Why is There Low Morbidity and Mortality of COVID-19 in Africa?

Three months since the detection of the first COVID-19 case in Africa, almost all countries of the continent continued to report lower morbidity and mortality than the global trend, including Europe and North America. We reviewed the merits of various hypotheses advanced to explain this phenomenon, including low seeding rate, effective mitigation measures, population that is more youthful, favorable weather, and possible prior exposure to a cross-reactive virus. Having a youthful population and favorable weather appears compelling, particularly their combined effect; however, progression of the pandemic in the region and globally may dispel these in the coming months.

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 Hospital. SUBJECTS: 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.

Reliability of community health worker collected data for planning and policy in a peri-urban area of Kisumu, Kenya.

A general introduction of this article is as follows: Reliable and timely health information is an essential foundation of public health action and health systems strengthening, both nationally and internationally (Aqil et al. in Health Policy Plan 24(3): 217-228, 2009; Bradshaw et al. in initial burden of disease estimates for South Africa, 2000. South African Medical Research Council, Cape Town, 2003). The need for sound information is especially urgent in the case of emergent diseases and other acute health threats, where rapid awareness, investigation and response can save lives and prevent broader national outbreaks and even global pandemics (Aqil et al. in Health Policy Plan 24(3): 217-228, 2009). The government of Kenya, through the ministry of public health and sanitation has rolled out the community health strategy as a way of improving health care at the household level. This involves community health workers collecting health status data at the household level, which is then used for dialogue at all the levels to inform decisions and actions towards improvement in health status. A lot of health interventions have involved the community health workers in reaching out to the community, hence successfully implementing these health interventions. Large scale involvement of community health workers in government initiatives and most especially to collect health data for use in the health systems has been minimal due to the assumption that the data may not be useful to the government, because its quality is uncertain. It was therefore necessary that the validity and reliability of the data collected by community health workers be determined, and whether this kind of data can be used for planning and policy formulation for the communities from which it is collected. This would go a long way to settle speculation on whether the data collected by these workers is valid and reliable for use in determining the health status, its causes and distribution, of a community. Our general objective of this article is to investigate the validity and reliability of Community Based Information, and we deal with research question "What is the reliability of data collected at the Community level by Community health workers?". The methods which we use to find an reliable answer to this question is "Ten percent of all households visited by CHWs for data collection were recollected by a technically trained team. Test/retest method was applied to the data to establish reliability. The Kappa score, sensitivity, specificity and positive predictive values were also used to measure reliability". Finally our findings are as follows: Latrine availability and Antenatal care presented good correspondence between the two sets of data. This was also true for exclusive breast feeding indicator. Measles immunization coverage showed less consistency than the rest of the child health indicators. At last we conclude and recommend that CHWs can accurately and reliably collect household data which can be used for health decisions and actions especially in resource poor settings where other approaches to population based data are too expensive.

Prognostic factors in patients hospitalised with diabetic ketoacidosis at Kenyatta National Hospital, Nairobi.

BACKGROUND: In spite of many advances in the management of diabetes in the last 25 years, the mortality associatedwith diabetic ketoacidosis (DKA) remains high, especially in the developing countries. The mortality appears greatest in the first 24-48 hours of their treatment. Most of the previous studies on DKA focused on children and the precipitating factors thereof but not particularly on clinical predictors of outcomes. OBJECTIVE: To determine the clinico-laboratory predictors of outcomes of patients hospitalised with diabetic ketoacidosis who were undergoing treatment. DESIGN: Cross-sectional descriptive study. SETTING: The accident and emergency department and medical wards of the Kenyatta National Hospital. SUBJECTS: Fifty one patients hospitalised with diabetic ketoacidosis over a nine month period were evaluated clinically and by laboratory tests. They were managed in the standard way with insulin, intravenous fluids and appropriate supportive care. MAIN OUTCOME MEASURES: Serial assays of serum electrolytes, glucose and blood pH, HbA1c and clinical outcome of either discharge home or death. RESULTS: Of the 51 patients enrolled, 47 were included in the final analysis. Fourteen (29.8%) patients died,andthe deaths occurred within less than48 hours of hospitalisation and treatment. Of the patients who died, all (100%) had altered level of consciousness at hospitalisation, 71.4% had abnormal renal functions, 64.3% were newly diagnosed and an equal proportion of 64.3% were females. The alteration in the level of consciousness was significantly associated systolic hypotension and severe metabolic acidosis, (p < 0.001). Patients with altered level of consciousness also had poorer renal function. CONCLUSION: Apparently DKA still carries high mortality during treatment in hospital. Altered level of consciousness, which is an obvious and easily discernible clinical sign, was a major predictor of mortality in our study patients. The majority of patients with altered level of consciousness also had systolic hypotension, severe metabolic acidosis and impaired renal function. Even where and when detailed laboratory evaluation is elusive, clinical signs, especially altered level of consciousness and systolic hypotension are very important markers of severity of DKA that may be associated with unfavourable outcomes. Further studies are necessary to establish why DKA still carries high mortality in the patients who are already receiving treatment in hospitals in developing countries.

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.

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 (IWGDF 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.

Acute coronary syndromes amongst type 2 diabetics with ischaemic electrocardiograms presenting to accident and emergency department of a Kenyan tertiary institution.

OBJECTIVE: To determine the prevalence of acute coronary syndromes among type 2 diabetic patients presenting to Accident and Emergency department. DESIGN: Prospective cross-sectional study. SETTING: Kenyatta National Hospital, a tertiary teaching and referral hospital. SUBJECTS: Type 2 diabetic patients with ischaemic electrocardiograms (ECG). MAIN OUTCOME MEASURES: Demographics, clinical symptoms, cardiovascular status and risk factors--central obesity, hypertension, dyslipidaemia, smoking. RESULTS: From 12,307 accident and emergency attendees, 400 (33%) diabetics aged > OR =30 years were screened with a resting ECG and 95 (24%) with ischaemic ECG were recruited; age range 41-87 years, 60% were male; diabetes duration ranged 0-30 years with 8.4% being newly diagnosed. The commonest enrolling ECG feature was nonspecific ST-T changes. The commonest presenting complaint were fatigue and dyspnoea. Majority had three coronary artery disease (CAD) risk factors: obesity 86%, elevated LDL 73% and hypertension 60%. Therapy in use was OHA 43%, insulin 42%, insulin and OHA 1%; prophylactic aspirin 14.7% and statins 8.4%. Thirty four (35.8%) were classified as acute coronary syndrome (ACS); 29 (30.5%) acute myocardial infarction (ACS-AMI) and five (5.2%) unstable angina (ACS-UA). Majority (79.4%) of the ACS presented more than six hours after symptom onset and majority had features of acute left ventricular failure. CONCLUSIONS: Acute coronary syndrome accounted for 35% of the morbidity in type 2 diabetics with ischaemic ECG's presenting to KNH accident and emergency department; patients presented late and 80% were not on CAD prophylactic therapy.

Type 2 diabetes mellitus: clinical and aetiologic types, therapy and quality of glycaemic control of ambulatory patients.

BACKGROUND: Type 2 diabetes is a heterogeneous disease with multiple causes revolving around beta cell dysfunction, insulin resistance and enhanced hepatic glucose output. Clinical judgement based on obesity status, age of onset and the clinical perception of residual beta cell insulin secretory function (hence insulin-requiring or not), has been used to determine therapeutic choices for each patient. Further laboratory testing of the clinically defined type 2 diabetes unmasks the various aetiologic types within the single clinical group. OBJECTIVE: To determine the aetiological types of the clinically defined type 2 diabetic patients, their chosen therapies at recruitment and the quality of glycaemic control achieved. DESIGN: Descriptive cross-sectional study. SETTING: Diabetes out-patient clinic of Kenyatta National Hospital, Nairobi, Kenya. RESULTS: A total of 124 patients with clinical type 2 diabetes were included, 49.2% were males. The mean duration of diabetes in males was 26.09 (20.95) months and that of females was 28.68 (20.54) months. The aetiological grouping revealed the following proportions: Type 1A-3.2%, Type 1B-12.1%, LADA-5.7%, and "true" type 2 diabetes 79.0%. All the patients with Type 1A were apparently, and rightly so, on "insulin-only" treatment even though they did not achieve optimal glycaemic control with HbA1c % = 9.06. However the study patients who were type 1B and LADA were distributed all over the treatment groups where most of them did not achieve optimal glycaemic control, range of HbA1c of 8.46 -10.6%. The patients with "true" type 2 were also distributed all over the treatment groups where only subjects on 'diet only' treatment had good HbA1c of 6.72% but those in other treatment groups did not achieve optimal glycaemic control of HbA1c, 8.07 - 9.32%. CONCLUSION: Type 2 diabetes is a heterogeneous disease where clinical judgement alone does not adequately tell the various aetiological types apart without additional laboratory testing of C-peptide levels and GAD antibody status. This may partly explain the inappropriate treatment choices for the various aetiological types with consequent sub-optimal glycaemic control of those patients.

Comparison of antibiotic use between an 'open' and a 'closed' intensive care unit.

OBJECTIVE: To determine differences in antibiotic use between a 'closed' ICU in a hospital in Israel and an 'open' ICU in a Kenyan hospital. DESIGN: Retrospective comparative study. SETTING: The ICU of Beilinson hospital in Rabin Medical Centre, Tel Aviv, Israel and the ICU of Mater Hospital, Nairobi Kenya. SUBJECTS: One hundred and forty patients from Beilinson and one hundred fifty one patients from Mater Hospital were enroled. MAIN OUTCOME MEASURES: Antibiotic use in the different ICU settings. RESULTS: Seven different antibiotics namely Erythromycin, Meropenem, Taxobactam/Piperacillin, Metronidazole, Gentamycin, Ceftriaxone and Cefuroxime were used in sufficient numbers in both centres to allow for statistical analysis. Four of these seven namely metronidazole, gentamycin, ceftriaxone and cefuroxime demonstrated statistically significant difference between the two centres. CONCLUSION: The level, of antibiotic use is demonstrably higher in 'open' ICUs with fewer controls to antibiotic prescriptions than in 'closed' ICUs with stricter control.

Acute aflatoxicosis: case report.

The objective of this presentation is to document the salient clinical findings in a case of aflatoxicosis and to review the literature on the same so as to increase the index of suspicion, enhance early diagnosis and improve management. The case was a 17-year-old schoolboy presenting with vomiting, features of infection and gastrointestinal tract symptoms. Examination revealed a very ill looking pale patient with abdominal distension, tenderness and rectal bleeding and easy bruisability. Investigations showed abnormal liver function tests, pancytopenia and elevated serum levels of aflatoxins. Management consisted of supportive care including antibiotics and antifungal therapy, transfusion of red blood cells and fresh frozen plasma. His recovery was uneventful. The literature on human aflatoxicosis shows that the presentation may be acute, subacute and chronic. The degree of emanating clinical events also conforms to status of the aflatoxicosis. Overall, the features are protean and may masquerade many other forms of toxaemias. In conclusion, the diagnosis of aflatoxicosis takes cognisance of geographical location, past events, staple diet and clinical features to exclude other infections. Also required are high index of suspicion and importantly serum levels of aflatoxin. Treatment strategies involved use of antimicrobials and supporting the damaged multi-organs.

Vasculitis in HIV: report of eight cases.

OBJECTIVE: To describe vasculitis in HIV patients, their CD4 levels, anatomical sites affected and clinical patterns. DESIGN: Prospective, descriptive study. SETTING: Kisumu District Hospital and Nairobi Rheumatology Clinic between January 2002 and May 2005. SUBJECTS: Eight patients with HIV and vasculitis. RESULTS: Eight patients (four males and four females) were recruited with an age range of 24-61 years, mean 33.13 years. Five had central nervous system vasculitis and three had peripheral vasculitis. The CD4 counts were low, range 2-200 cells/mm3 (mean of 79.25 cells/mm3), normal levels of CD4 are 355-1298 cells/mm3, indicating severe immunosuppression. Two patients tested positive for HBV (hepatitis B virus). CONCLUSION: HIV associated vasculitis is recognised and may be complicated by coinfection with hepatitis viruses. It occurs at low CD4 counts. Central nervous system involvement is a common site. Management is multidisciplinary.

Risk factor profile and the occurrence of microvascular complications in short-term type 2 diabetes mellitus at Kenyatta National Hospital, Nairobi.

BACKGROUND: Type 2 diabetes has a long pre-clinical period before diagnosis, during which there may be development of complications, both of microvascular and macrovascular types. OBJECTIVE: To determine the risk factor profile of hyperglycaemia, hypertension and dyslipidaemia in patients with short-term (=/ < 2 years) type 2 diabetes. DESIGN: Cross-sectional descriptive study over six months. SETTING: Outpatient diabetic clinic of Kenyatta National Hospital. SUBJECTS: Ambulatory patients with type 2 diabetes. RESULTS: One hundred patients were included. The mean (SD) duration of diabetes was 10.3 (7.5) months. There were 66% of the study subjects with obesity, 50% with hypertension, 29% had ideal glucose control and less than 40% had high LDL-cholesterol. Twenty eight (28%) who had polyneuropathy had significant differences in their older age, higher total and LDL-cholesterol compared with those who did not have polyneuropathy. Twenty five (25%) of the study patients had micro-albuminuria and only 1% had macro-albuminuria. There were no significant differences in the selected characteristics between study patients with and those without albuminuria. Only 7% of the study patients had retinopathy on direct ophthalmoscopy. CONCLUSION: Microvascular complications occurred in patients with type 2 diabetes of short duration of not more than two years. The risk factors of hypertension, poor glycaemic control, dyslipidaemia and cigarette smoking were present in a fair proportion of the study patients. Patients with type 2 diabetes should be actively screened for complications and the risk factors thereof, even if the diabetes was of recent onset.

Lipid profile of ambulatory patients with type 2 diabetes mellitus at Kenyatta National Hospital, Nairobi.

BACKGROUND: Patients with type 2 diabetes are at high of cardiovascular events because they have abnormal lipid status compared to their non-diabetic counterparts. OBJECTIVE: To determine the quantitative lipid profile of ambulatory patients with type 2 diabetes mellitus. DESIGN: Prospective, cross-sectional descriptive study. SETTING: Out-patient diabetic clinic of the Kenyatta National Hospital. SUBJECTS: Ambulatory patients with type 2 diabetes but without obvious cardiovascular, renal or foot complications. RESULTS: A total of 213 patients with type 2 diabetes were studied, 56.8% were females. The age range of the study population was 34 to 86 years, mean(sd) age of females was 54.45 (9.4) years and that of males was 55.83 (9.3) years. The mean body mass index (BMI) of females was 27.85 (6.2) kg/m2 and 25.98 (5.8) kg/m2 for males. The female subjects were more obese than the males in this study. Over 70% of the study participants had total cholesterol > 4.2 mmol/l, 43.8% and 57.6% of the females and males respectively had LDL-C > 2.6 mmol/l , 25.6% of the females and 30% of the males had HDL-C < 1.00 mmol/l. Only a modest proportion of males (28.3%) and females (32.2%) had triglycerides > 1.7 mmol/l. The LDL-C showed a significant positive correlation with age, duration of diabetes, fasting blood glucose, and total cholesterol but no correlation with glycated haemoglobin, body mass index, gender and the mode of glucose-lowering treatment. CONCLUSION: There was significant proportion of quantitative dyslipidaemia in the study population especially with the Total--and LDL- cholesterols. Although treatment goals and lipid thresholds for cardiovascular risk in diabetes are not yet well-defined, even by the large randomized trials, high-risk patients with significant quantitative dyslipidaemia would require deliberate effort to correct the abnormal values to reduce the risk status. These high-risk patients without complications but already had significant dyslipidaemia, which enhances the risk of cardiovascular events, certainly required therapeutic intervention.

Patterns of homocysteine in Kenyans with type 2 diabetes without overt cardiovascular disease at Kenyatta National Hospital, Nairobi.

BACKGROUND: Increased total homocysteine (tHcy) is an independent risk factor for cardiovascular disease. The measurement of tHcy in blood is therefore of potential great importance especially in patients with type 2 diabetes. OBJECTIVE: To determine the total homocysteine levels in ambulatory patients with type 2 diabetes. DESIGN: Cross-sectional, prospective study. SETTING: Outpatient diabetic clinic of the Kenyatta National Hospital. SUBJECTS: Ambulatory patients with Type 2 diabetes without overt cardiovascular, renal, liver or other chronic disease. MAIN OUTCOME MEASURES: Serum levels of tHcy, HbA1c, lipids and socio-demographic characteristics. RESULTS: A total of 115 patients, 48% males, with type 2 diabetes were included in the study. The mean (sd) age of the males was 56.85 (8.96) years and of the females was 55.68 (8.93) years. The mean (sd) total serum homocysteine for males of 12.97 (6.06) micromol/l was significantly higher than that of the females of 10.64 (4.41) micromol/l. The cholesterol, glycated haemoglobin, the body mass index and blood pressure of the study subjects did not show any statistically significant influence on their homocysteine levels. However, increasing age and duration of diabetes showed a significant linear relationship with rising level of total serum homocysteine. Some study participants reported smoking habit but unreliably. CONCLUSION: There was a significant proportion of the study patients with high levels of serum homocysteine, although most of them were of low to intermediate risk category. It may be prudent to assay homocysteine levels in patients with type 2 diabetes who are either older or have had diabetes for long duration for potential intervention.

Cardiovascular risk factors in patients with type 2 diabetes mellitus in Kenya: levels of control attained at the Outpatient Diabetic Clinic of Kenyatta National Hospital, Nairobi.

OBJECTIVES: To determine the proportion of specific cardiovascular risk factors in ambulatory patients with type 2 diabetes and the levels of control achieved in them. DESIGN: Prospective, cross-sectional study over a six month period. SETTING: Out-patient diabetic clinic of the Kenyatta National Hospital. SUBJECTS: Two hundred and eleven patients with type 2 diabetes. MAIN OUTCOME MEASURES: Sociodemographic attributes, duration of diabetes, levels of glycaemia, body weight, blood pressure, fasting lipids and modes of treatment. RESULTS: A total of 211 patients were enrolled, 57.3% were females. The mean (SD) age for women was 54.45 (9.44) and that of men was 55.8 (9.02) years. About 77% of the study population were on oral glucose-lowering agents with or without insulin but less than 30% achieved HbA1c < 7%; 15% were active cigarette smokers; about 50% were hypertensive with female predominance but 65% of them did not achieve desired blood pressure level inspite of treatment. Just over 50% had raised LDL-cholesterol and over 75% had raised total cholesterol but only three men were on statins without achieving desired targets. Body mass index above 30 kg/m2 as a measure obesity was found in 32% of females and 16% males. Most of the study patients admitted use of Aspirin at certain times in the course of their diabetes. CONCLUSION: The study showed that specific cardiovascular risk factors of hyperglycaemia, dyslipidaemia, hypertension and obesity were prevalent although not adequately controlled to targets. Statin use was extremely low in people who already needed them. Regular Aspirin use was infrequent because many patients did not quite understand its role in their diabetes treatment. It is recommended that a more pro-active approach in multifactorial address of cardiovascular risk factors be used in high-risk patients with type 2 diabetes to forestall future cardiovascular events.

Diabetic ketoacidosis: clinical presentation and precipitating factors at Kenyatta National Hospital, Nairobi.

OBJECTIVE: To determine the clinico-laboratory features and precipitating factors of diabetic ketoacidosis (DKA) at Kenyatta National Hospital (KNH). DESIGN: Prospective cross-sectional study. SETTING: Inpatient medical and surgical wards of KNH. SUBJECTS: Adult patients aged 12 years and above with known or previously unknown diabetes hospitalised with a diagnosis of diabetic ketoacidosis. RESULTS: Over a nine month period, 48 patients had DKA out of 648 diabetic patients hospitalised within the period, one died before full evaluation. Mean (SD) age was 37 (18.12) years for males, 29.9 (14.3) for females, range of 12 to 77 years. Half of the patients were newly diagnosed. More than 90% had HbA1c > 8%, only three patients had HbA1c of 7-8.0%. More than 90% had altered level of consciousness, with almost quarter in coma, 36% had systolic hypotension, almost 75% had moderate to severe dehydration. Blunted level of consciousness was significantly associated with severe dehydration and metabolic acidosis. Over 65% patients had leucocytosis but most (55%) of them did not have overt infection. Amongst the precipitating factors, 34% had missed insulin, 23.4% had overt infection and only 6.4% had both infection and missed insulin injections. Infection sites included respiratory, genito-urinary and septicaemia. Almost thirty (29.8%) percent of the study subjects died within 48 hours of hospitalisation. CONCLUSION: Diabetic ketoacidosis occurred in about 8% of the hospitalised diabetic patients. It was a major cause of morbidity and mortality. The main precipitant factors of DKA were infections and missed insulin injections. These factors are preventable in order to improve outcomes in the diabetic patients who complicate to DKA.

Diabetic ketoacidosis: risk factors, mechanisms and management strategies in sub-Saharan Africa: a review.

BACKGROUND: Diabetic ketoacidosis is the most common hyperglycaemic emergency in patients with diabetes mellitus, especially type 1 diabetes. It carries very high mortality in sub-Saharan Africa, both in the treated patients and those who are presenting to hospital with diabetes for the first time. OBJECTIVE: To review the risk factors, mechanisms and management approaches in diabetes ketoacidosis in published literature and to discuss them in the context of why a significant proportion of patients who develop diabetic ketoacidosis in sub-Saharan Africa still have high mortality. DATA SOURCE: Literature review of relevant published literature from both Africa and the rest of the world. DATA SYNTHESIS: The main causes or precipitants of DKA in patients in SSA are newly diagnosed diabetes, missed insulin doses and infections. The major underlying mechanism is insulin deficiency. Treated patients miss insulin doses for various reasons, for example, inaccessibility occasioned by; unavailability and unaffordability of insulin, missed clinics, perceived ill-health and alternative therapies like herbs, prayers and rituals. Infections also occur quite often, but are not overt, like urinary tract, tuberculosis and pneumonia. Due to widespread poverty of individuals and nations alike, the healthcare systems are scarce and the few available centres are unable to adequately maintain a reliable system of insulin supply and exhaustively investigate their hospitalised patients. Consequently, there is little guarantee of successful outcomes. Poor people may also have sub-optimal nutrition, caused or worsened by diabetes, more so, at first presentation to hospital. Intensive insulin therapy in such individuals mimics 're-feeding syndrome', an acute anabolic state whose outcome may be unfavourable during the period of treatment of diabetic ketoacidosis. CONCLUSIONS: Although mortality and morbidity from diabetic ketoacidosis remains high in sub-Saharan Africa, improved healthcare systems and reliable insulin supply can reverse the trend, at least, to a large extent. Individuals and populations need empowerment through education, nutrition and poverty eradication to improve self-care in health and living with diabetes.

Focus on delay as a strategy for care designs and evaluation of diabetic foot ulcers in developing countries: a review.

BACKGROUND: While foot care services for diabetic patients are necessary if limb morbidity and wastage are to be reduced, they may not be sufficient. Even when the few service centers and personnel that are available appear to be functioning relatively well, patients still face multiple barriers to derive maximum benefits from the services. OBJECTIVES: To review certain aspects of care of diabetes foot ulcers in developing countries with emphasis on causes of delay in care delivery. DATA SOURCES: Review of published literature on care of diabetic foot ulcers as well as our local experiences. MAIN OUTCOME MEASURES: Levels of potential or actual delay in care delivery and causes of such delay in pre-hospital phase, access to hospital and within-hospital phase of care. DATA SYNTHESIS AND CONCLUSIONS: The barriers or causes of delay are observed to occur at various levels: decision to seek care, reaching the treatment facility and receiving the desired optimal care. The usual main causative/ risk factors that include peripheral neuropathy causes inattention and delays the decision to seek care; peripheral vascular insufficiency and infection are both involved in initiation of diabetic foot ulcers and are also major causes of delay in ulcer healing process. Aside from the processes unique to diabetes, the health care providers and the facilities of care have had major contributions in delaying the desired care of the foot ulcers. This may arise from heavy workload, priority illnesses, shortage of required supply for standard care and/or just wrong attitudes. Patients' inadequate knowledge of self-care, unique socio-economic and socio-cultural characteristics are also contributors to the barriers that compound sub-optimal foot care. Care programme designs that lay emphasis on causes of delay are more likely to seek to eliminate such causes. Just like justice, footcare delayed is foot (care) denied.