UPPER GASTROINTESTINAL ENDOSCOPY FINDINGS IN PATIENTS REFERRED WITH UPPER GASTROINTESTINAL SYMPTOMS IN ELDORET, KENYA: A RETROSPECTIVE REVIEW.

BACKGROUND: Dyspepsia is one of the major indications for upper gastrointestinal endoscopy. Other indications include dysphagia, odynophagia and gastrointestinal bleeding. Endoscopy is an expensive procedure that is out of reach of many patients in resource constrained region such as western Kenya. We reviewed endoscopy records from both public and private health institutions spanning ten years. OBJECTIVE: To determine the pattern of referral and endoscopy diagnoses in patients referred for upper gastrointestinal endoscopy in Eldoret, Kenya. DESIGN: Retrospective chart review. SETTING: Moi Teaching and Referral Hospital, private hospitals and private clinics in Eldoret, Kenya. SUBJECTS: One thousand six hundred and ninety (1690) Patients who underwent upper GI endoscopy from 1993 to 2003 were reviewed after obtaining clearances from the respective institutions. Information on age, sex, symptoms, and endoscopy diagnosis were extracted and subjected to statistical analysis. RESULTS: The most common symptom was dyspepsia in 1059 (62.7%) followed by dysphagia in 224 (13.3%). Others were referred with diagnosis of cancer of the stomach or oesophagus. Common endoscopy diagnoses were cancer of the oesophagus in 199 (11.8%) and duodenal ulcer in 186 (11.0%). The majority of the patients (30.4%) had normal endoscopy findings. Of the 1059 patients with dyspepsia, only 154 (14.5%) had duodenal ulcer and 34 (3.2%) had gastric ulcers, the majority, 37.2% had normal endoscopy findings. CONCLUSION: Dyspepsia was main reason for referral, but the majority of such patients had normal findings. Cancer of the oesophagus was the main diagnosis in patients with dysphagia. In view of the cost of endoscopy, only those with dyspepsia and alarm symptoms be referred for the procedure.

Clinical diagnosis of malaria and the risk of chloroquine self-medication in rural health centres in Burkina Faso.

OBJECTIVE: To assess the quality of healthcare workers' performance with regard to malaria diagnosis and treatment and to assess patients' self-medication with chloroquine (CQ) before and after presentation at a health centre. METHODS: In the rainy season 2004, in five rural dispensaries in Burkina Faso, we observed 1101 general outpatient consultations and re-examined all these patients. CQ whole blood concentrations of confirmed malaria cases were measured before and after treatment. RESULTS: The clinical diagnosis based on fever and/or a history of fever had a sensitivity of 75% and a specificity of 41% when compared to confirmed malaria (defined as an axillary temperature of >/=37.5 degrees C and/or a history of fever and parasites of any density in the blood smear). Few febrile children under 5 years of age were assessed for other diseases than malaria such as pneumonia. No antimalarial was prescribed for 1.3% of patients with the clinical diagnosis malaria and for 24% of confirmed cases, while 2% received an antimalarial drug prescription without the corresponding clinical diagnosis. CQ was overdosed in 22% of the prescriptions. Before and 2 weeks after consultation, 25% and 46% respectively of the patients with confirmed malaria had potentially toxic CQ concentrations. CONCLUSION: As long as artemisinin-based combination therapy remains unavailable or unaffordable for most people in rural areas of Burkina Faso, self-medication with and prescription of CQ are likely to continue despite increasing resistance. Apart from considering more pragmatic first-line regimens for malaria treatment such as the combination of sulfadoxine-pyrimethamine with amodiaquine, more and better training on careful clinical management of febrile children including an appropriate consideration of other illnesses than malaria should be made available in the frame of the IMCI initiative in sub-Saharan Africa.

Diabetes and pre-diabetes in tuberculosis patients in western Kenya using point-of-care glycated haemoglobin.

Setting: The tuberculosis (TB) clinics of five health facilities in western Kenya. Objective: To assess the prevalence and associated determinants of diabetes mellitus (DM) and pre-diabetes hyperglycaemia among adult TB patients using point-of-care DCA Vantage glycated haemoglobin (HbA1c) devices. Design: This was a cross-sectional study. Results: Of 454 patients, 272 (60%) were males, the median age was 34 years, 175 (39%) were co-infected with the human immunodeficiency virus (HIV), and the median duration of anti-tuberculosis treatment was 8 weeks; 180 (40%) patients reported at least one classical symptom suggestive of DM. The prevalence of DM (HbA1c ⩾6.5%) was 5.1% (95%CI 3.2-7.5), while that of pre-diabetes (HbA1c 5.7-6.4%) was 37.5% (95%CI 33.1-42.2). The number needed to screen (NNS) was 19.6 for DM and 2.7 for pre-diabetes. Combined, 42.6% (95%CI 38.0-47.3) of the patients had either pre-diabetes or DM (NNS 2.3). Seven of the 23 patients with DM knew their prior DM status. Higher rates of DM were associated with age ⩾40 years and a family history of DM, but not obesity, type of TB, HIV status or suggestive symptoms. Conclusions: High rates of pre-diabetes and DM were found in adult TB patients. This study supports the need for routine screening of all patients with TB for DM in Kenya.

Contexte: Centres tuberculose (TB) de cinq structures de santé dans l'Ouest du Kenya.Objectif: Evaluer la prévalence et les déterminants associés du diabète (DM) et de l'hyperglycémie pré-diabète chez des patients adultes atteints de TB grâce aux appareils DCA Vantage de dosage d'hémoglobine glyquée (HbA1c) utilisés sur place.Schéma: Une étude transversale.Résultats: Sur 454 patients, 272 (60%) ont été des hommes, leur âge médian a été de 34 ans et 175 (39%) ont été co-infectés par le virus de l'immunodéficience humaine (VIH) ; la durée médiane du traitement de la TB a été de 8 semaines et 180 (40%) patients ont fait état d'au moins un symptôme classique suggérant un DM. La prévalence du DM (HbA1c ⩾ 6,5%) a été de 5,1% (IC95% 3,2­7,5) tandis que celle du pré-diabète (HbA1c 5,7­6,4%) a été de 37,5% (IC95% 33,1­422). Le nombre de dépistages requis (NNS) a été de 19,6 pour diagnostiquer un DM et de 2,7 pour un pré-diabète. En combinant les deux, 42,6% (IC95% 38,0­47,3) des patients avaient soit un pré-diabète soit un DM (NNS 2,3). Sept des 23 patients atteints de DM étaient au courant de leur statut. Des taux de DM plus élevés ont été associés avec un âge ⩾ 40 ans et des antécédents de DM dans la famille, mais pas avec l'obésité, le type de TB, le statut du VIH ou des symptômes suggestifs du VIH.Conclusions: Des taux élevés de pré-diabète et de DM ont été découverts chez des patients TB adultes. Cette étude est en faveur du dépistage de routine du DM chez tous les patients atteints de TB au Kenya.

Marco de referencia: Los consultorios de atención de la tuberculosis (TB) en cinco establecimientos de salud en el occidente de Kenya.Objetivo: Evaluar la prevalencia de diabetes (DM) e hiperglucemia prediabética y los factores determinantes asociados en los pacientes adultos con diagnóstico de TB, mediante la utilización de dispositivos de diagnóstico (DCA Vantage) que determinan la glucohemoglobina (HbA1c) en el lugar de atención.Método: Un estudio transversal.Resultados: De los 454 pacientes, 272 fueron de sexo masculino (60%), la mediana de la edad fue 34 años, 175 (39%) sufrían coinfección por el virus de la inmunodeficiencia humana (VIH), la mediana de la duración del tratamiento antituberculoso fue 8 semanas y 180 pacientes notificaron por lo menos un síntoma patognomónico de DM (40%). La prevalencia de DM (HbA1c ⩾ 6,5%) fue 5,1% (IC 95% 3,2­7,5) y la prevalencia de pre-diabetes (HbA1c 5,7­6,4%) fue 37,5% (IC95% 33,1­42,2). El número de pacientes que es necesario cribar (NNC) para detectar un caso de DM fue 19,6 y 2,7 para un caso de prediabetes. Combinados, el 42,6% de los pacientes presentaba ya sea prediabetes o DM (NNC 2,3; IC95% 38,0­47,3). Siete de los 23 pacientes con DM conocían ya su diagnóstico. Las tasas más altas de DM se asociaron con una edad de 40 años o más y el antecedente familiar de DM, pero no con la obesidad, el tipo de TB, la situación frente al VIH ni la presencia de síntomas indicativos.Conclusión: Se encontraron altas tasas de prediabetes y DM en los pacientes adultos con diagnóstico de TB. El presente estudio respalda la práctica de la detección sistemática de la DM en los pacientes con TB en Kenya.

Population pharmacokinetics and pharmacodynamics of piperaquine in children with uncomplicated falciparum malaria.

Dihydroartemisinin-piperaquine is being increasingly used as a first-line artemisinin combination treatment for malaria. The aim of this study was to describe the pharmacokinetic and pharmacodynamic properties of piperaquine in 236 children with uncomplicated falciparum malaria in Burkina Faso. They received a standard body weight-based oral 3-day fixed-dose dihydroartemisinin-piperaquine regimen. Capillary plasma concentration-time profiles were characterized using nonlinear mixed-effects modeling. The population pharmacokinetics of piperaquine were described accurately by a two-transit-compartment absorption model and a three-compartment distribution model. Body weight was a significant covariate affecting clearance and volume parameters. The individually predicted day 7 capillary plasma concentration of piperaquine was an important predictor (P < 0.0001) of recurrent malaria infection after treatment. Young children (2-5 years of age) received a significantly higher body weight-normalized dose than older children (P = 0.025) but had significantly lower day 7 piperaquine concentrations (P = 0.024) and total piperaquine exposures (P = 0.021), suggesting that an increased dose regimen for young children should be evaluated.