-94 MAtAwl MEDJOURNAL;15(3):91 DEC.2003
Morbidityand mortality amongdiabeticpatientsadmitted to MulagoHospital,Uganda M.A.Otim" J.R.Luleo,A.P.Nambuyau, M,H.Bateganyau, Uganda " DepartmentOf MedicineMakereneMedicalSchool,Uganda,b CDC-_Entebbe, FellowshipProgram,Institute of PublicHealth HIV/AIDS Addressall correspondenceto; Dr MosesBateganyi, Flllow'lPH/CDC E-mail; bmh-k@yahoo'com 7072,Kampala,Uganda, P,O.Box [email protected]
ABSTRACT OBJECTIVES: To document the causes of admission' clinical presentation and outcome of patients admitted with dia' betes mellitus to our medical wards. SETTING: Medical wards of Mulago Hospital, teaching hospital and national referral for the government ofUganda. STUDY DESIGN: Cross-sectional descriptive non-interventional study of diabetic medical admissions. RESULTS: During the study period 129 (4.2Vo) patients with diabetes mellitus out of 31,03total medical admissions were admitted. The commonest cause of admission was uncontrolled diabetes (48.3Vo)but infections were present in 27.7Vo of all the study patients. The commonest infections were pneumonia (LSVo)and urinary tract infections (11.87o). Diabetic ketoacidosis (DKA) was a cause of admission in
9.2Vo of all the study subjects. Glycaemic control was satisfactory among 50.6Vo(HbAlc less than 7) despite 84.5Vo of the study subjects being hyperglycaemic at admission (mean random blood sugar 20t9.0 mmol/L). Fifty'point seven of the subjects had tong term complications of diabetes at admission with hypertension (53.8Vo) and peripheral neu' ropathy (38.3Vo)being the commonest. There were L3 deaths f.:0.8%o) and 6l.5%o of the deaths were among patients admitted with infections. The aYerage length of hospitalisation was 9.5t4 days. CONCLUSION: The results show that the commonest causes of admission were uncontrolled diabetes and infections' The mortality rate was L0.87o.
lntroduction
Setting
Uganda's nationBy the year 2Ol0 the total number of people with diabetesis pro- The study was conductedin Mulago Hospital, Medical School Makerere for hospital and teaching referral greatest al the with jected to rcach 22I million and the regions actual admisalthough 1000 beds about of capacity bed with a prevawhere Africa potential increaseare likely to be Asia and The (Admission Summaries)' patients 1500 go to up can sions estimated lence rates are expected to rise 2-3 times its current the country usuall over from patients diabetic receives hospital valuest. diabetic clinic, which In Africa, diabetes mellitus is a major cause of hospitalization ally to benefit from the successfully run '3. treatment. Each of and investigation education, diabetic offers mortality premature adult and an important contributor to admit in turns which firms, two has general wards three the the disease of years, the burden However, over the subsequent from the casualpatients diabetic admit firms The day. 6'h every has steadily increased. ty (mainly those with acute life threatening complications) and district hospitals In Uganda, no prevalence studies have been done but hospital referrals from private clinics and up country hospitals own the from are admissions of majority the though people diawith of numbers basedevidence suggestsincreasing study was carried descriptive a. A cross-sectional clinic. diabetic betes The study was Previous studies in Mulago hospital have showed increasing out between 1"'Augustand 15* November 2001' Medical School numbers of registeredcasesfrom 1414 in 1982, 1853 casesin approved by researchcommittees of Makerere 1994 and 4937 by April 1998. This is an increase of more than and Mulago Hospital. l00%oin4 years.Between June 1999 and June 2000, the number of clinic attendeeshad increased to 4474, an average of 102 Patients patients per clinic visit. Of these 368 were new patients, with an All consenting diabetic patients admitted to the medical wards o averageof eight new patients per clinic day . during the study period were eligible for enrolment. These were prothe highlighted have in Africa studies Many retrospective identified daily from the admissionbooks by the principal invesportion of diabetic admissions to total medical admissions tigator and three diabetic nurse specialists and through direct ', 6, namely, 7Voin Sudan', IVo ir'Tanzania I.5Vo in S'Africa inquiry among each day's admitted patients. The study objec8. O.4Voin Nigeria Unpublished reports from Mulago Hospital tivis and procedures were explained to the patients and those show that diabetic admissionsaccountedfot 3.5Voof all medical who agreed signed the consent form and were each assigneda '. admissionsbetween Jan-Dec 2000 The main objective of this study number and recruited. presentation and outcome of study was to document clinical to devise means Procedures in order mellitus diabetes with patients admitted of these Medicalhistory mortality and rates admission morbidity, reducing of patients. A detailed history, relating to the presenting illness and infections, duration of diabetessince admission, and identification of Patientsand methods possible complications of diabetes mellitus such as peripheral Design neuropathy, nephropathy, retinopathy, vascular and autonomic was study non-interventional cross-sectional A descriptive neuropathy was obtained from the patients and entered into a discharge. to admission from up with follow undertaken questionnaire. Malawi Medical Journal
MorbidiW and mortality among diabetic patlents in Uganda 92
Examination A physical examination of all the body systemswas done looking for signs of infection, other lesions and complications of diabetes. Measurement was done of weight, height, waist circumference, abdominal (girth) circumference and from these, the BMI (Body Mass Index) and WHR (Waist Hip Ratio) were calculated. The ideal WHR was defined as 140190mmHg for those over 65 years according to the WHO-ISH guidelines ". The skin was examined for boils, ulcers and other lesions. The feet were examined for dryness, fissures, ulceration and presence or absence of arterial pulses. A complete neurological examination was done looking for visual field defects, cranial nerve palsies, and sensoryloss (using a tuning fork, small piece of cotton and a small blunt pin). Muscle power was graded according to standard procedure as grade 0 to 5 12.Reflexes were tested using a patella hammer. Obvious ocular abnormalities such as cataractswere noted. Laboratory methods A sample of 5 to 10 mls of blood was drawn from the antecubital fossa ofeach patient under sterile conditions (after cleaning with povidone iodine) for estimation of, HbAlc (measuredusing the calorimetric method -Human diagnostics),and serum creatinine (Sigma creatinine No.555-A Kit). Poor glycaemic control was defined as HbAlc >7Vo.A drop of blood obtained from the fingertip was used to estimate random blood glucose using a glucometer (Life scan). Urine sugar and protein were semi-quantitatively estimatedby dipstix method (Nephur-Test'). Patientswere followed up from admission to dischargeand clinical end points were dischargeand death.The duration of admission was recorded in days.
Statisticalmethods The total number of medical admissionswas computed from the ward admission books at the end of each admission day, added for the study period, and used to calculate the proportion of diabetic admissionsto total medical admissions.Data was analysed by Epiinfo (Version 6 Atlanta GA 1994) and SAS statistical programmes for means and associations.The level of statistical significance was taken as p
Morbidityand mortality amongdiabeticpatientsadmitted to MulagoHospital,Uganda M.A.Otim" J.R.Luleo,A.P.Nambuyau, M,H.Bateganyau, Uganda " DepartmentOf MedicineMakereneMedicalSchool,Uganda,b CDC-_Entebbe, FellowshipProgram,Institute of PublicHealth HIV/AIDS Addressall correspondenceto; Dr MosesBateganyi, Flllow'lPH/CDC E-mail; bmh-k@yahoo'com 7072,Kampala,Uganda, P,O.Box [email protected]
ABSTRACT OBJECTIVES: To document the causes of admission' clinical presentation and outcome of patients admitted with dia' betes mellitus to our medical wards. SETTING: Medical wards of Mulago Hospital, teaching hospital and national referral for the government ofUganda. STUDY DESIGN: Cross-sectional descriptive non-interventional study of diabetic medical admissions. RESULTS: During the study period 129 (4.2Vo) patients with diabetes mellitus out of 31,03total medical admissions were admitted. The commonest cause of admission was uncontrolled diabetes (48.3Vo)but infections were present in 27.7Vo of all the study patients. The commonest infections were pneumonia (LSVo)and urinary tract infections (11.87o). Diabetic ketoacidosis (DKA) was a cause of admission in
9.2Vo of all the study subjects. Glycaemic control was satisfactory among 50.6Vo(HbAlc less than 7) despite 84.5Vo of the study subjects being hyperglycaemic at admission (mean random blood sugar 20t9.0 mmol/L). Fifty'point seven of the subjects had tong term complications of diabetes at admission with hypertension (53.8Vo) and peripheral neu' ropathy (38.3Vo)being the commonest. There were L3 deaths f.:0.8%o) and 6l.5%o of the deaths were among patients admitted with infections. The aYerage length of hospitalisation was 9.5t4 days. CONCLUSION: The results show that the commonest causes of admission were uncontrolled diabetes and infections' The mortality rate was L0.87o.
lntroduction
Setting
Uganda's nationBy the year 2Ol0 the total number of people with diabetesis pro- The study was conductedin Mulago Hospital, Medical School Makerere for hospital and teaching referral greatest al the with jected to rcach 22I million and the regions actual admisalthough 1000 beds about of capacity bed with a prevawhere Africa potential increaseare likely to be Asia and The (Admission Summaries)' patients 1500 go to up can sions estimated lence rates are expected to rise 2-3 times its current the country usuall over from patients diabetic receives hospital valuest. diabetic clinic, which In Africa, diabetes mellitus is a major cause of hospitalization ally to benefit from the successfully run '3. treatment. Each of and investigation education, diabetic offers mortality premature adult and an important contributor to admit in turns which firms, two has general wards three the the disease of years, the burden However, over the subsequent from the casualpatients diabetic admit firms The day. 6'h every has steadily increased. ty (mainly those with acute life threatening complications) and district hospitals In Uganda, no prevalence studies have been done but hospital referrals from private clinics and up country hospitals own the from are admissions of majority the though people diawith of numbers basedevidence suggestsincreasing study was carried descriptive a. A cross-sectional clinic. diabetic betes The study was Previous studies in Mulago hospital have showed increasing out between 1"'Augustand 15* November 2001' Medical School numbers of registeredcasesfrom 1414 in 1982, 1853 casesin approved by researchcommittees of Makerere 1994 and 4937 by April 1998. This is an increase of more than and Mulago Hospital. l00%oin4 years.Between June 1999 and June 2000, the number of clinic attendeeshad increased to 4474, an average of 102 Patients patients per clinic visit. Of these 368 were new patients, with an All consenting diabetic patients admitted to the medical wards o averageof eight new patients per clinic day . during the study period were eligible for enrolment. These were prothe highlighted have in Africa studies Many retrospective identified daily from the admissionbooks by the principal invesportion of diabetic admissions to total medical admissions tigator and three diabetic nurse specialists and through direct ', 6, namely, 7Voin Sudan', IVo ir'Tanzania I.5Vo in S'Africa inquiry among each day's admitted patients. The study objec8. O.4Voin Nigeria Unpublished reports from Mulago Hospital tivis and procedures were explained to the patients and those show that diabetic admissionsaccountedfot 3.5Voof all medical who agreed signed the consent form and were each assigneda '. admissionsbetween Jan-Dec 2000 The main objective of this study number and recruited. presentation and outcome of study was to document clinical to devise means Procedures in order mellitus diabetes with patients admitted of these Medicalhistory mortality and rates admission morbidity, reducing of patients. A detailed history, relating to the presenting illness and infections, duration of diabetessince admission, and identification of Patientsand methods possible complications of diabetes mellitus such as peripheral Design neuropathy, nephropathy, retinopathy, vascular and autonomic was study non-interventional cross-sectional A descriptive neuropathy was obtained from the patients and entered into a discharge. to admission from up with follow undertaken questionnaire. Malawi Medical Journal
MorbidiW and mortality among diabetic patlents in Uganda 92
Examination A physical examination of all the body systemswas done looking for signs of infection, other lesions and complications of diabetes. Measurement was done of weight, height, waist circumference, abdominal (girth) circumference and from these, the BMI (Body Mass Index) and WHR (Waist Hip Ratio) were calculated. The ideal WHR was defined as 140190mmHg for those over 65 years according to the WHO-ISH guidelines ". The skin was examined for boils, ulcers and other lesions. The feet were examined for dryness, fissures, ulceration and presence or absence of arterial pulses. A complete neurological examination was done looking for visual field defects, cranial nerve palsies, and sensoryloss (using a tuning fork, small piece of cotton and a small blunt pin). Muscle power was graded according to standard procedure as grade 0 to 5 12.Reflexes were tested using a patella hammer. Obvious ocular abnormalities such as cataractswere noted. Laboratory methods A sample of 5 to 10 mls of blood was drawn from the antecubital fossa ofeach patient under sterile conditions (after cleaning with povidone iodine) for estimation of, HbAlc (measuredusing the calorimetric method -Human diagnostics),and serum creatinine (Sigma creatinine No.555-A Kit). Poor glycaemic control was defined as HbAlc >7Vo.A drop of blood obtained from the fingertip was used to estimate random blood glucose using a glucometer (Life scan). Urine sugar and protein were semi-quantitatively estimatedby dipstix method (Nephur-Test'). Patientswere followed up from admission to dischargeand clinical end points were dischargeand death.The duration of admission was recorded in days.
Statisticalmethods The total number of medical admissionswas computed from the ward admission books at the end of each admission day, added for the study period, and used to calculate the proportion of diabetic admissionsto total medical admissions.Data was analysed by Epiinfo (Version 6 Atlanta GA 1994) and SAS statistical programmes for means and associations.The level of statistical significance was taken as p
