| PROF. OTIENO C. F. FREDRICK

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(Last updated: July 3, 2019)

Publications

2016

Oyoo, GO, Genga EK, Otieno CF, Ilovi CS, Omondi EA, Otieno FO. 2016. Clinical and socio-demographic profile of patients on treatment for osteoporosis in Nairobi, Kenya, 9. East African Orthopaedic Journal. 9(2) Abstract

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, Kenya

2015

FO Otieno, GO Oyoo, CFOEAO, Oyoo GO, Otieno CF, Omondi EA. 2015. Clinical presentation of patients with adult onset still’s disease in Nairobi: case series. African Journal of Rheumatology. 3(1) AbstractWebsite

Introduction: Adult Still’s Disease (ASD) is a systemic inflammatory disorder of unknown etiology, typically characterized by a clinical triad (daily spiking high fevers, evanescent rash, arthritis), and a biological triad (hyperferritinemia, hyperleukocytosis with neutrophilia and abnormal liver function test).
Objective: This case series set out to describe the clinical characteristics of patients with ASD seen at a rheumatology clinic in Nairobi.
Results: After a record search, 8 patients were noted to have ASD. Fever and arthritis were noted to be most predominant presenting features with almost all the patients having hyperferritinemia.

CF Otieno, CSIGOO, Genga EK, Otieno FO, Ilovi CS, Ilovi CS. 2015. CF Otieno CF Otieno Clinical profiles of patients with osteoporosis in Nairobi. Abstract

Background: Osteoporosis, a chronic, progressive disease of multifactorial aetiology and one of the most common metabolic bone diseases worldwide. Despite ample sunshine, the Middle East and Africa register the highest rates of rickets worldwide. Low levels of vitamin D are prevalent throughout the region. 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 : This study sets out to describe the clinical characteristics of patients with osteoporosis seen at a rheumatology clinic in Nairobi. Methods : This was a cross-sectional study done on patients with the World Health Organization (WHO) definition of osteoporosis of a T-score of –2.5 on bone mineral density scan. The study site was a rheumatology clinic in Nairobi. The study variables were age, sex, clinical presentation and selected comorbidities. Results : Fifty six patients with a WHO definition of osteoporosis were recruited. The age distribution was 31- 95 years with a mean age of 63.95 years with the most affected being above the age of 60 years at 71.5%. Majority were female (89.3%), with the main presenting complaints as polyarthralgia (30.4%) followed by lower back pain (19.6%) and pathological fractures (12.5%). The most common comorbidity being rheumatoid arthritis (39.3%) followed by steroids therapy (25%). Others included osteoarthritis, fibromyalgia, systemic lupus erythromatosus and diabetes. Seven study participants had history of fracture with lumbar 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 21.4%. Conclusion: The findings of this study from age to comorbidities on osteoporosis are in keeping with literature. The presence of fibromyalgia as a comorbidity was an interesting finding. The number of patients on bisphosphonates was low which differed from Western literature. Stratification of patients at risk should be done so that active screening and prompt early management for osteoporosis can be instituted. Attempts should be to offer cheaper bisphosphonates so that the affected can benefit from the drugs

2014

Genga, EK, Oyoo GO, Otieno CF. 2014. WHEN IS THE LAST TIME YOU LOOKED FOR DIFFUSE INFILTRATIVE LYMPHOCYTOSIS SYNDROME (DILS) IN HIV PATIENT? African Journal of Rheumatology. 2(2):3-6. Abstract

BACKGROUND: Diffuse infiltrative lymphocytosis syndrome (DILS) is characterised by a persistent CD8+ lymphocytosis and lymphocytic infiltration of various organs. The exact prevalence isn’t known but some studies have reported between 0.85 – 3%, and appears to be more common in African population. Patients with DILS tend to have higher CD4cell counts and survive longer than those patients without DILS. Most patients present with bilateral parotid gland enlargement and features of the Sicca syndrome. Common sites of extra glandular involvement are the lungs being the most common site, followed by peripheral neuropathy and liver. With the high incidence of HIV in our population it is likely that DILS is under diagnosed probably due to our ignorance of this disease. Awareness of its various presentations may bring to light undiscovered patients with DILS.
OBJECTIVE: To review pathogenesis, diagnostic approach and current trends in the management of Diffuse interstitial lymphocytic syndrome
DATA SOURCE: Literature review of relevant published literature from both Africa and the rest of the world.
DATA SYNTHESIS:Pathologically, under light microscopy, DILS resembles the focal sialadenitis seen with Sjogren’s syndrome, although it tends to be less destructive of the glandular architecture than in Sjogren’s syndrome. Most of the inflammatory infiltrate is composed of CD8+ lymphocytes unlike Sjogren’s which are CD4+. Lymphoepithelial cysts are frequently observed in the parotid glands of patients with DILS. The variation in CD8 count in the course of HIV disease is less understood. The variation in CD8 lymphocytes is implicated in the pathogenesis of a number of clinical manifestations in HIV diseases including diffuse infiltrative lymphocytic syndrome (DILS) and HIV associated CD8+ lymphocytosis syndrome.Parotid gland enlargement in a patient with HIV infection should prompt clinicians to suspect DILS. In addition, clinicians should be aware that the pulmonary process associated with DILS may mimic clinically and radiographically the pneumonic process caused by Pneumocystis carinii. Other manifestations of DILS to consider include a severe form of peripheral neuropathy; lymphocytic infiltration of the liver, evident as hepatitis; myositis; and lymphocytic interstitial nephritis.Management of DILS is determined by the severity of glandular and extra glandularfeatures.Data on therapeutic trials are lacking although there are isolated reports of good response to antiretroviral and steroid therapy.

CONCLUSION: DILS, a subset of HIV disease manifestation, may present as parotid gland swellings. In general, an HIV patient presenting with DILS has a better prognosis than a patient with HIV alone.With the high incidence of HIV in our population it is likely that DILS is under diagnosed probably due to our ignorance of this disease. Awareness of its various presentations may bring to light undiscovered patients with DILS. Clinicians should watch for the possible transformation into B-cell lymphoma. There is still paucity of data about this disease from pathophysiology to treatment to studies correlating the plasma viral load with CD8 lymphocyte count in patients with HIV disease.

Genga, EK, Otieno CF, OGOLA EN, Maritim MC. 2014. Assessment of the Perceived Quality of Life of Non insulin Dependent D iabetic patients attending t he Diabetes Clinic in Kenyatta National H ospital. IOSR Journal Of Pharmacy. 4(3):15-21. Abstract

BACKGROUND: Diabetes Mellitus is a common and demanding health related problem that has a wide effect on every day’s life of the patients. It can have a profound effect on quality of life in terms of social and psychological well-being as well as physical ill-health. It is one of the most psychologically demanding of the chronic diseases; with psychosocial factors pertinent to nearly every aspect of the disease and its treatment.
OBJECTIVE: To Assess the perceived Health-related quality of life of diabetic patients not on insulin therapy using the WHOQoL-Bref (World Health Organization Quality of Life – Brief).
STUDY DESIGN: This was a cross-sectional study.
STUDY SITE: The study was conducted on patients attending the Diabetic clinic at Kenyatta National Hospital.
RESULTS: Study recruited 139 patients with type2 diabetes not on insulin therapy. The study population was predominantly female (61%) , majority were 40-60yrs, having had diabetes for less than 5yrs, 75% having more than one complication. Most (75%) of the study participants were poorly controlled with HbA1C mean score of 8.04% .Majority of the study participants( 84%) achieved a good score on the HRQoL scale using the WHOQoL-Bref tool. The determinants of HRQoL in our study were: age of study participants, duration of diabetes, presence of complications and income related factors. Age of the study subjects had significant association only in the social domain of HRQoL with a p-value of 0.037. Level of income had a significant association with overall HRQoL score (p-value of 0.029), psychological domain (p value of 0.023) and in the social domain (p-value of 0.029). Health care financing was significantly associated with psychological domain (p-value 0.006) and environmental domain (p-value 0f 0.04) and overall score (p-value 0.011). There was an association between employment status and HRQoL. Having a job improved the scores in physical domain (p-value of 0.013) and social domain (p value of 0.020). Duration with diabetes had significant association with physical domain where the p value was 0.007. The HRQoL of the study subjects was associated significantly with the number of complications. Indeed the association of complications with the HRQoL involved physical domain (p-value of <0.0001) and psychological domain (p-value of 0.041) which directly impacted on the overall total score (p value of 0.041).
CONCLUSION: The results of this study show that diabetes affected HRQoL of our study participants. There is a need for interventions programs to improve glycemic control and inclusion of HRQoL assessment as part of patients on follow up. Age and duration of disease are not modifiable but complications can be reduced by better health care initiaves. Income-related factors can be modifiable through poverty alleviation and pooled health care financing.

Genga, EK, Otieno CF. 2014. Case report of patient with pheochromocytoma presenting with gangrene and Diabetes. European International Journal of Applied Science and Technology . 1 (2):74-84.. Abstract

INTRODUCTION: A pheochromocytoma is a rare, catecholamine-secreting tumour that may precipitate life-threatening hypertension. The tumour is malignant in 10% of cases but may be cured completely by surgical removal. Because of excessive catecholamine secretion, pheochromocytomas may precipitate life-threatening hypertension or cardiac arrhythmias. If the diagnosis of a pheochromocytoma is overlooked, the consequences can be disastrous, even fatal; the diagnosis can be established by measuring catecholamines and metanephrines in plasma (blood) or through a 24-hour urine collection. The most common clinical sign of pheochromocytoma is sustained or paroxysmal hypertension, and the most common symptoms are headache, excessive truncal sweating, and palpitation. In some cases, the clinical symptoms are not clear. Roughly 70% of adrenal incidentalomas are non-functional. A small group of 5–7% of the functional ones (30%) may exist as pheochromocytoma. Ten percent of pheochromocytoma cases are diagnosed incidentally during computed tomography (CT) or magnetic resonance imaging (MRI) screenings for other reasons.
CASE PRESENTATION: 21 year old female patient who was referred to Kenyatta National Hospital with diagnosis of gangrene in a young lady newly diagnosed with diabetes in a known hypertensive for three years. The gangrene was of a duration of two weeks. She was diagnosed with diabetes during work up for the cause of the gangrene. Investigations revealed a 24 hour-urine norepinephrine levels of 5085nmol, Normetanephrines excretion of 45213nmol over 24hoursShe tested negative for HIV, Hepatitis B and C surface antigens, VDRL, ANA, C-Anca and P-Anca. Abdominal ultrasound showed normal sized kidneys with a suprarenal mass (80 *63) mm with ectopic right kidney in pelvis, ECG a sinus tachycardia, Echo cardiogram reported as normal with an LVEF of 54%. Arteriogram had a vaso- occlusive disorder at the digital femoral artery and CT abdomen showing a supra renal mass (8x6x5) cm border of head and body of pancreas displacing the right kidney inferiorly. The patient underwent an amputation of the limb and adrenelectomy. Following the surgery the blood pressure and the glucose has normalised and currently is of medication
CONCLUSION: Diagnosis of hypertension in a young patient should involve looking for secondary causes of the disease. A young hypertensive patient presenting with a triad of headaches, palpitations, and sweating was then investigated for pheochromocytoma. Pheochromocytoma can present and occur as an emergency ranging from pheochromocytoma-related multisystem failure, cardiovascular emergencies, pulmonary emergencies, abdominal emergencies, neurologic emergencies, renal emergencies, and metabolic emergencies. This presentations are associated with a high morbidity and mortality if pheochromocytoma is unsuspected. This presentation was unique because it was none of the expected emergencies but a rapidly evolving asymmetrical gangrene of the right foot.
Key words: pheochromocytoma, gangrene
Abbreviations: ANA- Antinuclear antibody
C-Anca- Cytoplasmic antineutrophil cytoplasmic antibodies
P-Anca- Perinuclear Anti-Neutrophil Cytoplasmic Antibodies

2013

Maritim, MC, Otieno CF, Omonge EO, LULE GN. 2013. Evolution of HIV Training for Enhanced Care Provision in Kenya: Challenges and Opportunities. East African Medical Journal. 90(12) AbstractWebsite

Background: Healthcare worker capacity building efforts over the past decade have resulted in decentralisation of HIV prevention, care and treatment services
Objective: To provide an overview of the evolution of HIV training in Kenya, from 2003 to date
Data 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.

AEO Otedo, GO Oyoo, JOOCFOEOO. 2013. Pyomyositis in HIV: A Series of 12 Cases. East African Medical Journal Vol.. 90(12) AbstractWebsite

Background: Pyomyositis is a bacterial infection of the large skeletal muscles presenting with muscle pain and swelling. It is commonly seen in the tropics but is being recognised more in end-stage HIV/AIDS. In HIV-associated pyomyositis, leukocytosis and bacteraemia is rare due to deranged immune response. Surgical drainage, antibiotic treatment and HAART are the mainstay of treatment.
Objective: To describe pyomyositis in HIV positive patients, their CD4+ cell counts, clinical stages of pyomyositis and anatomical sites affected.
Design: Cross sectional, prospective, descriptive, consecutive entry study.
Setting: Kisumu District Hospital and Nairobi Rheumatology Clinic between January 2002 to December 2007.
Subjects: Twelve patients with HIV infection and pyomyositis.
Main Outcome Measures: CD4+ cell counts, clinical stage and site of pyomyositis.
Results: Twelve patients (six males and six females) were enrolled with mean age of 39.3 years (24-52). Pyomyositis was localised in the following regions:two each in gluteal and calf, six in the thigh and one each in the right arm and abdominal wall. CD4+ cell counts were low with a mean of 166.8 cells/µl (1.0-433) (normal range is 355-1600 cells/µl), indicating severe immunosuppression. They also had leucocytopaenia with a mean white blood cell count of 3.67 ~ 103/µl (1.5-7.1 ~ 103/µl) with a mean neutrophil count of 62.7% (43-78). Random blood sugar and creatine kinase levels were all normal. The co-morbidities comprised one case of deep venous thrombosis (DVT) and five of oral candidiasis. Pus swab grew Staphylococcous aureus in eight instances and Streptococcous pyogenes in four.
Conclusion: Pyomyositis in HIV positive patients tends to occur at low CD4+ cell counts. Staphylococcus aureus was the most common causative organism.

CF Otieno, AEO Otedo, MYOEOOGOO. 2013. Reasons for Change of Anti-Retroviral Therapy (ART) Drugs: Local Experience. East African Medical Journal. 90(12) AbstractWebsite

Background: Highly active anti-retroviral therapy (HAART) reduces morbidity and mortality in HIV/AIDS infected patients. HAART is used indefinitely and the regimens are changed over the course of treatment due to resistance, adverse drug reactions or access to drugs. Few studies have been done in resource constrained setting to assess these factors that have a bearing on compliance and success of treatment.
Objective: To determine the number of patients who changed HAART regimen and reasons for change, their CD4+ cell counts and clinical events in the course of HAART.
Design: A prospective, observational study.
Setting: Kisumu District Hospital and Nairobi Rheumatology Clinic.
Subjects: Twenty nine of the 101 patients who were on HAART.
Main Outcome Measures: Resistance to HAART, adverse drug reactions, change of drugs (HAART) regimen or failed response to HAART regimen.
Results: One hundred and one (60 males and 41 females) patients were screened and initiated on HAART. Twenty nine (12 males and 17 females) were included in the study. The mean age was 41.7 years, mean CD4+ cell count prior HAART initiation was 140.8 cells/µl. Thirteen patients developed treatment failure on HAART and their mean CD4+ cell count at the 12th month when the drug were changed was 96.5 cells/µl. Five patients developed neuropathy, one developed lipodystrophy, one ART related
liver injury, three pancreatitis, four changed due to cost and one due to Steven Johnson syndrome. Thirteen patients had resistance to HAART and ten of the 13 had new clinical events: - cryptococcous meningitis, pulmonary tuberculosis, cytomegalovirus (CMV), herpes zoster virus (HZV), pneumocystis jiroveci pneumonia and chronic diarrhoea. Five patients had a documented high HIV-RNA viral load mean of 619,919.5 copies/ml (5.792 log units) at the time of changing HAART at 12 months. Eight of the 13 did not have HIV-RNA viral load due to high cost.
Conclusion: Reasons for Changing HAART included: cost of HAART, Poor tolerability Toxicities (neuropathy, and lipodystrophy, anti-retroviral related liver injury (ARLI), Steven Johnson Syndrome, pancreatitis) and probable failure of to HAART. CD4+ cell count was declining in the HAART resistance group. Failing response to HAART in routine clinical practice is recognised. Effort must be made to put in place resistance surveillance without HAART, CD4+ cell count, HIV viral load and clinical assessment are in patients on parameters to consider when changing treatment.

Otieno, CF, Otedo AEO, Oyoo GO, Omonge EO. 2013. Diabetes Mellitus/ HIV Interphase: A Series of 10 Cases. . East African Medical Journal. 90(12):53-56.

Otedo, AEO, Oyoo GO, Otieno JO, Otieno CF, Omonge EO. 2013. Pyomyositis in HIV: A Series of 12 Cases.. East African Medical Journal. 90(12):48-52.

Otedo, AEO, Otieno CF, Oyoo GO, Omonge EO. 2013. Anti-Retroviral Therapy Related Liver Injury (ARLI): A Series of 11 Cases.. East African Medical Journal. 90(12):40-47.

Otedo, AEO, Otieno CF, Jowi J, Oyoo GO, Omonge EO. 2013. Cryptococcus Meningitis in a Cohort of HIV Positive Kenyan Patients: Outcome after Two Weeks of Therapy. East Afr Med J.201. East African Medical Journal. 90(12):33-39.

Otedo, AEO, Otieno JO, Otieno CF, Oyoo GO. 2013. Cholangiopathy in a Cohort of HIV Positive Kenyan Patients. East African Medical Journal. 90(12):25-32.

Otieno, CF, Otedo AEO, Othero D, Otiende MY, Okoth P, Omonge EO, Oyoo GO. 2013. CD4+ Cell Response to Anti-Retroviral Therapy (ARTS) in Routine Clinical Care over One Year Period in a Cohort of HAART Naïve, HIV Positive Kenyan Patients. East African Medical Journal. 90(12):15-24..

Otedo, A. E, O, Otieno CF, Okal C, Othero D, Oyoo GO, Omonge EO. 2013. Morbidity and CD4+Cell Counts at Initial Presentation of a Cohort of HAARTNaïve, HIV Positive Kenyan Patients: Implications to Initiating HAART.. East African Medical Journal. 90(12):3-14.

Otieno, CF. 2013. HIV: Situation Analysis for Kenya.. East African Medical Journal. 90(12):1-2.

A.A. McLigeyo, G. Lule, C.F.OTIENO, J.K. Kayima, E. Omonge. 2013. Human immunodeficiency virus (HIV) associated lipodystrophy: The prevalence, severity and phenotypes in patients on highly active anti-retroviral therapy (HAART) in Kenya. Academic journals. 5(4):107-113. Abstract

Highly active antiretroviral therapy (HAART) is widely accessible to human immunodeficiency virus (HIV)-infected individuals in Kenya. Their long term use is associated with chronic complications such as lipodystrophy which may lead to stigmatization, reduced self esteem and poor adherence to HAART. This cross-sectional study described the prevalence of lipodystrophy, the phenotypes and severity among adult HIV infected patients on chronic HAART at a HIV clinic in Kenya. Data were collected using an investigator administered questionnaire and anthropometric measurements done using a protocol based on the Third National Health and Nutrition Examination Survey. The prevalence of lipodystrophy was 51.3% (confidence interval (CI) 45.6 to 57.6). Lipoatrophy occurred in 44%, lipohypertrophy in 15% and mixed syndrome in 41% of patients with lipodystrophy. Facial atrophy occurred in 75.7% of patients with lipodystrophy, upper limb atrophy in 48.5%, and lower limb atrophy in 36.8%. Abdominal obesity occurred in 40.4% of patients with lipodystrophy, breast enlargement in 30.9% and dorsocervical fat accumulation in 5.1%. Most patients had severe lipoatrophy, whereas lipohypertrophy was described as mild to moderate using the HIV out-patient study (HOPS) scale. HIV associated lipodystrophy was common in HIV-infected patients on chronic HAART. The main phenotype was lipoatrophy which majority of the patients described as severe.

A.A. McLigeyo, G. Lule, C.F.OTIENO, J.K. Kayima, Omonge E. 2013. Metabolic factors associated with the development of lipodystrophy in patients on long-term highly active anti-retroviral therapy (HAART). Academic journals. 5(5):142-148. Abstract

Dyslipidemia, insulin resistance and diabetes are frequent in patients on highly active anti-retroviral
therapy (HAART) and especially in patients with lipodystrophy, and may lead to atherosclerosis. This
study described the metabolic alterations associated with lipodystrophy in adults on chronic HAART in
Kenya. The prevalence of dyslipidaemia amongst the study participants was (211) 79.6%. Elevated total
cholesterol was found in 129, high low-density-lipoprotein cholesterol (LDL-C) in 107, low High-density
lipoprotein cholesterol (HDL-C) in 110 and high triglycerides in 131 participants. Lipodystrophic
patients were more likely to have dyslipidemia than normal lipids (55.4 versus 35.1%, p = 0.007 OR 2.2
CI 1.3 to 4.6) with 57, 45.9, 65.9 and 45.2% having elevated total cholesterol, elevated LDL-C, elevated
triglycerides and low HDL-C, respectively. Hypertriglyceridemia and hypercholesterolemia were
significantly associated with lipodystrophy (OR 3.8 CI 2.3 to 6.4; p = 0.000) and (OR 1.94 CI 1.2 to 3.2; p
= 0.008), respectively. The odds of lipodystrophy was 2.913 times higher for patients with elevated
triglycerides than for those with normal triglycerides (p < 0.001). Sixty-four (24.3%) participants had
dysglycemia, with 3.5% having diabetes and 20.8% having impaired fasting glucose (IFG). Among
patient with lipodystrophy, 69.8% had normal fasting glucose, 25.1% had IFG and 5.1% were diabetic.
Lipodystrophic patients were not more likely to have abnormal blood sugars than normal blood sugars
(p value 0.125).

Ayah, R, Joshi MD, Wanjiru R, Njau EK, Otieno CF, Njeru EK, Mutai KK. 2013. A population-based survey of prevalence of diabetes and correlates in an urban slum community in Nairobi, Kenya. Abstract

Urban slum populations in Africa continue to grow faster than national populations. Health strategies that focus on non-communicable diseases (NCD) in this segment of the population are generally lacking. We determined the prevalence of diabetes and associated cardiovascular disease (CVD) risk factors correlates in Kibera, Nairobi’s largest slum. Methods We conducted a population-based household survey utilising cluster sampling with probability proportional to size. Households were selected using a random walk method and consenting residents aged 18 years and above were recruited. The WHO STEPS instrument was administered. A random capillary blood sugar (RCBS) was obtained; known persons with diabetes and subjects with a RCBS >11.1 had an 8 hours fasting blood sugar (FBS) drawn. Diabetes was defined as a RCBS of ≥ 11.1 mmol/l and a FBS of ≥ 7.0 mmol/l, or a prior diagnosis or receiving diabetes drug treatment. Results Out of 2061 enrolled; 50.9% were males, mean age was 33.4 years and 87% had a minimum of primary education. Only 10.6% had ever had a blood sugar measurement. Age adjusted prevalence of diabetes was 5.3% (95% CI 4.2-6.4) and prevalence increased with age peaking at 10.5% (95% CI 6.8-14.3%) in the 45–54 year age category. Diabetes mellitus (DM) correlates were: 13.1% smoking, 74.9% alcohol consumption, 75.7% high level of physical activity; 16.3% obese and 29% overweight with higher rates in women. Among persons with diabetes the odds of obesity, elevated waist circumference and hypertension were three, two and three fold respectively compared to those without diabetes. Cardiovascular risk factors among subjects with diabetes were high and mirrored that of the entire sample; however they had a significantly higher use of tobacco. Conclusions This previously unstudied urban slum has a high prevalence of DM yet low screening rates. Key correlates include cigarette smoking and high alcohol consumption. However high levels of physical activity were also reported. Findings have important implications for NCD prevention and care. For this rapidly growing youthful urban slum population policy makers need to focus their attention on strategies that address not just communicable diseases but non communicable diseases as well.

2012

A.A McLigeyo, G. Lule, Otieno CF, J.K Kayima, Omonge E. 2012. Factors associated with the development of HIV associated lipodystrophy in patients on long-term HAART. academic journals. 5(12):448-454. Abstract

Highly active antiretroviral therapy is effective in reducing viral load and increasing survival in HIV-1-infected patients. It consists of two nucleoside reverse transcriptase inhibitors and a protease inhibitor or two nucleoside reverse transcriptase inhibitors and a non-nucleoside reverse transcriptase inhibitor. The efficacy of Highly active anti-retroviral therapy (HAART) is however compromised by adverse events such as lipodystrophy in patients on long-term HAART. This study was carried out in 265 HIV-1 seropositive patients treated with HAART for 6 months and longer, in order to correlate patients’ age, gender, CD4 counts, WHO stage at initiation of HAART, duration and type of anti-retroviral therapy with development of lipodystrophy. A longer duration of therapy was found to be significantly associated with the development of lipodystrophy with 19 patients (24.7%), 73 patients (60.8%) (OR 2.06; CI 1.21 to 3.51, p value 0.004) and 39 patients (67.2%) (OR 2.34; CI 1.21 to 1.46, p value 0.006) having lipodystrophy at 6 to 18, 18 to 36 and 36 to 72 months of treatment, respectively. The odds of lipodystrophy after HAART for 18 to 36 months and 36 to 72 months was 4.14 (p < 0.0001) and 6.179 (p < 0.0001) times, respectively, higher than after HAART for 6 to 18 months. There was no association between age, gender, CD4 counts, WHO stage and the development of lipodystrophy.

Key words: Lipodystrophy, immune reconstitution, protease inhibitors, WHO clinical stage, duration of highly active anti-retroviral therapy (HAART).

Otieno, CF, Kaseje D, Ochieng' BM, Githae MN. 2012. Reliability of community health worker collected data for planning and policy in a peri-urban area of Kisumu, Kenya. Abstractreliability_of_community_health_worker_collected_data.pdf

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.

2010

J.O. Anino, A. Affulo, Otieno F. 2010. Occupational noise-induced hearing loss among workers at Jomo Kenyatta International Airport, Nairobi.. East African Medical Journal. 87(2):49-57. Abstract

BACKGROUND:

Occupational noise induced hearing loss (NIHL) occurs among workers exposed to excessive amounts of noise for long durations. The average level of noise in some locations at Jomo Kenyatta International Airport (JKIA) was above the safe limit of 85dB hence workers were thought to be at risk.
OBJECTIVE:

To determine the occurrence and socio demographic attributes for NIHL at JKIA.
DESIGN:

Cross sectional descriptive study. Setting: Jomo Kenyatta International Airport, Nairobi, Kenya.
RESULTS:

Mean age of respondents was 37 years with range 22 to 62, SD 8.98. Mean duration of exposure to noise was 10.7 years with range 1 to 40, SD 8.15. Prevalence of NIHL was 15.3%, with ground crew at 14.8% and air crew 16.1%. Ground crew had significantly poorer mean hearing threshold level at 3, 4 and 6 kHz than air crew (p = 0.015). Male workers were affected more than female counterparts with a male to female ratio of 4:3. 97% of those affected were non-managers, 3% managers while 68% of those affected resided in Embakasi Division close to the airport. Hearing threshold level at 4 kHz deteriorated with increasing age whereby those aged 50 years and above had a 13.7 times higher relative risk than those aged 20 to 29 years. Duration of exposure more than 10 years also had significantly higher risk (p < 0.01) for hearing loss at 4 kHz.
CONCLUSION:

Occupational noise induced hearing loss occurs atJKIA and that ground crew and older workers are more vulnerable. We recommend that prevention programmes be put in place.

Otieno, CF, KAYIMA JK, MBUGUA PK, AMAYO AA, MCLIGEYO SO. 2010. Prognostic factors in patients hospitalised with diabetic ketoacidosis at Kenyatta National Hospital, Nairobi. Abstract

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

CF, O. 2010. Thyroid dysfunction in HIV/AIDS--cause or consequence?

2009

Owino, BO, Oyoo GO, Otieno CF. 2009. Socio-demographic and clinical aspects of rheumatoid arthritis. Abstract

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.

Nguchu, HK, JOSHI MD, Otieno CF. 2009. Acute coronary syndromes amongst type 2 diabetics with ischaemic electrocardiograms presenting to accident and emergency department of a Kenyan tertiary institution. AbstractWebsite

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.

2008

FREDRICK, DROTIENOCF, ENOCH DROMONGE. 2008. Otieno CF, Huho AN, Omonge EO, Amayo AA, Njagi E.Type 2 diabetes mellitus: clinical and aetiologic types, therapy and quality of glycaemic control of ambulatory patients.East Afr Med J. 2008 Jan;85(1):24-9.. East Afr Med J. 2008 Jan;85(1):24-9. : F.N. kamau, G. N Thothi and I.O Kibwage Abstract

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.

2007

Owino, BO, Otieno CF, Oyoo GO. 2007. Rheumatoid arthritis at Kenyatta National Hospital: a clinical and quality of life evaluation.

2005

Otieno, CF; Mwendwa, VOAFW; V;. 2005. Lipid profile of ambulatory patients with type 2 diabetes mellitus at Kenyatta National Hospital, Nairobi..

Mugambi-Nturibi, E, Otieno CF, kwasa TO, Oyoo GO, Acharya K. 2005. Stratification of persons with diabetes into risk categories for foot ulceration. Abstract

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.

PK Mbugua, CF Otieno, JKKAAASOML. 2005. Diabetic ketoacidosis: clinical presentation and precipitating factors at Kenyatta National Hospital, Nairobi . East African Medical Journal. 82(12) Abstract

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.

FREDRICK, DROTIENOCF. 2005. Otieno CF, Vaghela V, Mwendwa FW, Kayima JK, Ogola EN.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. East Afr Med J. 2005. East Afr Med J. 2005 Jun;82(6):320-4.. : F.N. kamau, G. N Thothi and I.O Kibwage Abstract

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.

Murunga, EM, Reriani M, Otieno CF, Wanyoike NM. 2005. Comparison of antibiotic use between an 'open' and a 'closed' intensive care unit. East Afr Med J. 2005 Aug;82(8):414-7.. East Afr Med J. 2005 Aug;82(8):414-7.. : F.N. kamau, G. N Thothi and I.O Kibwage AbstractWebsite

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.

FREDRICK, DROTIENOCF. 2005. Acute aflatoxicosis: case report. East Afr Med J. 2005 Jun;82(6):320-4.. East Afr Med J. 2005 Jun;82(6):320-4.. : F.N. kamau, G. N Thothi and I.O Kibwage Abstract

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.

FREDRICK, DROTIENOCF. 2005. Diabetes care in Kenya–where are we and which way forward? East Afr Med J. 2005 Dec;82(12 Suppl):S161-2 East Afr Med J. 2005 Dec;82(12 Suppl):S161-2. : F.N. kamau, G. N Thothi and I.O Kibwage Abstract

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.

FREDRICK, DROTIENOCF. 2005. Vasculitis in HIV: report of eight cases. East Afr Med J. 2005 Dec;82(12):656-9.. East Afr Med J. 2005 Dec;82(12):656-9.. : F.N. kamau, G. N Thothi and I.O Kibwage Abstract

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.

FREDRICK, DROTIENOCF, N PROFOGOLAELIJAHS. 2005. Lipid profile of ambulatory patients with type 2 diabetes mellitus at Kenyatta National Hospital, Nairobi. East Afr Med J. 2005 Dec;82(12 Suppl):S173-9.. East Afr Med J. 2005 Dec;82(12 Suppl):S173-9.. : F.N. kamau, G. N Thothi and I.O Kibwage Abstract

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.

OLONDE, PROFAMAYOERASTUS, FREDRICK DROTIENOCF. 2005. Mwendwa FM, Otieno CF, Kayima JK, Amayo EO, Otieno PO.Risk factor profile and the occurrence of microvascular complications in short-term type 2 diabetes mellitus at Kenyatta National Hospital, Nairobi.East Afr Med J. 2005 Dec;82(12 Suppl):S163-72. East Afr Med J. 2005 Dec;82(12 Suppl):S163-72. : F.N. kamau, G. N Thothi and I.O Kibwage Abstract

OMONDI, DROYOOGEORGE, FREDRICK DROTIENOCF. 2005. Diabetic ketoacidosis: risk factors, mechanisms and management strategies in sub-Saharan Africa: a review.East Afr Med J. 2005 Dec;82(12 Suppl):S197-203.. East Afr Med J. 2005 Dec;82(12 Suppl):S197-203. : F.N. kamau, G. N Thothi and I.O Kibwage Abstract

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.

PROF. OTIENO C. F. FREDRICK

M.Med,MBChB

Bio