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N PROFOGOLAELIJAHS, OTIENO PROFOGUTUELLY. "Ogola EN, Yonga GO.Comparative study of the efficacy and tolerability of hydroflumethiazide versus propranolol in Africans with mild to moderate hypertension.East Afr Med J. 1993 May;70(5):277-9.". In: East Afr Med J. 1993 May;70(5):277-9. Journal of British Ceramic Transactions, 99 [5], 206-211.; 1993. Abstract

Sixty patients with Diastolic Blood Pressure (DBP) of 100-110mmHg matched for age, sex and Bp levels were randomly assigned to propranolol 80mg daily or Hydroflumethiazide (HFM) 50mg daily. HFM causes a significant reduction in systolic blood pressure (SBP) and DBP within 4 weeks compared both with baseline and propranolol (SBP 143.7 +/- 12.3 vs 158.1 +/- 10.9mmHg, P < 0.05; DBP 92.0 +/- 4.5 vs 102.4 +/- 5.1mmHg, P < 0.05), (SBP 143.7 +/- 12.2 vs 152 +/- 11.0mmHg P < 0.05; DBP 92.0 +/- 4.5 vs 101.1 +/- 6.1mmHg, P < 0.05), respectively. Propranolol produced no significant difference from the baseline at 4 weeks (SBP 152.0 +/- H.0 vs 154.1 +/- 11.5mmHg NS; DBP 101.1 +/- 6.1 vs 102.2 +/- 5.6mmHg, NS). Reduction in BP by HFM was maintained after 8 and 12 weeks with further reduction but which did not achieve statistical significance. Increased dose of propranolol (160mg daily) after 4 weeks caused significant reduction in BP by 8 week (SBP 146.8 +/- 11.8 vs 152.0 +/- 11.0mmHg, P < 0.05; DBP 95.9 +/- 4.4 vs 101.1 +/- 6.1mmHg P < 0.05), which was maintained upto 12 weeks. The values however remained higher than in the HFM group. More patients in the HFM group achieved target BP (< 140/90), SBP 53.8% vs 29.6% P < 0.05, DBP 69.2% vs 14.8% P < 0.01. Incidence of side effects was similar and will be discussed. Thiazides are superior to B'blockers as initial monotherapy in black hypertensives.

N PROFOGOLAELIJAHS, OTIENO PROFOGUTUELLY. "Ogola ES.Use of aspirin in preeclampsia.East Afr Med J. 1995 Nov;72(11):689.". In: East Afr Med J. 1995 Nov;72(11):689. Journal of British Ceramic Transactions, 99 [5], 206-211.; 1995. Abstract
One hundred and twenty consecutive patients above 12 years of age with dyspepsia were studied from June 1993 to September 1994. They underwent upper gastrointestinal endoscopy to find the mucosal lesions which were associated with their dyspeptic symptoms. At endoscopy gastric mucosal biopsies were taken in order to identify Helicobacter pylori (H. pylori) using three different techniques: culture, histology and the rapid urease test. Normal looking mucosa was the commonest single endoscopic finding, accounting for 34.2%, followed by gastritis 31.7% and duodenal ulcer 29.2%. However, when duodenal ulcers and gastric ulcers were put together, then peptic ulcer was the most prevalent finding accounting for 38.4%. Peptic ulcer was the most prevalent pathological finding in both young (less than 50 years) and older patients (50 years and above). Duodenal ulcer was more prevalent than gastric ulcer in the younger age group with a ratio of 5.8:1, however, the ratio in the older age group was 1:1. Gastric cancer was only found in patients aged 50 years and above, accounting for 17.4% of dyspeptic symptoms in this age group. Females were found to have more normal endoscopic findings than males (59.6%, versus 17.8% respectively). The difference being statistically significant (p < 0.001). All our cases of peptic ulcer disease had evidence of H. pylori infection while dyspeptic patients with normal endoscopic mucosal findings had H. pylori in 80.5% of cases. The difference in prevalence of H. pylori in the two groups was statistically significant (p < 0.001). Surprisingly, evidence of H. pylori in gastric cancer cases was very low in this study, being found in only 25% of patients.
OTIENO PROFOGUTUELLY. "Ogutu E.O. Aetiology of Pancreatic Pseudocyst at Kenyatta National Hospital, Nairobi Journal of Medicine, 13:24, 1987.". In: East Afr Med J. 1989 Dec;66(12):830-3. Journal of British Ceramic Transactions, 99 [5], 206-211.; 1989. Abstract

The mean fasting insulin level in 30 apparently normal Kenyan Africans was determined by Radio-Immuno Assay (RIA) technique based on coat A-count. The mean value was found as 16.33 microIu/ml with a standard deviation (s.d) of 10.51 microIu/ml. The mean at 95% confidence interval (CI) for the population studied was 16.33 +/- 1.92. The findings are similar to what have been reported among the caucasians. This paper also reports on a case of insulinoma in a young female patient at Kenyatta National Hospital (KNH).

OTIENO PROFOGUTUELLY. "Ogutu E.O., Kanja C., Kimanzi, Kangethe S.K., Nyongo A. Prevalence of intestinal parasites in Kenyans with dyspepsia. EAMJ 75: 16, 1998.". In: East Afr Med J. 1998 Jan;75(1):16-8. Journal of British Ceramic Transactions, 99 [5], 206-211.; 1998. Abstract
Department of Medicine, University of Nairobi, Kenya. Dyspepsia and intestinal worm infestation are both common clinical conditions in a developing country like Kenya and thus this study was designed to look at the correlation between the two in a referral gastroenterology clinic at Kenyatta National Hospital. One hundred and twenty five patients with dyspepsia had their stool, duodenal aspirate and duodenal biopsy analysed for evidence of intestinal parasites. Seven (5.6%) were found to have various types of intestinal parasites with giardia lamblia comprising 42.8% of worms isolated. 71.4% of patients with dyspepsia and worm infestation had their symptoms improved after deworming, but the low prevalence of intestinal parasite in dyspeptic patients makes routine deworming not cost effective. Stool examination had the best yield for intestinal parasites.
OTIENO PROFOGUTUELLY. "Ogutu E.O., Okoth F.A., Lule G.N. Colonoscopic Findings in Kenyan African Patients EAMJ Vol 75 pp 540 .". In: East Afr Med J. 1998 Sep;75(9):540-3. Journal of British Ceramic Transactions, 99 [5], 206-211.; 1998. Abstract

Kenyatta National Hospital, Nairobi, Kenya. OBJECTIVE: To determine the types and prevalence of colonic diseases in Kenyan African patients referred for colonoscopy with lower gastrointestinal tract symptoms. DESIGN: A cross sectional survey conducted over a two year period. SETTING: Major private hospitals in Nairobi. PATIENTS: Two hundred forty seven consecutive patients of both sexes and all ages referred for colonoscopy between January 1996 and December 1997. Only Kenyans of African origin were included. Patients were referred from all over the country though the majority of cases were from Nairobi and its surrounding districts. RESULTS: The major indications for colonoscopy were lower abdominal pain (35.6%), non-bloody diarrhoea (22.3%), constipation (21.4%) and rectal bleeding (19.8%). Nearly 53% of patients colonoscoped had abnormal mucosal findings, with the main abnormalities being: proctocolitis (20.2%), colorectal cancers (12.1%), haemorrhoids (7.3%), colorectal polyps (6.5%) and diverticulosis (5.3%). The main histological diagnosis among patients whose colonic biopsy were done included normal colonic mucosa (29%), non-specific colitis (28.5%), adenocarcinoma (18.2%), benign colonic polyp (9.7%) and ulcerative colitis (7.3%). There was one case of Crohn's colitis and five cases (3%) of infective colitis. CONCLUSION: The study shows that the African colon has a number of pathological lesions contrary to previous reported literature.

OTIENO PROFOGUTUELLY. "Ogutu E.O., Wankya B.M., Shah M.V., Ndinya Achola J.O. The prevalence of Spontaneous Bacterial Peritonitis at Kenyatta National Hospital. E. Afr. Med. J. 65: 547, 1988.". In: East Afr Med J. 1989 Dec;66(12):830-3. Journal of British Ceramic Transactions, 99 [5], 206-211.; 1988. Abstract
The mean fasting insulin level in 30 apparently normal Kenyan Africans was determined by Radio-Immuno Assay (RIA) technique based on coat A-count. The mean value was found as 16.33 microIu/ml with a standard deviation (s.d) of 10.51 microIu/ml. The mean at 95% confidence interval (CI) for the population studied was 16.33 +/- 1.92. The findings are similar to what have been reported among the caucasians. This paper also reports on a case of insulinoma in a young female patient at Kenyatta National Hospital (KNH).
N PROFLULEGODFREY, OTIENO PROFOGUTUELLY, OLONDE PROFAMAYOERASTUS. "Ogutu EO, Amayo EO, Okoth F, Lule GN. The prevalence of hepatitis B surface antigen (HBsAg), anti-hepatitis B surface (anti-HBs) and anti-hepatitis B core (anti-HBc) in patients with acquired immuno-deficiency syndrome (AIDS). East Afr Med J. 1990 May;67(.". In: East Afr Med J. 1990 May;67(5):355-8. Journal of British Ceramic Transactions, 99 [5], 206-211.; 1990. Abstract
Forty one consecutive patients (24 males and 17 females) with AIDS had their blood assayed for HBsAg, anti-HBs and anti-HBc by Reversed Passive Haemagglutination (RPHA), Passive Haemagglutination (PHA) and Enzyme Linked Immunosorbent Assay (ELISA) techniques respectively. 5 (12.2%) were found positive for HBsAg. 10 (24.4%) for anti-HBs and 31 (75.6%) for anti-HBc. 32 (78%) out of 41 patients with AIDS had serological evidence of exposure to hepatitis B virus (HBV). The prevalence of HBsAg found in this study is not different from what has been found in the Kenyan community without AIDS, while that of anti-HBs is much lower than what has been reported in the general community.
OTIENO PROFOGUTUELLY. "Ogutu EO, Kang'ethe SK, Nyabola L, Nyong'o A.Endoscopic findings and prevalence of Helicobacter pylori in Kenyan patients with dyspepsia.East Afr Med J. 1998 Feb;75(2):85-9.". In: East Afr Med J. 1998 Feb;75(2):85-9. Journal of British Ceramic Transactions, 99 [5], 206-211.; 1998. Abstract
One hundred and twenty consecutive patients above 12 years of age with dyspepsia were studied from June 1993 to September 1994. They underwent upper gastrointestinal endoscopy to find the mucosal lesions which were associated with their dyspeptic symptoms. At endoscopy gastric mucosal biopsies were taken in order to identify Helicobacter pylori (H. pylori) using three different techniques: culture, histology and the rapid urease test. Normal looking mucosa was the commonest single endoscopic finding, accounting for 34.2%, followed by gastritis 31.7% and duodenal ulcer 29.2%. However, when duodenal ulcers and gastric ulcers were put together, then peptic ulcer was the most prevalent finding accounting for 38.4%. Peptic ulcer was the most prevalent pathological finding in both young (less than 50 years) and older patients (50 years and above). Duodenal ulcer was more prevalent than gastric ulcer in the younger age group with a ratio of 5.8:1, however, the ratio in the older age group was 1:1. Gastric cancer was only found in patients aged 50 years and above, accounting for 17.4% of dyspeptic symptoms in this age group. Females were found to have more normal endoscopic findings than males (59.6%, versus 17.8% respectively). The difference being statistically significant (p < 0.001). All our cases of peptic ulcer disease had evidence of H. pylori infection while dyspeptic patients with normal endoscopic mucosal findings had H. pylori in 80.5% of cases. The difference in prevalence of H. pylori in the two groups was statistically significant (p < 0.001). Surprisingly, evidence of H. pylori in gastric cancer cases was very low in this study, being found in only 25% of patients.
OTIENO PROFOGUTUELLY. "Ogutu EO, Lore W.The aetiology and presentation of chronic calcific pancreatitis in patients seen at Kenyatta National Hospital. East Afr Med J. 1988 Mar;65(3):155-9. No abstract available.". In: East Afr Med J. 1989 Dec;66(12):830-3. Journal of British Ceramic Transactions, 99 [5], 206-211.; 1988. Abstract
The mean fasting insulin level in 30 apparently normal Kenyan Africans was determined by Radio-Immuno Assay (RIA) technique based on coat A-count. The mean value was found as 16.33 microIu/ml with a standard deviation (s.d) of 10.51 microIu/ml. The mean at 95% confidence interval (CI) for the population studied was 16.33 +/- 1.92. The findings are similar to what have been reported among the caucasians. This paper also reports on a case of insulinoma in a young female patient at Kenyatta National Hospital (KNH).
OTIENO PROFOGUTUELLY. "Ogutu EO, Lule GN, Okoth F, Musewe AO.Gastric carcinoma in the Kenyan African population.East Afr Med J. 1991 May;68(5):334-9.". In: East Afr Med J. 1991 May;68(5):334-9. Journal of British Ceramic Transactions, 99 [5], 206-211.; 1991. Abstract

Fifty three consecutive patients with histological evidence of gastric carcinoma were studied between June 1987 and June 1989 at Kenyatta National Hospital (KNH). The male to female ration was 3.4:1 and the peak age of occurrence was in the 7th decade with 62.3% of gastric carcinoma being at the gastric antrum. Poorly differentiated adenocarcinoma was found in 68.2% of patients while well differentiated adenocarcinoma in 4.5% of cases. Intestinal metaplasia was a rare finding. If Lauren's classification of gastric carcinoma is considered then diffuse type of gastric cancer is by far the commoner type in our environment.

N PROFLULEGODFREY, OTIENO PROFOGUTUELLY. "Ogutu EO, Lule GN, Okoth F, Mwai SJ. The clinical pattern of duodenogastric bile reflux in the Kenyan Africans. East Afr Med J. 1989 Jan;66(1):35-9.". In: East Afr Med J. 1989 Jan;66(1):35-9. Journal of British Ceramic Transactions, 99 [5], 206-211.; 1989. Abstract
Forty consecutive African patients found to have duodenogastric bile reflux at endoscopy were studied. Bile reflux was found more commonly among males than females, giving a male/female ratio of 2.3:1, with a peak age at 41-60 years. ABO blood groups had no significant influence on duodenogastric bile reflux. Flatulence and borborygmi were the most consistent symptoms other than the classical dyspeptic pain pattern. Bilious vomiting was a rare finding. Duodenogastric bile reflux was more commonly associated with endoscopic gastritis (67.5%), gastric ulcer (35%) and oesophagitis (30%) than with duodenal ulcer (22.5%), deformed pyloric ring (5%) or distorted duodenal bulb (2.5%). The dysfunction in the pyloric sphincter in people with duodenogastric bile reflux appears to be more of a physiological defect than structural.
N PROFLULEGODFREY, OTIENO PROFOGUTUELLY. "Ogutu EO, Lule GN, Okoth FN, Were BO. The pattern of chronic gastric ulcer at Kenyatta National Hospital (K.N.H.). East Afr Med J. 1989 Jan;66(1):10-4.". In: East Afr Med J. 1989 Jan;66(1):10-4. Journal of British Ceramic Transactions, 99 [5], 206-211.; 1989. Abstract
Thirty consecutive patients with gastric ulcer diagnosed during upper gastrointestinal fibreoptic panendoscopy at both Kenya Medical Research Institute and Kenyatta National Hospital endoscopy rooms were studied. The male/female ratio was 5:1 with a peak prevalence in the 6th decade. 76.6% of the patients were from the Kikuyu ethnic group. Smoking habit was found in only 50% of patients with gastric ulcers. There were a total of 32 gastric ulcers in 30 patients. 84.4% of these were at the incisura angularis. All the incisural ulcers were benign. Two (6.25%) of the 32 ulcers were malignant (one at the cardia and the other at the antrum). Gastric ulcers whose diameter were greater than 30 mm had a higher tendency of being malignant. Five patients (16.7%) had both gastric (4 benign and 1 malignant) and duodenal ulcers while 4 (13.3%) patients had both gastric and pyloric ring ulcers. Apparent healing of a gastric ulcer while on an H2-antagonist does not totally exclude malignancy. Upper gastrointestinal bleed which was present in 53.3% of cases was the most frequent complication.
OTIENO PROFOGUTUELLY. "Ogutu EO, McLigeyo SO. Adult polycystic liver disease.East Afr Med J. 1991 May;68(5):352-8.". In: East Afr Med J. 1991 May;68(5):352-8. Journal of British Ceramic Transactions, 99 [5], 206-211.; 1991. Abstract
Characteristics of 14 patients above 12 years of age with congenital polycystic liver disease attending liver clinic at KNH were analysed. The diagnosis was mainly based on ultrasonographic findings. The disease was found predominantly among the Kikuyu ethnic group with a female/male ratio of 6:1 and the peak age at presentation was in the 5th decade. The liver function tests were essentially normal in all cases with no complication directly relating to liver disease. Hypertension was found in 78.6% of cases and chronic renal failure in 35.7% of cases. There was an associated polycystic disease in at least one other abdominal organ in all cases.
OTIENO PROFOGUTUELLY. "Ogutu EO, Orinda DA.Fasting insulin levels in normal Kenyan Africans and a case report on insulinoma.East Afr Med J. 1989 Dec;66(12):830-3.". In: East Afr Med J. 1989 Dec;66(12):830-3. Journal of British Ceramic Transactions, 99 [5], 206-211.; 1989. Abstract
The mean fasting insulin level in 30 apparently normal Kenyan Africans was determined by Radio-Immuno Assay (RIA) technique based on coat A-count. The mean value was found as 16.33 microIu/ml with a standard deviation (s.d) of 10.51 microIu/ml. The mean at 95% confidence interval (CI) for the population studied was 16.33 +/- 1.92. The findings are similar to what have been reported among the caucasians. This paper also reports on a case of insulinoma in a young female patient at Kenyatta National Hospital (KNH).
OTIENO PROFOGUTUELLY. "Ogutu EO.The pattern of acute pancreatitis at Kenyatta National Hospital (KNH): retrospective study. East Afr Med J. 1988 Feb;65(2):86-91. No abstract available.". In: East Afr Med J. 1989 Dec;66(12):830-3. Journal of British Ceramic Transactions, 99 [5], 206-211.; 1988. Abstract
The mean fasting insulin level in 30 apparently normal Kenyan Africans was determined by Radio-Immuno Assay (RIA) technique based on coat A-count. The mean value was found as 16.33 microIu/ml with a standard deviation (s.d) of 10.51 microIu/ml. The mean at 95% confidence interval (CI) for the population studied was 16.33 +/- 1.92. The findings are similar to what have been reported among the caucasians. This paper also reports on a case of insulinoma in a young female patient at Kenyatta National Hospital (KNH).
OTIENO PROFOGUTUELLY. "Ogutu EO.The pattern of pancreatic carcinoma at Kenyatta National Hospital. East Afr Med J. 1989 Feb;66(2):105-8.". In: East Afr Med J. 1989 Jan;66(1):10-4. Journal of British Ceramic Transactions, 99 [5], 206-211.; 1989. Abstract
A 10-year (1976-1986) retrospective study was done on 30 cases with histological diagnosis of pancreatic carcinoma. The male to female ratio was 1.3:1 and the peak incidence was in the 6th and 7th decades. The head of the pancreas was involved in 96% of cases while solid adenocarcinoma of duct cell origin accounted for 73.3% of cases, followed by anaplastic carcinoma (23.3%). The commonest complications were distinct metastasis (86.6%), obstructive jaundice (73.3%) and upper gastrointestinal bleed (13.6%).
N PROFLULEGODFREY, OTIENO PROFOGUTUELLY. "Okoth FA, Lule GN, Ogutu EO, Pilczer S, Dubois C. Famotidine in the management of gastro-oesophageal reflux. East Afr Med J. 1994 Jan;71(1):44-8.". In: East Afr Med J. 1994 Jan;71(1):44-8. Journal of British Ceramic Transactions, 99 [5], 206-211.; 1994. Abstract
Famotidine has been used for the treatment of peptic ulcers and Zollinger Ellison syndrome and is also useful in reflux and erosive oesophagitis. To evaluate the effects of Famotidine 20 mg given twice daily in the symptomatic relief of gastro-oesophageal reflux disease with normal oesophagus or mild endoscopic oesophagitis, patients were followed over a period of six weeks. 70% of the patients had complete day-time heartburn relief during the study and 75% had complete night-time heartburn relief during the study. Famotidine was found to be safe and there were no serious clinical or laboratory adverse experiences.
OTIENO PROFOGUTUELLY. "Okoth FA, Ogutu EO, Lule GN, Wambugu MN.Some aspects of obstructive jaundice at Kenyatta National Hospital. East Afr Med J. 1989 Sep;66(9):594-7.". In: East Afr Med J. 1989 Jan;66(1):10-4. Journal of British Ceramic Transactions, 99 [5], 206-211.; 1989. Abstract
A prospective study was carried out at Kenyatta National Hospital (KNH) between June 1987 and September 1988 to look at some aspects of obstructive jaundice in patients above 12 years of age. Screening for cases was done by use of abdominal ultrasonography. A total of 20 cases (11 females, 9 males) were diagnosed. Carcinoma of the head of pancreas accounted for 55% of cases of the obstruction, followed by gallstones (10%), hepatocellular carcinoma (10%) and gall bladder tumour (10%).
OTIENO PROFOGUTUELLY. "Omonge E., Ogutu E.O., Aluoch J.R. Clinical and laboratory predictors of Cholelithiasis in patients with sickle cell anaemia. EAMJ 75: 347, 1998.". In: East Afr Med J. 1998 Jun;75(6):347-50. Journal of British Ceramic Transactions, 99 [5], 206-211.; 1998. Abstract
Kiambu District Hospital, Nairobi, Kenya. Cholelithiasis is a common clinical condition in patients with sickle cell disease and there are conflicting reports on laboratory indices useful in predicting those patients who are likely to have gallstones. There is however lack of similar studies from Kenya. We therefore studied the role of clinical (Body Mass Index), haematological (reticulocyte count, haemoglobin level), and biochemical (serum bilirubin: direct and indirect, serum alkaline phosphatase, serum transaminase) indices in predicting sickle cell anaemia patients likely to develop gallstones. A cross sectional descriptive study was conducted from October 1993 to December 1994 on consecutive male and female patients of all ages with homozygous sickle cell disease (HbSS) confirmed by cellulose acetate paper electrophoresis. A total of 64 patients aged between three and 37 years were recruited into the study. They were classified into two groups: stone formers and non-formers. The difference in the two groups with respect to clinical, haematological and biochemical indices were determined by Chi-square contingency test. Body mass index (BMI), reticulocyte count and alkaline phosphatase were found to have a significant positive association with increased likelihood of gallstone formation at p values of 0.004, 0.007 and 0.007, respectively. The rest of the study indices had no association. The cut-off points were reticulocyte counts above ten per cent and alkaline phosphatase levels above 13 K.A. units. Though sickle cell anaemia patients with BMI > 20 had significant increased likelihood of cholelithiasis, we could not determine its cut-off value.
N PROFOGOLAELIJAHS, OTIENO PROFOGUTUELLY. "Oyoo GO, Ogola EN.Clinical and socio demographic aspects of congestive heart failure patients at Kenyatta National Hospital, Nairobi.East Afr Med J. 1999 Jan;76(1):23-7.". In: East Afr Med J. 1999 Jan;76(1):23-7. Journal of British Ceramic Transactions, 99 [5], 206-211.; 1999. Abstract
socio-demographic determinants in patients admitted to Kenyatta National Hospital, Nairobi in congestive heart failure. DESIGN: Cross sectional descriptive study. SUBJECT: All patients aged thirteen years and above of either sex consecutively admitted with clinical diagnosis of congestive heart failure. SETTING: Kenyatta National Hospital (KNH), a national referral hospital. PATIENT EVALUATION: Detailed history including socio-demographic characteristics and physical examination was done. Patients underwent haematological and biochemistry tests followed by a chest x-ray, ECG and 2D Echo-doppler examination. Blood culture sensitivity was done when clinically indicated. RESULTS: Ninety one patients were studied, 44 males and 47 females. Almost 32% had rheumatic heart disease, 25.2% had cardiomyopathy, 17.6% hypertensive heart disease, 13.2% had pericardial disease while 2.2% had ischaemic heart disease. Three quarters of patients with hypertensive heart disease were above the age of 50 years, while 79% of patients with rheumatic heart disease were below the age of 30 years. Factors associated with patient deterioration leading to admission with congestive heart failure (CHF) included inadequate therapy (27.4%), arrhythmia (20.9%), respiratory infections (17.6%), anaemia (13.2%) and infective endocardiatis. Sixty two per cent of patients investigated were in New York Heart Association (NYHA) functional classification class IV, 31.9% in class III and 5.5% in class II. CONCLUSION: Congestive heart failure constitutes 3.3% of all medical admissions at KNH. Rheumatic heart disease is the commonest cause of congestive heart failure in our set-up while inadequate therapy, arrhythmias and respiratory infections are the three major causes of decompensation in our patients with cardiac disease.

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