The management of gout in Africa: challenges and opportunities.

The rise in non-communicable diseases in Africa presents challenges for health systems that are burdened by infectious diseases. Gout is one of those diseases that has seen an increase in numbers worldwide, including Africa. Gout is commonly associated with comorbidities and mortality. It directly impacts the quality of life, increases health costs, decreases physical function, and significantly increases the time from work, much of which is potentially avoided if treatment is instituted early. Despite advances in understanding the pathophysiology and outcomes of gout, the quality of care delivered to patients in Africa is still suboptimal. Existing data on gout in Africa reveals a general low index of suspicion due to limited knowledge of the disease by healthcare workers resulting in late diagnosis, with severe polyarticular tophaceous gout being a common presenting feature. These late presentations are associated with avoidable disability and increase the direct and indirect costs of managing gout. The challenges are related to lack of government budgetary support for staff training, infrastructure for diagnosis, and availing medicines. The picture of gout in Africa largely mirrors the west concerning risk factors, comorbidities, and burden of disease, but with some unique presentations seen in HIV, sickle cell disease, and vertigo. We discuss the challenges of gout diagnosis and management in Africa and propose a roadmap to improve gout outcomes across Africa.

PREVALENCE OF ANTI-CYCLIC CITRULLINATED PEPTIDE ANTIBODIES IN PATIENTS CLASSIFIED AS RHEUMATOID AND UNDIFFERENTIATED ARTHRITIS AT KENYATTA NATIONAL HOSPITAL.

BACKGROUND: Rheumatoid arthritis(RA) is a debilitating condition.Early diagnosis of RA can be difficult as the disease may initially be indistinguishable from Undifferentiated arthritis(UA). American College of Rheumatology criteria(ACR)is not suitable for early diagnosis as its characteristics are fulfilled when bone damage has already taken place.Anti-cyclic citrullinated antibodies(Anti-CCP) are highly specific for RA and have been used to confirm early diagnosis. OBJECTIVE: To determine the prevalence and clinical utility of Anti-CCP antibodies in patients with rheumatoid and undifferentiated arthritis at presentation to KNH medical clinics. Design: A cross-sectional descriptive study. SETTING: Kenyatta National Hospital Medical Outpatient Clinics (MOPCs) between the month of October 2008 to February 2009. RESULTS: A total of 95 patients were recruited.The mean age of the patients studied in the RA and UA was 44.7 and 41.2(p=0.356) respectively. Sixty four patients(64) satisfied ACR criteria.The overall prevalence of Anti-ccp antibodies in the population studied was 47.4%.The prevalence of Anti-ccp antibodies in patients who satisfied the ACR criteria was 62.5%.The prevalence of Rheumatoid Factor (RF) in patients who satisfied the ACR criteria was 50% compared to 9.7% for those who did not(p=0.000). The male to female ratio of subjects studied was 1:11. CONCLUSION: Anti-ccp antibodies are more prevalent in this cohort of patients with rheumatoid and undifferentiated arthritis than RF It was also concluded that ACR characteristics correlated well with Anti-ccp and RF. A greater percentage of patients who were RF negative were Anti-ccp positive.

Prevalence and characteristics of articular manifestations in human immunodeficiency virus infection.

BACKGROUND: Articular manifestations have been reported in HIV infection with a prevalence ranging from 2.5 to 68%. OBJECTIVES: To determine the prevalence, types and characteristics of articular manifestations in the anti-retroviral treatment naive HIV infected patients. DESIGN: Cross sectional descriptive study. SETTING: Comprehensive care clinic (HIV outpatient clinic) at the Kenyatta National Hospital (KNH) from October 2007 to March 2008. SUBJECTS: One hundread and ninety three patients; 135 females and 58 males, aged between 19 to 65 years with Human immunodeficiency virus (HIV) infection who were naive to anti - retroviral drug therapy. MAIN OUTCOME MEASURE: Presence of articular manifestations that included HIV associated arthritis, HIV associated spondyloarthropathies, HIV associated arthralgia, painful articular syndrome and avascular necrosis. RESULTS: Thirty three of these 193 patients had articular manifestation with a prevalence of 17.1%. The type prevalence was; HIV associated arthralgia, 15.6%; undifferentiated spondyloarthropathy, 1% and HIV associated arthritis; 0.5%. Their mean age was 36 +/- 9 years, range 23-63 years; majority were female, male to female ratio of 1: 2.3 and the majority were in World health organization (WHO) clinical staging of HIV infection, class II and III with a mean CD4 cell count of 330 cells/mm3. Seventeen (51.5%) of the patients with articular disease had oligo - articular presentation, 10(30.3%) mono - articular while 6(18.2%) had poly - articular presentation. The mean duration of joint pains was 53.3 days (range of 2-365 days). Six (18.2%) of these 33 patients missed work, home making activities or school due to the articular disease. CONCLUSION: Articular manifestations are common in HIV infection with a prevalence of 17.1%. HIV associated arthralgia was the most common manifestation. Majority of these patients were female, male to female ratio of 1: 2.3. The mean age of these patients was 36 years with a mean CD4 cell count of 330 cells/mm3 with 18.2% of them missing school or work.

Socio-demographic and clinical aspects of rheumatoid arthritis.

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

Stratification of persons with diabetes into risk categories for foot ulceration.

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

Osteoporosis--from hormonal replacement therapy to bisphosphonates and beyond: a review.

OBJECTIVE: To review the old, current, and emerging agents in pharmacological treatment of osteoporosis. DATA SOURCES: Published original research work and reviews from 1993 to 31 December 2006 were searched in English on subjects related to epidemiology, pathophysiology, diagnosis, treatment, and prevention of osteoporosis. STUDY DESIGN: Only articles that emphasise on management. DATA EXTRACTION: Online and manual library searches done. DATA SYNTHESIS: Data added up and summarised. CONCLUSION: Osteoporosis is a serious public health issue. The past 10 years has seen great advances in our understanding of its epidemiology, pathophysiology, and treatment, and further advances are rapidly being made. Bisphosphonates represent the biggest advance in the treatment of osteoporosis, and will probably remain the mainstay of therapy. At the same time other diagnostic and therapeutic approaches, including biological agents, are likely to become more widespread. Combination therapy is generally not recommended due to paucity of data concerning antifracture effectiveness, and, there is currently no definitive answer on the length of treatment with antiresoptive agents.

Vasculitis in HIV: report of eight cases.

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

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

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

Rheumatic disorders in Sub-saharan Africa

OBJECTIVE: To review prevalence of rheumatic disorders in Sub-saharan Africa and in the context of current medical practice in the region assess the need for service and educational provision. DATA SOURCES: Medline, (English, French). Pre-Medline literature review from the 1950's (Current contents). Various conference reports including attendance at all three AFLAR (African League Against Rheumatism) congresses in the 1990's. Author's personal database. All cited references read in full. CONCLUSIONS: The evidence shows rheumatoid arthritis and systemic lupus erythematosus to be increasing in frequency in the indigenous populations of East, Central and South Africa but remaining rare in West Africans. Gout is now more prevalent than ever throughout the subcontinent. HIV has spawned a variety of previously rare spondyloarthropathies (reactive arthritis, psoriatic arthritis, enthesopathy) and changed the epidemiology of pyomyositis and osteomyelitis. Osteoarthritis is a universal problem. Juvenile chronic arthritis is not rare and rheumatic fever is common. Acute and chronic locomotor problems associated with diverse entities such as leprosy, brucellosis, meningococcus, alpha viruses, parasites, fluorosis, rickets and haemoglobinopathies enhance diagnostic diversity and therapeutic and educational requirements. Suggestions made to address the challenge posed by the burden of rheumatic disorders.

Rheumatic disorders in Sub-saharan Africa.

OBJECTIVE: To review prevalence of rheumatic disorders in Sub-saharan Africa and in the context of current medical practice in the region assess the need for service and educational provision. DATA SOURCES: Medline, (English, French). Pre-Medline literature review from the 1950's (Current contents). Various conference reports including attendance at all three AFLAR (African League Against Rheumatism) congresses in the 1990's. Author's personal database. All cited references read in full. CONCLUSIONS: The evidence shows rheumatoid arthritis and systemic lupus erythematosus to be increasing in frequency in the indigenous populations of East, Central and South Africa but remaining rare in West Africans. Gout is now more prevalent than ever throughout the subcontinent. HIV has spawned a variety of previously rare spondyloarthropathies (reactive arthritis, psoriatic arthritis, enthesopathy) and changed the epidemiology of pyomyositis and osteomyelitis. Osteoarthritis is a universal problem. Juvenile chronic arthritis is not rare and rheumatic fever is common. Acute and chronic locomotor problems associated with diverse entities such as leprosy, brucellosis, meningococcus, alpha viruses, parasites, fluorosis, rickets and haemoglobinopathies enhance diagnostic diversity and therapeutic and educational requirements. Suggestions made to address the challenge posed by the burden of rheumatic disorders.

Clinical and socio demographic aspects of congestive heart failure patients at Kenyatta National Hospital, Nairobi.

OBJECTIVE: To analyse the underlying aetiology, precipitating factors and certain 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.