ cell count was 106.5 } 125.2 cells/µl manifesting severe immnosuppression. Fifteen (3.2%), 19(4.1%), 43(9.3%) and 387(83.5%) had CD4+ cell counts of > 500, 350-499, 200-349 and < 200 cells/ƒÊl respectively. The mean white blood cell count was 8.63 } 8.8 ~ 103/ml (4.8-10.8 ~ 103/µl). Over half (51.3%) patients had leucopaenia, white cell count < 4.8 ~ 103/µl, 35 (7.5%) had leucocytosis and the rest 191 (41.2%) patients had normal white blood cell counts. The mean haemoglobin level was 7.16 } 5.01 g/dl (12-18 g/dl) and 154 (33.2%) had haemoglobin level < 5g/dl manifesting severe anaemia. The patients had multiple co-morbidities and 248 (53.4%) had . 2 co-morbidities.Conclusion: The patients presented with severe immunosuppression evidenced by low CD4+ cell counts, anaemia and multiple co-morbidities. Majority presented late at which point the cost of management is high and outcomes are likely to be poor. They required HAART and prompt  management of the co-morbidities to mitigate morbidity and reduce mortality. It would be prudent to study treatment outcomes and their determinants overtime in patients with severe HIV disease. Also, requiring study is how long such patients with severe HIV disease who commence HAART would last on first line treatment before requirement of alternative treatment

CD4 + Cell Response to Anti-Retroviral Therapy (ARTS) In Routine Clinical Care Over One Year Period in a Cohort of HAART Naive, HIV Positive Kenyan Patients

Background: Untreated HIV/AIDS leads to severe immune depletion with opportunistic                                                                    infections and other co-morbidities. Highly active anti-retroviral therapy (HAART) enhances immunity by sustained HIV- viral suppression, increase in CD4+ cell count and immune restoration. HAART reduces risk of neutropaenia, anaemia and accompanied decrease in incidence of opportunistic infections.Objectives: To study the CD4+ cell response in patients with severe HIV/AIDS disease over one year period while on HAART.Design: Observational, descriptive, longitudinal study.Setting: Kisumu District Hospital (Medical outpatient clinic, medical and surgical wards), Nairobi Rhematology clinic and The Mater Hospital between July 2001 and March 2007.Subjects: Four hundred and sixty three consenting patients were screened for the study.Intervention: The 103 patients included received HAART within one to four weeks and appropriate treatment for the opportunistic infections and other co-morbidities. Various HAART combinations including combivir/efavirenz, stavudine/lamivudine/nevirapine and triomune 30/40 (fixed dose combination of stavudine, nevirapine and lamivudine) were used. Some delayed HAART because of the co- morbidities which had to be managed first (severe anaemia, hepatitis and meningitis).Main outcome measures: CD4+ cell increase, new clinical events.Results: Four hundred and sixty three patients (256 males and 207 females) were screened. One hundred and three patients (55 males and 48 females) were included and 360 (201 males and 159 females) patients were excluded. Mean age was 37.9 ± 9.0 years range of (15-70). The mean CD4+ cell counts over the study period were 141.7 ± 176.5 (1-1022), 192.4 ± 198.5 (3-1275), 221.2 ± 178.0 (3-1300), 247.2 ± 197.7 (1-1401) and 268.6 ± 189.9 (1-1390) cells/µl at 0,3,6,9 and 12 months respectively. Nine patients had higher CD4+ cell counts > 350 cells/µl (433-1022) at baseline and higher HIV-viral RNA range between  51,830-1million copies/µl. The patients had multiple co-morbidities,namely, had tuberculosis, sepsis, cryptococcus meningitis, herpes zoster virus, four had non- Hodgkinfs lymphoma, oral candidiasis, hepatitis B virus, pneumocytis jiroveci pneumonia and HIV with renal dysfunction. Seventy (68%) patients had . 2 opportunistic infections. Mean AST, ALT and haemoglobin levels were 127.8 ± 79.8 IU/L, 157.2 ± 50.1 IU/L and 9.1 ± 4.3 g/dl respectively. No patient tested positive foranti-HCV antibodies.Conclusion: The majority of patients had advanced HIV infection at baseline. There was a slow but steady increase in CD4+ cell count over one year. However only 30(29.1%) of patients achieved immune restoration. Seventy three (70.9%) of patients still had immune depletion with low CD4+ cell counts at one year of receiving HAART. Patients with low CD4 + cell counts at baseline had a steady increase of CD4+ cells over the first six months and this emphasises the need to initiate HAART early in public health policy strategy. Expedited HAART initiation should be done in  patients with CD4+ cell counts < 350 cells/µl. Delayed HAART, at low CD4+ cell counts, is associated with poor immune recovery/restoration

Clinical features, predictive factors and outcome of hyperglycaemic emergencies in a developing country

<p>Abstract</p> <p>Background</p> <p>Hyperglycaemic emergencies are common acute complications of diabetes mellitus (DM) but unfortunately, there is a dearth of published data on this entity from Nigeria. This study attempts to describe the clinical and laboratory scenario associated with this complication of DM.</p> <p>Methods</p> <p>This study was carried out in DM patients who presented to an urban hospital in Nigeria with hyperglycaemic emergencies (HEs). The information extracted included biodata, laboratory data and hospitalization outcome. Outcome measures included mortality rates, case fatality rates and predictive factors for HEs mortality. Statistical tests used are <it>χ</it>², Student's t test and logistic regression.</p> <p>Results</p> <p>A total of 111 subjects with HEs were recruited for the study. Diabetes ketoacidosis (DKA) and hyperosomolar hyperglycaemic state (HHS) accounted for 94 (85%) and 17 (15%) respectively of the HEs. The mean age (SD) of the subjects was 53.9 (14.4) years and their ages ranged from 22 to 86 years. DKA occurred in all subjects with type 1 DM and 73 (81%) of subjects with type 2 DM. The presence of HSS was noted in 17 (19%) of the subjects with type 2 DM.</p> <p>Hypokalaemia (HK) was documented in 41 (37%) of the study subjects. Elevated urea levels and hyponatraemia were noted more in subjects with DKA than in those subjects with HHS (57.5%,19% vs 53%,18%). The mortality rate for HEs in this report is 20% and the case fatality rates for DKA and HHS are 18% and 35% respectively.</p> <p>The predictive factors for HEs mortality include, sepsis, foot ulceration, previously undetected DM, hypokalaemia and being elderly.</p> <p>Conclusion</p> <p>HHS carry a higher case fatality rate than DKA and the predictive factors for hyperglycaemic emergencies' mortality in the Nigerian with DM include foot ulcers, hypokalaemia and being elderly.</p