Aga Khan Hospital, Kisumu

Abstract Pregnant women, especially primigravidas, are highly susceptible to malaria infection, resulting in maternal anemia and low birth weight infants. Because circulating parasitemia is rare in the newborn, the cause of poor fetal outcomes has been unclear. We measured cytokine concentrations in placentas collected from women delivering in urban hospitals in malaria-holoendemic or nonendemic areas of Kenya. Normal placentas displayed a bias toward type 2 cytokines; type 1 cytokines IFN-γ and IL-2 were absent in placentas not exposed to malaria but present in a large proportion of placentas from a holoendemic area. TNF-α and TGF-β concentrations were significantly higher, and IL-10 concentrations significantly lower, in placentas from the holoendemic area. Among primigravidas, placental TNF-α concentrations were significantly higher in the presence of severe maternal anemia, and both IFN-γ and TNF-α were significantly elevated when a low birth weight, rather than normal weight, infant was delivered. We conclude that maternal malaria decreases IL-10 concentrations and elicits IFN-γ, IL-2, and TNF-α in the placenta, shifting the balance toward type 1 cytokines. This is the first demonstration that these placental cytokine changes are associated with poor pregnancy outcomes in humans.

Canine transmissible venereal tumour (CTVT) is a clonally transmissible cancer that originated approximately 11,000 years ago and affects dogs worldwide. Despite the clonal origin of the CTVT nuclear genome, CTVT mitochondrial genomes (mtDNAs) have been acquired by periodic capture from transient hosts. We sequenced 449 complete mtDNAs from a global population of CTVTs, and show that mtDNA horizontal transfer has occurred at least five times, delineating five tumour clades whose distributions track two millennia of dog global migration. Negative selection has operated to prevent accumulation of deleterious mutations in captured mtDNA, and recombination has caused occasional mtDNA re-assortment. These findings implicate functional mtDNA as a driver of CTVT global metastatic spread, further highlighting the important role of mtDNA in cancer evolution.

Background: Little is known about the impact of HIV-1 group M subtypes on mother-to-child transmission (MTCT) of HIV-1 in African settings where multiple HIV-1 group M subtypes are co-circulating. Objective: To assess the role of subtype variation on MTCT. Methods: HIV-1-infected women attending an antenatal clinic in western Kenya were enrolled for a prospective study (1996–2000) of MTCT. HIV-1 subtype analysis of p24gag and gp41env identified potential recombinants, and their role in MTCT was determined. Results: Among 414 women for whom HIV-1 subtype and HIV transmission status were available, MTCT occurred in 80 (19.3%). MTCT rates were higher among women with subtype D compared with subtype A in either the gp41 region [31.6 versus 16.1%, relative risk (RR) 2.0, P = 0.002] or p24 region (29.9 versus 18.0%, RR 1.7, P = 0.02). Discordant subtype combinations were identified in 103 of the women (25.9%), and were associated with higher rates of MTCT (28.2 versus 17.0%, RR 1.7, P = 0.01). In multivariate analysis, women with subtype combinations D/D, D/A, and A/D had an increased risk of MTCT (adjusted odds ratios 3.5, 2.5, 6.2; P = 0.005, 0.05, and 0.0003, respectively) compared with A/A women after adjustment for maternal HIV viral load, placental malaria infection, episiotomy or perineal tear, and low birthweight. Conclusion: MTCT appears to be more common among mothers infected with subtype D compared with subtype A. Such differences in MTCT frequency may be caused by altered cellular tropism for placental cell types.

BACKGROUND: Breast cancer is the most common cancer of women in Kenya. There are no national breast cancer early diagnosis programs in Kenya. OBJECTIVE: The objective was to conduct a pilot breast cancer awareness and diagnosis program at three different types of facilities in Kenya. METHODS: This program was conducted at a not-for-profit private hospital, a faith-based public hospital, and a government public referral hospital. Women aged 15 years and older were invited. Demographic, risk factor, knowledge, attitudes, and screening practice data were collected. Breast health information was delivered, and clinical breast examinations (CBEs) were performed. When appropriate, ultrasound imaging, fine-needle aspirate (FNA) diagnoses, core biopsies, and onward referrals were provided. RESULTS: A total of 1,094 women were enrolled in the three breast camps. Of those, 56% knew the symptoms and signs of breast cancer, 44% knew how breast cancer was diagnosed, 37% performed regular breast self-exams, and 7% had a mammogram or breast ultrasound in the past year. Of the 1,094 women enrolled, 246 (23%) had previously noticed a lump in their breast. A total of 157 participants (14%) had abnormal CBEs, of whom 111 had ultrasound exams, 65 had FNAs, and 18 had core biopsies. A total of 14 invasive breast cancers and 1 malignant phyllodes tumor were diagnosed CONCLUSION: Conducting a multidisciplinary breast camp awareness and early diagnosis program is feasible in different types of health facilities within a low- and middle-income country setting. This can be a model for breast cancer awareness and point-of-care diagnosis in countries with limited resources like Kenya. IMPLICATIONS FOR PRACTICE: This work describes a novel breast cancer awareness and early diagnosis demonstration program in a low- and middle-income country within a limited resource setting. The program includes breast self-awareness and breast cancer education, clinical exams, and point-of-care diagnostics for women in three different types of health facilities in Kenya. This pilot program has the potential of being replicated on a national scale to create awareness about breast cancer and downstage its presentation.

Abstract Background Following agricultural use and large-scale distribution of insecticide-treated nets (ITNs), malaria vector resistance to pyrethroids is widespread in sub-Saharan Africa. Interceptor® G2 is a new dual active ingredient (AI) ITN treated with alpha-cypermethrin and chlorfenapyr for the control of pyrethroid-resistant malaria vectors. In anticipation of these new nets being more widely distributed, testing was conducted to develop a chlorfenapyr susceptibility bioassay protocol and gather susceptibility information. Methods Bottle bioassay tests were conducted using five concentrations of chlorfenapyr at 12.5, 25, 50, 100, and 200 µg AI/bottle in 10 countries in sub-Saharan Africa using 13,639 wild-collected Anopheles gambiae sensu lato ( s.l .) (56 vector populations per dose) and 4,494 pyrethroid-susceptible insectary mosquitoes from 8 colonized strains. In parallel, susceptibility tests were conducted using a provisional discriminating concentration of 100 µg AI/bottle in 16 countries using 23,422 wild-collected, pyrethroid-resistant An. gambiae s.l. (259 vector populations). Exposure time was 60 min, with mortality recorded at 24, 48 and 72 h after exposure. Results Median mortality rates (up to 72 h after exposure) of insectary colony mosquitoes was 100% at all five concentrations tested, but the lowest dose to kill all mosquitoes tested was 50 µg AI/bottle. The median 72-h mortality of wild An. gambiae s.l. in 10 countries was 71.5, 90.5, 96.5, 100, and 100% at concentrations of 12.5, 25, 50, 100, and 200 µg AI/bottle, respectively. Log-probit analysis of the five concentrations tested determined that the LC 95 of wild An. gambiae s .l. was 67.9 µg AI/bottle (95% CI: 48.8–119.5). The discriminating concentration of 203.8 µg AI/bottle (95% CI: 146–359) was calculated by multiplying the LC 95 by three. However, the difference in mortality between 100 and 200 µg AI/bottle was minimal and large-scale testing using 100 µg AI/bottle with wild An. gambiae s.l. in 16 countries showed that this concentration was generally suitable, with a median mortality rate of 100% at 72 h. Conclusions This study determined that 100 or 200 µg AI/bottle chlorfenapyr in bottle bioassays are suitable discriminating concentrations for monitoring susceptibility of wild An. gambiae s.l ., using mortality recorded up to 72 h. Testing in 16 countries in sub-Saharan Africa demonstrated vector susceptibility to chlorfenapyr, including mosquitoes with multiple resistance mechanisms to pyrethroids.

Waning of neutralizing titres along with decline of protection efficacy after the second dose of COVID-19 vaccines was observed, including China-made inactivated vaccines. Efficacy of a heterologous boosting using one dose of a recombinant SARS-CoV-2 fusion protein vaccine (V-01) in inactivated vaccine-primed population was studied, aimed to restore the immunity. A randomized, double-blind and placebo-controlled phase III trial was conducted in healthy people aged 18 years or older in Pakistan and Malaysia. Each eligible participant received one dose of the V-01 vaccine developed by Livzon Mabpharm Inc. or placebo within the 3-6 months after the two-dose primary regimen, and was monitored for safety and efficacy. The primary endpoint was protection against confirmed symptomatic SARS-CoV-2 infection. A total of 10,218 participants were randomly assigned to receive a vaccine or placebo. Virus-neutralizing antibodies were assessed in 419 participants. A dramatic increase (11.3-fold; 128.3–1452.8) of neutralizing titres was measured in the V-01 group at 14 days after the booster. Over two months of surveillance, vaccine efficacy was 47.8% (95%CI: 22.6–64.7) according to the intention-to-treat principle. The most common adverse events were transient, mild-to-moderate pain at the injection site, fever, headache, and fatigue. Serious adverse events occurred almost equally in V-01 (0.12%) and placebo (0.16%) groups. The heterologous boosting with the V-01 vaccine was safe and efficacious, which could elicit robust humoral immunity under the epidemic of the Omicron variant.Trial registration: ClinicalTrials.gov identifier: NCT05096832.

BACKGROUND: Postpartum haemorrhage remains an important cause of maternal death despite treatment with conventional therapy. Uncontrolled studies and one randomised comparison with conventional oxytocics have reported dramatic effects with high-dose misoprostol, usually given rectally, for treatment of postpartum haemorrhage, but this has not been evaluated in a placebo-controlled trial. METHODS: The study was conducted at East London Hospital Complex, Tembisa and Chris Hani Baragwanath Hospitals, South Africa. Routine active management of the third stage of labour was practised. Women with more than usual postpartum bleeding thought to be related to inadequate uterine contraction were invited to participate, and to sign informed consent. All routine treatment was given from a special 'Postpartum Haemorrhage Trolley'. In addition, participants who consented were enrolled by drawing the next in a series of randomised treatment packs containing either misoprostol 5 x 200 microg or similar placebo, which were given 1 orally, 2 sublingually and 2 rectally. RESULTS: With misoprostol there was a trend to reduced blood loss >/=500 ml in 1 hour after enrolment measured in a flat plastic 'fracture bedpan', the primary outcome (6/117 vs 11/120, relative risk 0.56; 95% confidence interval 0.21 to 1.46). There was no difference in mean blood loss or haemoglobin level on day 1 after birth < 6 g/dl or blood transfusion. Side-effects were increased, namely shivering (63/116 vs 30/118; 2.14, 1.50 to 3.04) and pyrexia > 38.5 degrees C (11/114 vs 2/118; 5.69, 1.29 to 25). In the misoprostol group 3 women underwent hysterectomy of whom 1 died, and there were 2 further maternal deaths. CONCLUSIONS: Because of a lower than expected incidence of the primary outcome in the placebo group, the study was underpowered. We could not confirm the dramatic effect of misoprostol reported in several unblinded studies, but the results do not exclude a clinically important effect. Larger studies are needed to assess substantive outcomes and risks before misoprostol enters routine use.

A particular extra-nodal lymphoma type arises from B cells of the marginal zone (MZ) of mucosa-associated lymphoid tissue (MALT). The aetiology of MZ lymphomas suggests that they are associated with chronic antigenic stimulation by microbial pathogens, among which Helicobacter pylori-associated gastric MALT lymphoma is the best studied. Recently, MALT lymphomas have been described in the context of chronic conjunctivitis, which can be associated with Chlamydia spp. infection. Studies from Italy showed the presence of Chlamydia psittaci in 87% of ocular adnexal lymphomas (OAL), and C. psittaci has been described in a large part of samples from Austria and Korea as well. However, this finding was not always confirmed by other studies, suggesting that the association with C. psittaci may depend on geographic heterogeneity. Interestingly, none of the studies up to now has been carried out in the African population, where a strong association between infectious agents and the occurrence of human neoplasms has been reported. This study was designed to investigate the possible association of Chlamydia psittaci in cases retrieved from Kenya, compared to cases from Italy. Our results showed that there was a marked variation between the two geographical areas in terms of association with C. psittaci, as 17% (5/30) of the samples from Italy were positive for C. psittaci, whereas no association with this pathogen was observed in any of the African samples (0/9), suggesting that other cofactors may determine the OAL occurrence in those areas. OAL cases are often characterized by down-regulation of p16/INK4a expression and promoter hypermethylation of the p16/INK4a gene. Our results showed a partial methylation of p16/INK4a promoter in C. psittaci-negative cases, whereas no hypermethylation of this gene was found in C. psittaci-positive cases, suggesting that mechanisms other than promoter hypermethylation lead to p16/INK4a silencing in C. psittaci-positive cases. We may conclude that the role of epidemiologic, environmental and genetic factors, must be considered in the aetiology of this disease.

Abstract Provision of safe water supplies is a priority for the global community and for villages in Kenya. An extended case study from the highlands of Western Kenya shows that local communities can be successful in self‐organisation for improved water supply, but only by mobilising considerable amounts of investment resources and local collective action. Gender relations are crucial to success, with women having primary responsibility for water management, but more or less hidden roles in community groups. There are legitimate concerns that Kenya's new water laws and institutions may make it more difficult for local community groups to self‐organise, with additional biases against women. Copyright © 2008 John Wiley &amp; Sons, Ltd.

Acid Fast Bacilli (AFB) microscopy smear remains the most widely used laboratory diagnostic technique for Pulmonary Tuberculosis (PTB) in low-and-middle income countries. Although it is highly specific, the sensitivity varies between 20-80% in immune-competent people, with only 50% case detection among HIV/TB co-infected patients, hence the need to determine the diagnostic accuracy of Th1 and Th2 cytokine response in AFB microscopy smear negative PTB-HIV co-infected patients. A total of 86 participants were recruited; 70 (81.4%) AFB microscopy smear negative and 16 (18.6%) AFB microscopy smear positive. The AFB microscopy smear negative samples were then cultured using Lowenstein Jensen Medium with 46 being culture-negative and 24 being culture-positive. Blood samples were also collected, cultured using QFT-GIT and the supernatant (plasma) harvested to evaluate cytokine profiles using Enzyme-Linked Immunosorbent Assay. IFN-γ (P < 0.001), TNF-α (P = 0.004), IL-2 (P = 0.004) and IL-4 (P = 0.009) median levels were elevated in PTB culture-positive (AFB microscopy smear negative) as compared to PTB culture-negative (AFB microscopy smear negative) participants. Finally, when Th1 cytokines (IFN-γ, TNF-α and IL-2), Th2 cytokines (IL-6 and IL-10) and T cells were included in the logistic regression fit for PTB outcome, the predictive power of discriminating between those who were AFB smear negative in the diagnosis of PTB was good with cross validated area under the curve (AUC) being 0.87 (95% CI: 0.78, 0.96). This study provides evidence for the ability of Th1 and Th2 cytokines to determine PTB status in AFB microscopy smear negative patients co-infected with HIV.

Cervicofacial actinomycosis still occurs infrequently and should be included in the differential diagnosis of neoplasms, and chronic suppurative and granulomatous lesions of the head and neck region. The authors present two cases of actinomycosis. Patient 1 was a 32-year-old man who was first seen with a firm, suppurative mass at his left frontal region. Patient 2 was a 36-year-old woman with an indurated mass at her left parotid area. Both patients were diagnosed histopathologically with cervicofacial actinomycosis, but each patient had a different clinical course and different response to antimicrobial and surgical treatments.

Background: Myocarditis is a challenging diagnosis due to the heterogeneity of clinical presentations. Myocarditis can present with a mildly raised cardiac enzyme to severe myocarditis leading to congestive heart failure, arrhythmias, cardiogenic shock, and death. It is a predictor of morbidity and mortality in dengue-infected patients. The exact prevalence of dengue myocarditis and its outcomes are unknown in Pakistan. Objectives: We aim to study the prevalence and association of myocarditis with the length of stay in the hospital and mortality of dengue-infected patients. Methods: A retrospective observational study done at a tertiary care hospital. We reviewed hospital record files of 1008 consecutive patients with dengue viral infection admitted from November 2018 to November 2019. Results: Out of 1008 dengue-infected patients, 55.4% of patients were older than 35 years and 68.4% were males. Hypertension (HTN) was the most common comorbid condition. The prevalence of myocarditis in hospitalized dengue-infected patients was 4.2%. All (100%) of dengue myocarditis patients had raised cardiac troponin I (cTn-I), 59.5% of patients had at least one electrocardiography (ECG) change, and 24% had reduced ejection fraction (EF) (defined as EF < 55%). On multivariable analysis, patients with raised cTn-I levels (adjusted odds ratios = 5.29; [95% confidence interval (CI): 2.16-12.96]) and abnormal echocardiography (ECHO) [aOR = 4.38; 95% CI: 1.26-15.27)] had a prolonged hospital stay (>3 days). Raised cTn-I levels (aOR = 8.2; [95% CI: 1.83-36.84]) was significantly associated with in-hospital mortality. Conclusions: Raised cTn-I is the predictor of length of stay and in-hospital mortality in dengue-infected patients. Atrial fibrillation, diabetes mellitus, hypertension, low serum bicarbonate, high serum creatinine, and any abnormality on echocardiography were associated with adverse outcomes in dengue-infected patients.

BACKGROUND: Albuminuria is long recognised as a sign of renal disease in diabetes. In type 1 diabetes, renal disease occurs after a longer duration of diabetic state. In type 2 diabetes, it is more variable. OBJECTIVE: To determine the prevalence and any risk factors of albuminuria in short-term (< or = 2 yrs) type 2 diabetes. DESIGN: Cross sectional, descriptive study. Microalbuminuria was assessed using micro II strips. SETTING: Outpatient diabetic clinic at Kenyatta National Hospital, Nairobi. SUBJECTS: Patients who were newly diagnosed or had had type 2 diabetes for two years or less. MAIN OUTCOME MEASURES: Microalbuminuria, lipids, glycated haemoglobin, fasting blood glucose and blood pressure. RESULTS: One hundred and thirty nine patients who had type 2 diabetes mellitus for < or = 2 yrs were seen, but only 100 patients were included in the study over a six month period. Their mean (SD) age was 53.7 (9.3) years. Mean (SD) duration of diabetes was 10.3 (7.5) months. Fifty per cent of the study patients were hypertensive. Only 48% had HbA1c < 8% while 36% had HbA1c > 9%. The lipid profile of total, LDL-HDL-cholesterol and triglycerides were predominantly within normal limits. Twenty six per cent were established to have albuminuria of which one patient had macroalbuminuria. Blood pressure, glycated haemoglobin and lipid parameters were not significantly different from patients without albuminuria CONCLUSION: Albuminuria occurred in a significant proportion of patients with short term type 2 diabetes. Comparable to studies done elsewhere on short-term type 2 diabetes, albuminuria is both a sign of nephropathy and a cardiovascular risk factor. It should be looked for in all patients with type 2 diabetes attending this clinic, even at diagnosis.

Imperforate hymen is a rare condition that presents with amenorrhea, cyclical abdominal pains and urine retention among pubertal girls. A 14 year old girl with imperforate hymen underwent hymenotomy for hematocolpometra, having presented with abdominal pains and tenesmus.

// Maria Raffaella Ambrosio 1,* , Lucia Mundo 1,* , Sara Gazaneo 1 , Matteo Picciolini 2 , Prasad Satya Vara 3 , Shaheen Sayed 4 , Alessandro Ginori 1,5 , Giuseppe Lo Bello 1 , Leonardo Del Porro 1 , Mohsen Navari 6,7,8 , Stefano Ascani 9 , Amhed Yonis 10 , Lorenzo Leoncini 1 , Pier Paolo Piccaluga 7,8,* and Stefano Lazzi 1,* 1 Department of Medical Biotechnology, Section of Pathology, University of Siena, Siena, Italy 2 Diatech Pharmacogenetics, Jesi, Italy 3 Aga Khan Hospital, Kisumu, Kenya 4 Aga Khan University Hospital, Nairobi, Kenya 5 Pathology Unit, Ospedale Civico di Carrara, Carrara, Italy 6 Research Center of Advanced Technologies in Medicine, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran 7 Department of Experimental, Diagnostic, and Experimental Medicine, Bologna University School of Medicine, Bologna, Italy 8 Euro-Mediterranean Institute of Science and Technology (IEMEST), Palermo, Italy 9 Section of Pathology, Azienda Ospedaliera S. Maria di Terni, University of Perugia, Perugia, Italy 10 Alexandria University, Alexandria, Egypt * These authors have contributed equally to this work Correspondence to: Lorenzo Leoncini, email: // Pier Paolo Piccaluga, email: // Keywords : plasmablastic lymphoma; miRNA expression profiling; Burkitt lymphoma; extramedullary plasmacytoma; Epstein-Barr virus; Pathology section Received : June 20, 2017 Accepted : September 08, 2017 Published : October 31, 2017 Abstract Plasmablastic lymphoma (PBL) is an aggressive lymphoma, often arising in the context of immunodeficiency and associated with Epstein-Barr virus (EBV) infection. The most frequently detected genetic alteration is the deregulation of MYC gene through the translocation - t(8;14)(q24;q32). The diagnosis of PBL is often challenging because it has an overlap in morphology, immunophenotype, cytogenetics and virus association with other lymphomas and plasma cell neoplasms; further, its molecular basis remains elusive. In the present study we aimed to better define the possible contribution of EBV infection as well as miRNA deregulation in PBL pathogenesis. We studied 23 cases of PBL, 19 Burkitt lymphomas (BL), and 17 extra-medullary plasmacytoma (EMPC). We used qPCR and immunohistochemistry to assess EBV latency patterns, while micro-RNA (miRNA) profiling was performed by next generation sequencing (Illumina) and validated by qPCR. Our analysis revealed a non-canonical EBV latency program with the partial expression of some proteins characterizing latency II and the activation of an abortive lytic cycle. Moreover, we identified miRNA signatures discriminating PBL from BL and EMPC. Interestingly, based on the miRNA profile, PBL appeared constituted by two discrete subgroups more similar to either BL or EMPC, respectively. This pattern was confirmed in an independent set of cases studied by qPCR and corresponded to different clinico-pathological features in the two groups, including HIV infection, MYC rearrangement and disease localization. In conclusion, we uncovered for the first time 1) an atypical EBV latency program in PBL; 2) a miRNA signature distinguishing PBL from the closest malignant counterparts; 3) the molecular basis of PBL heterogeneity.

OBJECTIVE: We investigated the prevalence and pattern of electroencephalographic (EEG) features of epilepsy and the associated factors in Africans with active convulsive epilepsy (ACE). METHODS: We characterized electroencephalographic features and determined associated factors in a sample of people with ACE in five African sites. Mixed-effects modified Poisson regression model was used to determine factors associated with abnormal EEGs. RESULTS: Recordings were performed on 1426 people of whom 751 (53%) had abnormal EEGs, being an adjusted prevalence of 2.7 (95% confidence interval (95% CI), 2.5-2.9) per 1000. 52% of the abnormal EEG had focal features (75% with temporal lobe involvement). The frequency and pattern of changes differed with site. Abnormal EEGs were associated with adverse perinatal events (risk ratio (RR)=1.19 (95% CI, 1.07-1.33)), cognitive impairments (RR=1.50 (95% CI, 1.30-1.73)), use of anti-epileptic drugs (RR=1.25 (95% CI, 1.05-1.49)), focal seizures (RR=1.09 (95% CI, 1.00-1.19)) and seizure frequency (RR=1.18 (95% CI, 1.10-1.26) for daily seizures; RR=1.22 (95% CI, 1.10-1.35) for weekly seizures and RR=1.15 (95% CI, 1.03-1.28) for monthly seizures)). CONCLUSIONS: EEG abnormalities are common in Africans with epilepsy and are associated with preventable risk factors. SIGNIFICANCE: EEG is helpful in identifying focal epilepsy in Africa, where timing of focal aetiologies is problematic and there is a lack of neuroimaging services.

We conducted a pilot study to assess the feasibility of telecytology as a diagnostic tool in difficult cases originating from a hospital in East Africa. Forty cytology cases considered difficult by a referring pathologist were posted on a telepathology website. Six pathologists independently assessed the static images. Telecytology diagnoses were compared with the consensus diagnoses made on glass slides and also with the histogical diagnoses when available. The diagnostic agreement of the six pathologists was 71-93% and tended to be higher for pathologists with more experience. Reasons for discordance included poor image quality, presence of diagnostic cells in thick areas of smears, sampling bias and screening errors. The consensus diagnoses agreed with histological diagnoses in all 17 cases in which a biopsy was performed. Diagnostic accuracy rates (i.e. telecytology diagnosis vs. histological diagnosis) for individual pathologists were 65-88%. To ensure diagnostic accuracy both referring and consulting pathologists must have adequate training in cytology, image acquisition and image-based diagnosis and the diagnostic questions of importance must be clearly communicated by the referring pathologist when posting a case.

INTRODUCTION: This study aims to assess common organisms causing urinary tract infection (UTI) in the Gaza Strip, Palestinian Authority and to examine the incidence of ciprofloxacin resistance in the strains of bacteria isolated from patients suspected with UTI over a six-month period. METHODS: Ciprofloxacin was evaluated along with other commonly-used antibiotics against a total of 480 clinical isolates obtained from urine samples. The samples were collected from community patients from different parts of the Gaza Strip. Susceptibility tests were done by the Kerby Bauer method. RESULTS: Among the tested drugs, the percent resistance rate to ciprofloxacin was 15.0 percent. However, high resistance to ciprofloxacin was detected among Acinetobacter haemolyticus (28.6 percent), Staphylococcus saprophyticus (25.0 percent), Pseudomonas aeruginosa (20.0 percent), Klebsiella pneumonia (17.6 percent) and Escherichia coli (12.0 percent). Minimal inhibitory concentration of ciprofloxacin was measured for all resistant UTI isolates. CONCLUSION: This study indicates emerging ciprofloxacin resistance among most UTI bacterial pathogens. Increasing resistance against ciprofloxacin demands coordinated monitoring of its activity and rational use of the antibiotics.

In the beginning of 2003, one of the authors (JvR) was privileged to attend a home birth in The Gambia guided by a traditional birth attendant (TBA). The woman was a gravida 2 para 1 and had started labour in the morning. Everybody in the whole compound was anxiously waiting for the child to be born. Nobody (the TBA included) would know whether the baby would be born alive, because there was no foetal monitoring whatsoever. The TBA gave continuous emotional support to the woman, an evidence-based strategy to improve the outcome of labour (Hodnett et al. 2004). She would have been rather empty-handed had serious complications suddenly occurred. Only in the case of postpartum haemorrhage (PPH) she would be able to administer misoprostol to the woman (Walraven et al. 2004). In fact the TBA was participating in a randomized trial of misoprostol for the prevention of PPH and although she was illiterate, she was able to follow the necessary procedures for the trial (Walraven 2003). In case of obstructed labour, antepartum haemorrhage, transverse lie and eclampsia, the TBA would have had no tools to deal with these serious complications. Hence, TBAs will not have any impact to reduce the appallingly high maternal mortality ratios in the less privileged parts of our global village. TBA practice was therefore considered to be of less value and the international safe motherhood movement started from 1997 onwards to concentrate on skilled attendance during labour and emergency obstetric care when complications would occur (Kruske & Barclay 2004). In the early afternoon, the woman gave birth to a full term normal weight baby with an Apgar score of 9/10 and there was great relief and joy all over the place. How different, however, is the situation in many of the delivery rooms of health facilities in sub-Saharan Africa and Asia. Pregnant women in labour are generally not allowed to bring a relative with them into the labour ward to give continuous support. One of the authors (JvR) happened to be a guest-worker early this year in the big university hospital in Dar es Salaam with a case load of 30–60 births a day. Women in labour lay in bed in complete isolation in pain without a continuous support giver. They are assessed by medical students, intern, resident and specialist doctors and midwives infrequently, in view of the overwhelming numbers. Those workers are trained in life-saving skills, but they seem to have forgotten (or may never have been taught) the importance of continuous emotional support. This aspect of care seems not to be emphasized, and assumed to be impossible or neglected in the prevailing circumstances. Lack of emotional support for women in labour has been described as ‘violence against women in health-care institutions’ (d'Oliveira et al. 2002). Furthermore, when women have caesarean sections, the newborns are admitted to the neonatology ward, because the woman cannot care for the baby herself without the help of a caregiver. This practice does contribute to an already high perinatal mortality rate (of over 120 per 1000), while at the same time the caesarean section rate (of over 30%) is extremely high (Kidanto et al. 2004). Continuous support for women during childbirth, especially when the caregiver is not a member of the hospital staff, when it begins in early labour and in settings where epidural analgesia is not available, has been shown in a Cochrane Review to be effective in reducing operative vaginal birth and caesarean section (Hodnett et al. 2004). It also reduces the need for intrapartum analgesia and women report less dissatisfaction with their childbirth experiences. In addition to the midwifery and emergency obstetric care skills provided by midwives and doctors, women in childbirth thus need continous emotional support, nowadays often only provided by TBAs. ‘Being supported’ is one of the major factors which determine women's positive perceptions of their birthing experience (Fenwick et al. 2003). International safe motherhood programmes have forgotten to pay attention to this important part of obstetric care. It is now time to recognize that we need both in our labour rooms and that we should allow women to bring a continuous support giver with them into the labour ward. For reasons of privacy this can only be other women in the large labour wards in low resource countries. We have to resist the objections which will be made by the professional caregivers as they may not be willing to accept people, not in pain, who watch their performance. The introduction of the continuous supportive caregiver will lead to better perinatal outcome and less unnecessary intervention. It is a strategy that can be implemented immediately without any cost. Now is the time to introduce this in all those places where women up till now suffer from anxiety and loneliness during childbirth. Perinatal care should be re-humanized (Chalmers 2002).

Introduction. Telemedicine is the provision of health services over a distance using information communication technology devices. Telemedicine is emerging as a promising component of healthcare care delivery worldwide, accelerated by the COVID-19 pandemic. This study assessed the factors promoting uptake, barriers, and opportunities for telemedicine among doctors in Kenya. Methodology. A semiquantitative, cross-sectional online survey was conducted among doctors in Kenya. During a month, between February and March 2021, 1,200 doctors were approached by email and WhatsApp, of whom 13% responded. Findings. A total of 157 interviewees participated in the study. The general usage of telemedicine was 50%. Seventy-three percent of doctors reported using a mix of in-person care and telemedicine. Fifty percent reported using telemedicine to support physician-to-physician consultations. Telemedicine had limited utility as a standalone clinical service. The inadequate information communication technology infrastructure was the most reported barrier to telemedicine, followed by a cultural resistance to using technology to deliver healthcare services. Other notable barriers were the high cost of initial setup limited skills among patients, limited skills among doctors, inadequate funding to support telemedicine services, weak legislative/policy framework, and lack of dedicated time for telemedicine services. The COVID-19 pandemic increased the uptake of telemedicine in Kenya. Conclusion. The most extensive use of telemedicine in Kenya supports physician-to-physician consultations. There is limited single use of telemedicine in providing direct clinical services to patients. However, telemedicine is regularly used in combination with in-person clinical services, allowing for continuity of clinical services beyond the physical hospital infrastructure. With the widespread adoption of digital technologies in Kenya, especially mobile telephone technologies, the growth opportunities for telemedicine services are immense. Numerous mobile applications will improve access capabilities for both service providers and users and bridge the gaps in care.