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

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

Diversity, distribution and role of wild crucifers in major cabbage and kale growing areas of Kenya.

An investigation of the diversity and distribution of wild crucifer species and their importance for cultivated crucifers was conducted during 2005 and 2006 in the highland and mid-altitude semi-arid areas of Kenya. Thirteen species of wild crucifers in nine genera were recorded: Raphanus raphanistrum, Erucastrum arabicum, Sisymbrium officinale, Crambe kilimandscharica, Capsella bursa-pastoris, Rorippa nudiuscula, Ro. micrantha, Ro. microphylla, Lepidium bonariense, Coronopus didymus, Brassica rapa, B. juncea and an unidentified Brassica species. Highland areas had significantly higher species diversity and species richness than mid-altitude semi-arid areas. Species richness, diversity and evenness varied with season and location. Raphanus raphanistrum was the dominant non-cultivated species in the highlands followed by E. arabicum, which was also present and dominant in the semi-arid study sites. Diamondback moth (DBM) was recorded from ten wild crucifer species and R. raphanistrum and E. arabicum were the preferred host plant species. Overall, four larval, one larval-pupal and one pupal parasitoid of DBM were recorded: Diadegma semiclausum, D. mollipla, Apanteles sp., Cotesia plutellae, Oomyzus sokolowskii and Brachymeria species, respectively. Diadegma semiclausum was the most dominant species on all crucifers. We conclude that wild crucifers act as alternative hosts for DBM and provide refugia for DBM parasitoids, which risk local extinction through pesticide application or competition from introduced exotic parasitoid species. The wild crucifers also act as recolonization sites for DBM parasitoids.

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

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