Journal of Kenya Assocation of Physicians

Message from the Chair

Nancy Kunyiha — Tue, 25 Jun 2024 00:00:00 +0000

No Abstract

Precipitating Factors, Presentation and Outcomes of Diabetic Ketoacidosis among Patients Seen at Moi Teaching and Referral Hospital, Eldoret Kenya

C. Msagha , J. Kamano, P. Ayuo — Tue, 25 Jun 2024 00:00:00 +0000

Background: Diabetes Ketoacidosis (DKA) is a major complication of Diabetes Mellitus (DM) with a likelihood of high mortality if not managed appropriately. It is diagnosed with a triad of hyperglycemia, ketonemia and metabolic acidosis.

Objectives: To describe the precipitating factors, clinical presentation and outcomes of DKA among patients attending Moi Teaching and Referral Hospital (MTRH).

Methods: This prospective study involved 120 consecutively recruited participants diagnosed with DKA. Participants were drawn from the Emergency Department and Diabetes Outpatient clinic and followed up in the wards and Intensive Care Unit (ICU) in MTRH for up to 10 days. Focused history and physical examination was done. Blood sugar was measured daily; blood ketones and blood gases were measured on days 1,2,3 and 5. Precipitating factors, presentation and outcomes were summarised as frequencies and their corresponding percentages and presented in tables and charts.

Results: The median age of participants was 33 years (IQR 23, 44.5). Type 1 DM represented 63.3% and type 2 DM 34.2% of the patients. The most common precipitating factors for DKA were; new onset undiagnosed DM (37.5%), missed medication (36.7%) and infection (35.8%). The most common presentation was dehydration (97.5%) with 49.2% of the patients having severe DKA while 22.5% had mild DKA. Urine and blood ketones for diagnosis of DKA were present in 46.4% and 100% of patients respectively. The median length of hospital stay was 6 days (IQR 5,7) with infection being a significant determinant (aOR 2.63). The number of days taken for DKA to resolve ranged from 1 to 5 days with a median period of 3 days (IQR 2,3). DKA in-hospital mortality was 9.2% with new onset DM being a significant determinant (uOR 5.19).

Conclusion: Some of the identified DKA precipitants in the study are preventable. The impact of DKA in MTRH is notable given the significant hospital stay and mortality.

Recommendation: We recommend implementation research studies that would develop and test different strategies to address the precipitants to prevent DKA. For the hospital to undertake an audit of current DKA management process with the aim of improving outcomes in terms of hospital stay and mortality.

Factors Associated with Poor Glycaemic Control Among Patients With Type 2 Diabetes Mellitus at Gatundu Level 5 Hospital, Kiambu County, Kenya

C. Ndungu , W. Too , D. Kassaman — Tue, 25 Jun 2024 00:00:00 +0000

Background: Diabetes Mellitus poses a significant global public health concern, marked by a surge in morbidity and mortality rates. Its incidence and prevalence have witnessed a consistent rise over recent decades, with a projected rise. Occurrence of complications is primarily attributed to poor glycemic control, which leads to diabetes-related complications, among them retinopathy, atherosclerosis, renal complications, limb amputations, as well as life threatening emergencies; Diabetes Ketoacidosis (DKA) and Hyperosmolar Hyperglycaemic State (HHS).

Objectives: To determine the prevalence of and factors linked to poor glycemic control among Type 2 Diabetes Mellitus patients at Gatundu Level 5 in Kiambu County, Kenya.

Methodology: This was a cross-sectional study conducted between May and June 2022. Patients were selected via systematic sampling, intervieweradministered semi-structured questionnaires were completed and files reviewed for recorded random blood sugar. Data analysis was done using SPSS V25. Chi-square test and t-test were employed to identify factors associated with poor glycemic control, while logistic regression estimated the odds ratio (UOR), while ethical considerations were diligently observed.

Results: One hundred and ninety seven participants were selected. The study found that a third of the participants (36%), (95% CI: 0.295 -0.4295), exhibited poor glycemic control, while the mean random blood sugar was 10.8mmol/l. The age of the participants was significantly associated with poor glycemic control (p = 0.012), revealing a 3% decrease in the risk of PGC with each year noting increase in age. Duration of disease (p = 0.007), and medication non adherence, (missing medication due to reasons other than forgetting (p = 0.03) and stopping medication without telling the healthcare provider (p = 0.049), (p = 0.03), were also significantly linked to poor glycemic control.

Implications: The study not only addresses the critical issue of poor glycaemic control but also contributes to bridging existing knowledge gaps in identifying factors hindering euglycemia.

Conclusion/ Recommendations: Findings underscore the need for targeted interventions, particularly among the younger age group, and emphasize the importance of increasing awareness regarding factors influencing PGC, which also impact medication adherence.

Therapeutic Effects of Glucagon-Like Peptide -1 Receptor Agonist in Adult Overweight and Obese Women with Polycystic Ovary Syndrome: A Narrative Review

F. Keli , S. Panicker — Tue, 25 Jun 2024 00:00:00 +0000

No Abstract

Compliance to Pharmacotherapy and Lifestyle Modification Among Diabetic Patients at Gatundu Level 5 Hospital, Kiambu County, Kenya

Katanu N. Isabella , C. Wangulu, A.W. Wairagu — Tue, 25 Jun 2024 00:00:00 +0000

Background: Diabetes Mellitus together with its complications is becoming more prevalent globally. Complications of diabetes result from poor glycemic control which can be due to non-compliance to medication and lifestyle modification.

Objectives: To determine the types pharmacotherapies used by patients with diabetes at Gatundu L5H, to assess their level of adherence to drugs and lifestyle modification as well as to evaluate the reasons for nonadherence to pharmacotherapy.

Methodology: This was a cross-sectional survey conducted between October 2022 and December, 2022. Systematically sampled diabetic patients (n=310) were interviewed using a structured questionnaire. A validated Morisky Green Levine Medication Adherence Scale (MGLS) and a two-point adherence scale were used to determine adherence to medication and lifestyle modification respectively. Descriptive reporting was done and quantitative data analyzed using chisquare test (p <0.05).

Results: The adherence level was high with 70% of the patients scoring an MGLS score of zero (0) and only 15% scoring poorly at a MGLS score of 3-4. Seventy-eight percent spent between Kshs.1000- 5000 (US$7 – 36) monthly on medications. Poor adherence to medication was directly associated with poor-adherence to recommended lifestyle modification. Those with poor adherence were likely to be on insulin therapy or a high-dosing frequency of OHAs.

Conclusion: Biguanides and sulphonyureas were the most prescribed medications. The adherence level to pharmacotherapy was high but low for lifestyle modification. There was a positive correlation between non-adherence to pharmacotherapy and lifestyle interventions. Insulin therapy and pill-burden were independently linked to poor adherence to pharmacotherapy.

Recommendations: We recommend the following; (i) Patient education on adherence and ways to improve it, (ii) Aggressive follow up of patients on insulin therapy via phone calls or engaging Community Health Promoters (CHP), (iii) Encourage use of Fixed Drug Combinations (FDC) to reduce the pill burden, (iv) Health education regarding lifestyle modifications and footwear, (v) Healthcare providers at the hospital to be educated on foot care examination.

Knowledge, Attitudes, and Practices Regarding Diabetes Mellitus Management by Patients at Gatundu Level V Hospital, Kiambu County, Kenya

N.M. Nyambura, M.A. Siteki , O. Okoth — Tue, 25 Jun 2024 00:00:00 +0000

Background: Diabetes Mellitus is a major health challenge and is associated with severe morbidity and mortality. The management is heavily reliant on patient knowledge attitudes and practices to prevent complications and enhance overall wellbeing.

Objective: The research aims to assess the level of understanding regarding diabetes mellitus management, examine attitudes towards treatment adherence and analyze practices employed by patients in managing their condition.

Methods: The study was carried out using a descriptive cross-sectional study design among patients with types 1 and 2 diabetes at Gatundu Level V Hospital aged between 18 and 60 years. A sample size of 50 participants was arrived at using the Fisher formula. Sampling was done using simple random sampling. Formal questionnaires were used in collecting data. The Morisky Adherence Scale questionnaire was used to assess adherence. Verification and reliability checks were done on questionnaires and data was analyzed via the Statistical Package of Social Science software package (SPSS) version 23. Ethical considerations were observed appropriately.

Results: Fifty questionnaires were fully completed and analyzed (100%). The study participants were predominantly middle-aged (74%) and females (64%). More than half of the study participants had attained secondary education. They had diverse employment statuses. The level of knowledge was average (61%) and this was coupled with favorable attitudes (97%). Regarding practices, a significant proportion engaged in regular physical activity (80%), healthy dietary habits (74%), and adherence to medication and monitoring regimens (78%). Nevertheless, notable percentages reported non-adherence to recommended practices, suggesting areas for improvement.

Conclusions: These findings emphasize the importance of targeted education programs, accessible healthcare services, behavioral interventions, support networks, and continuous monitoring and evaluation to enhance diabetes management efforts. By implementing these recommendations, stakeholders can work towards improving outcomes and enhancing the quality of life for individuals living with diabetes in the community.

Primary Hyperaldosteronism Presenting as Severe Symptomatic Hypocalcemia in a Postpartum Woman: A Case Report Highlighting its Variable Presentations and the Effects of Pregnancy

M.S. Hassan , N. Mongare , J. Bwombengi, E. Njenga — Tue, 25 Jun 2024 00:00:00 +0000

Background: Non-suppressible secretion of aldosterone is an important, underdiagnosed cause of secondary hypertension that typically presents with a triad of hypertension, hypokalemia, and metabolic alkalosis. However, its impact on calcium, magnesium, and parathyroid metabolism, as well as renal handling of these electrolytes, remains less documented. Additionally, descriptions of the variable presentation of primary hyperaldosteronism in pregnancy remain limited.

Objective: To highlight the broader clinical spectrum of primary aldosteronism beyond the classic triad of hypertension, hypokalemia, and metabolic alkalosis, and its varied presentation in pregnancy.

Method: We describe a case of a postpartum woman who presented with severe symptomatic hypocalcemia and grade 2 hypertension, whose evaluation diagnosed primary hyperaldosteronism.

Results: A 24-year-old female, para 4 + 0, presented one month postpartum with difficulty breathing and sudden spasms of her jaw, neck, and limb muscles, along with stiff posturing of her hands, without associated loss of consciousness. These symptoms interfered with her ability to care for her newborn. Her past medical history was significant for chronic hypertension diagnosed during her third pregnancy, associated with severe symptomatic hypocalcemia post-delivery. Following treatment with anti-hypertensives, Vitamin D, and calcium supplementation, she discontinued all her medications approximately a year later, with no further evaluation or followup documented. Her blood pressure, while off treatment, was within normal limits during her antenatal follow-up for her most recent pregnancy. There was no family history of hypertension or any other chronic illness. On general examination, her blood pressure was elevated at 175/65 mmHg, she was tachycardic at 122 b/min, afebrile, diaphoretic, in respiratory distress, and in pain. Both Chvostek’s and Trousseau’s signs were positive. The rest of her systemic examination was non-contributory. Targeted laboratory test revealed severe hypocalcemia (1.59mmol/L), hypokalemia (1.47mmol/L), hypomagnesemia (0.33 mmol/L), and severe metabolic alkalosis with respiratory compensation (pH=7.64, pCO₂=57.6 mmHg, HCO₃=64.8 mmol/L). Her urinalysis was normal. A 2D-echo found heart failure with reduced ejection fraction (left ventricular ejection fraction of 35-40%) and left ventricular hypertrophy. A CT coronary angiogram did not show any evidence of coronary arterial disease. Further evaluation revealed an elevated plasma Aldosterone: Renin Ratio (ARR) of 54.45, against a plasma renin activity of 1.75 ng/ml/h, suggestive of non-suppressible hyperaldosteronism. An adrenal protocol CT scan demonstrated a 3.3 x 2.0cm left adrenal mass consistent with a lipid-poor adenoma. The free plasma metanephrines and serum cortisol levels were within the normal range. Management included intravenous electrolyte supplementation and initiation of triple-agent antihypertensive therapy, with close monitoring in our high dependency unit. She awaits a planned laparoscopic adrenalectomy.

Conclusions: Our case underscores the diverse clinical presentation of primary aldosteronism. Recognition of electrolyte abnormalities beyond hypokalemia, including hypocalcemia and hypomagnesemia, is crucial in the evaluation of secondary hypertension due to primary aldosteronism. Pregnancy may conceal the clinical symptoms of primary aldosteronism, presenting as unexpected severe hypertension in the postpartum period. Increased awareness of these variable presentations would hopefully lead to early diagnosis, intervention, and mitigation of the increased cardiovascular morbidity and mortality associated with untreated hyperaldosteronism.

Metformin-Associated Vitamin B12 Deficiency in Patients with Type 2 Diabetes in Sub-Saharan Africa: A Narrative Review

A. Wairagu , R. Sadeghimakki — Tue, 25 Jun 2024 00:00:00 +0000

No Abstract