Aga Khan Hospital, Mombasa

There is no consensus regarding how the growth of preterm infants should be monitored or what constitutes their ideal pattern of growth, especially after term-corrected age. The concept that the growth of preterm infants should match that of healthy fetuses is not substantiated by data and, in practice, is seldom attained, particularly for very preterm infants. Hence, by hospital discharge, many preterm infants are classified as postnatal growth-restricted. In a recent systematic review, 61 longitudinal reference charts were identified, most with considerable limitations in the quality of gestational age estimation, anthropometric measures, feeding regimens, and how morbidities were described. We suggest that the correct comparator for assessing the growth of preterm infants, especially those who are moderately or late preterm, is a cohort of preterm newborns (not fetuses or term infants) with an uncomplicated intrauterine life and low neonatal and infant morbidity. Such growth monitoring should be comprehensive, as recommended for term infants, and should include assessments of postnatal length, head circumference, weight/length ratio, and, if possible, fat and fat-free mass. Preterm postnatal growth standards meeting these criteria are now available and may be used to assess preterm infants until 64 weeks' postmenstrual age (6 months' corrected age), the time at which they overlap, without the need for any adjustment, with the World Health Organization Child Growth Standards for term newborns. Despite remaining nutritional gaps, 90% of preterm newborns (ie, moderate to late preterm infants) can be monitored by using the International Fetal and Newborn Growth Consortium for the 21st Century Preterm Postnatal Growth Standards from birth until life at home.

As populations move to urban centres across East Africa, lifestyle habits that affect cardiovascular disease have changed, affecting non-communicable disease risk. In particular, the prevalence of hypertension, and associated awareness of this life-threatening condition, has not been studied in Mombasa, Kenya. This paper assesses the rates of prevalence, awareness, treatment and control of hypertension in Old Town, an urban district of the coastal city. We surveyed 469 subjects, gathered via a clustered sampling technique. Age-adjusted prevalence of hypertension was measured at 32.6% (± 2.2) for adults over 18 and was linearly related to age. Results indicate that hypertension awareness was associated with age and sex, as women were substantially more likely to be aware of and to control their hypertension. Only 23.2% (± 2.0) of subjects had knowledge of both the causes of and practical solutions to hypertension, and practical hypertension knowledge was associated with hypertension awareness and gender (women had higher rates of knowledge than men). These results indicate that hypertension is a real public health concern in Old Town, and that younger individuals, particularly males, are least likely to be aware of the dangers of hypertension. Public health measures should focus on this population.

INTRODUCTION: The human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) has long affected millions of individuals across the globe. Historically, the prevalence of this disease is particularly noted within the African continent. Before the coronavirus disease 2019 (COVID-19) pandemic, many African countries struggled to effectively manage the increasing burden associated with HIV/AIDS. There is now a need to reassess this in a COVID-19 pandemic context so that the impact of COVID-19 on HIV/AIDS healthcare within Africa can be adequately evaluated. METHODS: Data collection was performed on the PubMed, Ovid MEDLINE and Embase bibliographical databases with a predefined search strategy. Searches were performed in blind duplicate and all articles considering COVID-19 and HIV/AIDS within African healthcare were considered. RESULTS: The COVID-19 pandemic has severely exacerbated the many issues surrounding HIV/AIDS care within many African countries. These impacts are noticeable in medical, psychological, and socio-political contexts. CONCLUSIONS: Before efforts are made to improve the provision of HIV/AIDS and COVID-19 care within Africa, it is important that this issue is brought to the attention of the scientific and clinical community so that the continent can receive the necessary support and aid.

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.

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.

Lassa fever, caused by the Lassa virus of the Arenaviruses family, is a re-emerging public health concern that has led to 300,000 infections and 5000 deaths annually in Africa. Highly prevalent in Sierra Leone, Liberia, Guinea, Nigeria, Côte d'lvoire, Ghana, Togo, and Benin, patients infected with the virus can manifest with cough, sore throat, headache, nausea, and vomiting among other symptoms. Coexisting with the coronavirus disease 2019 (COVID-19) pandemic and its impacts, cases of Lassa fever in the African population have been reported to decrease due to hesitancy in visiting clinics that leads to unreported cases-all contributing to a silent outbreak in West Africa. Thus, to overcome current burdens, gaps, and challenges caused by Lassa fever amidst COVID-19 in Africa, various recommendations for efficient control of transmission, measures for disease containment, and strategies to correct misperceptions were made.

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.

The Cook Island government has made several efforts to ensure zero confirmed cases and transmission of COVID-19, especially among visiting travelers. However, the Cook Island ministry of health has to deal with the new strain of dengue fever outbreak, known as dengue fever type 2 (DEN-2), by adopting several measures to control its spread, especially in the affected parts of the subtropical country. This paper aims to describe the dengue fever response taken in Cook Island and suggest recommendations to control the risk of transmission in endemic parts of the world.

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.

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Challenges to developing an adequate infrastructure and the capacity to manage large numbers of patients taking antiretroviral therapy are being addressed in Kenya, where an estimated 2.1 million people were living with HIV infection at the end of 1999 and approximately 700 individuals die from HIV disease daily [1,2]. The gross national product per capita was US$340 a year in 1997, making antiretroviral therapy out of reach for the vast majority of Kenyans. However, Kenya has a substantial working population, especially in Nairobi, which can afford antiretroviral drugs through the private sector. We conducted a standardized chart abstraction and structured interview of five physicians in private practice in Nairobi, considered among the best practitioners providing care for HIV-infected patients taking antiretroviral therapy. We reviewed the charts of 337 patients [40% women; 80% antiretroviral naive; median CD4 cell count 80 cells/mm3 (n = 173); viral load 136 167 copies/ml (n = 117)] started on antiretroviral drugs. No generic antiretroviral agents were available in Kenya during this time. Since October 1996, 300 patients were started on antiretroviral drugs and were the basis for this analysis. Of these, 217 (72%) were started on highly active antiretroviral therapy (HAART; including two nucleoside reverse transcriptase inhibitors plus either abacavir, a non-nucleoside reverse transcriptase inhibitor, or a protease inhibitor) [3]. The percentage started on a HAART regimen increased annually from 43% (22/51) in 1997 to 96% (48/50) in 2000 (Fig. 1; chi-square for trend, P < 0.001). For the remaining 83 not started on HAART, the reasons were financial for 27 (33%), drug interaction with rifampin for 21 (25%), HAART not widely available for 15 (18%), and other reasons for 20 (24%).Fig. 1.: Antiretroviral therapy prescribed at baseline visit by year. In January 2001, a 30-day supply of a typical regimen of highly active antiretroviral therapy consisting of brand-name drugs from pharmaceutical companies cost US$330–630, but by June 2001 the prices for some combinations had declined to US$80–175. □ Unclassified; ▧ one nucleoside reverse transcriptase inhibitor (NRTI); ▪ two to three NRTI; ▒ other highly active antiretroviral therapy; ▥ NRTI plus two protease inhibitors (PI); ▪ NRTI plus PI; ▪ NRTI plus non-NNRTI. aTo 15 June 2001.Laboratory monitoring for antiretroviral drug effect and toxicity is available in Nairobi, but the cost has limited the use of these tests. In June 2001, the cost of a CD4 cell count (FACScan; Becton Dickinson, San Jose, CA, USA) was US$20–35 and a viral load test (Amplicor HIV-1 Monitor Version 1.5 Assay; Roche Diagnostics, Branchburg, NJ, USA; or branched chain-DNA Version 3.0; Chiron, Emeryville, CA, USA) was US$87–112. In 6-month intervals since 1998, a CD4 cell count was performed for 41–56% of patients and a viral load for 31–44%. No patient in this evaluation was monitored in a manner consistent with internationally recognized standards, which recommend a viral load 2–8 weeks after the initiation of therapy and every 3–4 months thereafter [3], because such an aggressive approach is unaffordable to most Kenyans. Among those with tests performed, the median CD4 cell count increase during the first year on HAART was 74 cells/mm3 (n = 71). The median change in viral load during the first year on HAART was −1.9 log copies/ml (n = 42) and was less than 400 copies/ml between 1–6 months for 45 out of 76 (59%), 7–12 months for 26 out of 55 (47%), 13–18 months for 20 out of 41 (49%), and 19–24 months for 10 out of 31 (32%) patients. As of 15 June 2001, 159 (53%) were active in care, 45 (15%) were lost to follow-up, 34 (11%) were known to have died, 27 (9%) transferred care, 23 (8%) stopped antiretroviral therapy, and 12 (4%) moved. The probability of a patient remaining on antiretroviral therapy at 6 months was 0.86 [95% confidence interval (CI) 0.81–0.90], at one year was 0.78 (95% CI 0.72–0.83), and at 2 years was 0.66 (95% CI 0.59–0.74). This evaluation provides evidence that antiretroviral drugs can be effectively prescribed in the private sector in Nairobi, Kenya, and highlights some of the constraints to providing optimal therapy and monitoring. Patients were able to stay on prescribed regimens for an extended time, and obtain virological and immunological responses to antiretroviral therapy similar to those reported in North America, Europe, as well as other African settings [4–8]. Treatment regimens, the frequency of clinic visits, and laboratory monitoring were constrained by patients' finances. This underscores the need for simpler and less expensive strategies and technologies to provide and monitor antiretroviral therapy. As a result of the magnitude of the epidemic in many resource-poor countries, the potential numbers of individuals who could be managed in the private sector is large [9]. As antiretroviral drug prices continue to decline, there will be an increased demand for antiretroviral treatment among the working class. Models of care that provide training and assistance for private practitioners to channel this growing expertise to assist with the management of large numbers of patients should be explored. This expertise can be a valuable resource for the private sector as well as larger public programmes within countries. Acknowledgements The authors would like to thank Tedd Ellerbrock, Lois Conley, and Linda Scoles of the Centers for Disease Control and Prevention in Atlanta for their assistance with analysis and comments on the project.

BACKGROUND: The HIV epidemic among men who have sex with men (MSM) continues to expand globally. The addition of an efficacious, prophylactic vaccine to combination prevention offers immense hope, particularly in low- and middle- income countries which bear the greatest global impact. However, in these settings, there is a paucity of vaccine preparedness studies that specifically pertain to MSM. Our study is the first vaccine preparedness study among MSM and female sex workers (FSWs) in Kenya. In this paper, we explore willingness of Kenyan MSM to participate in HIV vaccine efficacy trials. In addition to individual and socio-cultural motivators and barriers that influence willingness to participate (WTP), we explore the associations or linkages that participants draw between their experiences with or knowledge of medical research both generally and within the context of HIV/AIDS, their perceptions of a future HIV vaccine and their willingness to participate in HIV vaccine trials. METHODS: Using a social network-based approach, we employed snowball sampling to recruit MSM into the study from Kisumu, Mombasa, and Nairobi. A field team consisting of seven community researchers conducted in-depth interviews with a total of 70 study participants. A coding scheme for transcribed and translated data was developed and the data was then analysed thematically. RESULTS: Most participants felt that an HIV vaccine would bring a number of benefits to self, as well as to MSM communities, including quelling personal fears related to HIV acquisition and reducing/eliminating stigma and discrimination shouldered by their community. Willingness to participate in HIV vaccine efficacy trials was highly motivated by various forms of altruism. Specific researcher responsibilities centred on safe-guarding the rights and well-being of participants were also found to govern WTP, as were reflections on the acceptability of a future preventive HIV vaccine. CONCLUSION: Strategies for engagement of communities and recruitment of trial volunteers for HIV vaccine efficacy trials should not only be grounded in and informed by investigations into individual and socio-cultural factors that impact WTP, but also by explorations of participants' existing experiences with or knowledge of medical research as well as attitudes and acceptance towards a future HIV vaccine.

OBJECTIVE: To evaluate the effect of passive smoking and breastfeeding on the severity and age of onset of bronchial asthma. DESIGN: Cross-sectional study. SETTING: Paediatric observation ward and paediatric chest clinic, Kenyatta National Hospital. PATIENTS: Children aged between one and 120 months. RESULTS: More than fifty per cent of the children had their first wheeze at less than 12 months of age and 68% were categorised as having moderate to severe asthma. Passive smoking was positively significantly associated with early onset of wheezing (chi 2 = 6.22, p = 0.012, Odds ratio = 2.44, 95% CI 1.2,5.0), and also, at a non significant level, to severity of asthma (chi 2 = 2.8, p = 0.09, Odds ratio = 2.1, 95% CI 0.9,4.7). On the other hand, exclusive breastfeeding was significantly negatively associated with severity of bronchial asthma (chi 2 = 4.02, p = 0.045, Odds ratio = 0.4, 95% CI 0.14,0.98), but did not seen to have effect on age of onset of the disease (chi 2 = 0.0006, p = 0.94, Odds ratio = 0.9, 95% CI 0.4,2.2). CONCLUSION: Passive smoking is associated with early onset of asthma and possibly with development of severe asthma while exclusive breastfeeding is protective against development of severe asthma but does not seem to affect the age of onset of this disease.

Experimental studies to test interventions for people living with HIV in low- and middle-income countries are essential to ensure appropriate and effective clinical care. The implications of study participation on outcome data in such populations have been discussed theoretically, but rarely empirically examined. We aimed to explore the effects of participating in a randomised controlled trial conducted in an HIV clinic in Mombasa, Kenya. We report qualitative data from the Treatment Outcomes in Palliative Care trial, which evaluated the impact of a nurse-led palliative care intervention for HIV positive adults on antiretroviral therapy compared to standard care. Participants in both arms attended five monthly quantitative data collection appointments. Post-trial exit, 10 control and 20 intervention patients participated in semi-structured qualitative interviews, analysed using thematic analysis. We found benefit attributed to the compassion of the research team, social support, communication, completion of patient reported outcome measures (PROMs) and material support (transport reimbursement). Being treated with compassion and receiving social support enabled participants to build positive relationships with the research team, which improved mental health and well-being. Open and non-judgmental communication made participants feel accepted. Participants described how repeated completion of the PROMs was a prompt for reflection, through which they began to help themselves and self-care. Participant reimbursements relieved financial hardship and enabled them to fulfil their social responsibilities, enhancing self-worth. These findings emphasise the importance of compassion, support and effective communication in the clinical encounter, particularly in stigmatised and isolated populations, and the potential of the integration of simple PROMs to improve patient outcomes. Participation in research has unexpected positive benefits for participants, which should be taken into account when designing research in similar populations. Researchers should be aware of the effects of financial reimbursement and contact with researchers in isolated and impoverished communities.

OBJECTIVE: To evaluate our experience of laparoscopic appendicectomy at the Aga Khan Hospital, Nairobi over a six year period from the inception of the technique and to assess its advantages and disadvantages. DESIGN: Case series study. SETTING: The Aga Khan Hospital, Nairobi. PATIENTS: One hundred and six cases operated on from May 1996 to June 2002. MAIN OUTCOME MEASURES: Clinical presentation, age and sex demographics, average hospital stay, operating time, intra-operative and post-operative complications and outcome. RESULTS: There was a female preponderance with a female to male ratio of 2:3:1. Mean age was 30.6 years. There was a slightly more number of patients with recurrent appendicitis as opposed to the acute form. Totally laparoscopic procedure was in 39.6% of the cases, laparoscopic assisted in 45.3%. The conversion rate to an open procedure was 15.1%. Post operative port-site infection was 8.5%. No mortality was reported in these series. However there was one case which required re-operation following significant port site haemorrhage. Mean post-operative hospital stay was 2.2 days. CONCLUSION: Laparoscopic appendicectomy is a safe procedure in well trained hands. The major advantages are less morbidity and excellent cosmesis. Discovery of other intraabdominal pathologies is possible through laparoscopy as opposed to classical appendicectomy.

The increasing burden of cancer in Kenya has serious implications particularly for women. Understanding how women access breast-cancer treatment services is essential for mitigating its effects. The aim of this study was to examine access to breast cancer treatment services and implications on quality of care in Mombasa County, Kenya. Focus group discussions (N= 3), in-depth interviews (N=7) and a questionnaire were used in data collection. Qualitative data were analyzed using preset themes of access. Other emergent themes were identified and analyzed. Quantitative data were analyzed in SPSS V.23 and tabulated as descriptive. Lack of equipment, distance to facilities, unavailability of specialized personnel, high cost of care and cultural stigma, were the main barriers of access to cancer services. These barriers impacted on quality of care in terms of timeliness, equity, effectiveness, patient-centeredness, safety and efficiency. Poor quality of care was exhibited in reports of wrong and late diagnosis, poor outcomes in surgery, severe burns, broken down equipment, among others. There were also social consequences of being diagnosed with breast cancer including loss of business and termination from employment. Concerted efforts including investments in health workers, equipment and awareness creation are required to support access to quality breast cancer care.

OBJECTIVE: To evaluate our experience of laparoscopic cholecystectomies at the Aga Khan Hospital, Nairobi over a three-year period from the inception of the technique, and to assess its value and advantages to the patients. DESIGN: A prospective case series study. SETTING: The Aga Khan Hospital, Nairobi. PATIENTS: One hundred and thirty five cases operated from February 1996 to April 1999. All patients were subjected to the American method of laparoscopic cholecystectomy, which is described in detail in this paper. MAIN OUTCOME MEASURES: Clinical presentation, age and sex demographics, average hospital stay, intraoperative and postoperative complications and outcome. RESULTS: There was a female preponderance with a female to male ratio of 5:1. Mean age was forty nine years. Majority of patients suffered from chronic cholecystitis. The conversion rate to an open procedure was five per cent. There were two cases of significant bile leakage which required laparotomy. No mortality was reported in this series. CONCLUSION: This technique was found to have distinct advantages such as shorter hospital stay, lesser postoperative pain and very good cosmesis. It is a safe procedure if performed by a well trained surgeon.

INTRODUCTION: The majority of women with breast cancer in Kenya present with node-positive (stage II) or locally advanced Q7 disease (stage IIIB). Diagnosis is made on fine needle aspirate cytology and treatment is with surgery if resectable. Diagnostic core biopsy is available only at subspecialty hospitals. Processing and reporting of biopsy tissue are not standardised. Hormone receptor and HER2 analyses are rarely done preoperatively. METHODS: As part of a larger study investigating the prevalence of triple negative breast cancer in Kenya, a multidisciplinary workshop of collaborators from 10 healthcare facilities was held. Process gaps were identified, preanalytic variables impacting on ER/PR/HER2 discussed and training in core biopsy provided. Local remedial strategies were deliberated. CONCLUSION: We describe our experience and outcome from the workshop, which can be modelled for other resource poor settings.

OBJECTIVE: To study the causes of perceived high mortality in patients with diabetic foot in Mombasa, Kenya. DESIGN: A retrospective study. SETTING: The Mombasa Hospital Private Clinics, from January 2001 to December 2005. An urban set up. SUBJECTS: Ninety five patients with diabetic foot disease out of 830 in-hospital patients admitted with diabetes mellitus, aged between 40 and 90 years, treated mainly at The Mombasa Hospital. INTERVENTION: Patients were managed conservatively and operatively. The operations were incision and drainage, debridement and amputation. RESULTS: The majority of the males were between 50-70 years (76%) while the majority of the females were between 60-80 years (69%), with the mean age for males of 58 years and 65 years for the females. Overall mortality was 13%. Post-amputation mortality was 28%. The mortality was found to be associated with high co-morbidity, mainly uncontrolled diabetes mellitus (100%), Sepsis (75%), ischaemic heart disease (42%), uncontrolled hypertension (25%) and renal insufficiency (25%). The measurable characteristics included high blood sugars, raised WBC count, high creatinine, high serum lipids, abnormal ECG and abnormal arterial Doppler scans. CONCLUSION: The mortality associated with diabetic foot ulcer disease may be predicted by measurable characteristics. These parameters point to conditions that are themselves complications of diabetes mellitus and whose management will reduce mortality. The management of diabetic foot is therefore, multidisciplinary. Amputation appears to carry an added risk and should not be rushed until the patient is fully resuscitated.

OBJECTIVE: To determine the reliability of ultrasonographic features in differentiating benign from malignant solid breast masses. DESIGN: Descriptive, analytical study. PLACE AND DURATION OF STUDY: Radiology Department, Aga Khan University Hospital, Karachi from July 2000 to June 2002. SUBJECTS AND METHODS: One hundred solid breast masses in females with a tissue diagnosis available were reviewed. Two radiologists reviewed the sonographic features of masses without knowledge of clinical history or histologic examination results. Ultrasound features were corrected later with histologic features to determine the reliability of the former in benign or malignant nature of nodules. RESULTS: Ultrasound features that most reliably characterize masses as benign were a round or oval shape, circumscribed margins and a width to antero-posterior (AP) dimension ratio greater than 1.4. Features that characterized masses as malignant included irregular shape, spiculated margins and width to antero-posterior (AP) dimension ratio of 1.4 or less. If these three most reliable criteria had been strictly applied by the primary reporting radiologist, the overall cancer biopsy yield would have increased. CONCLUSION: The data confirms that certain ultrasound features can help differentiate benign from malignant masses. However, practice and interpreter variability should be further explored before these criteria are applied to defer biopsy of solid masses.