African Journals OnLine
East African Medical Journal

Volume 80 No 2 February 2003
ABSTRACTS

HEALTH STATUS AND HEALTH SEEKING BEHAVIOUR OF THE ELDERLY PERSONS IN DAGORETTI DIVISION, NAIROBI

L.M. Waweru, MPHE, Senior Lecturer, Kenya Medical Training College, P.O. Box 30195, Nairobi

E.W. Kabiru, PhD, Senior Lecturer

J.N. Mbithi, Senior Lecturer, Zoology Department, Kenyatta University, P.O. Box 43844 Nairobi

E.S. Some, Director of Programmes, AMREF Headquarters, P.O. Box 30125, Nairobi, Kenya

Request for reprints to: L.M Waweru, Kenya Medical Training College, P.O. Box 30195, Nairobi, Kenya

ABSTRACT

Objective: To determine the health status and the health seeking behaviour of the elderly people aged 65 years and above.

Design:A descriptive cross sectional study of individuals interviewed through questionnaires and focus groups discussions.

Setting:Dagoretti Division, Nairobi Province, Kenya.

Subjects:Four hundred non-institutionalised elderly persons.

Results:Four hundred people including 276(69%) women and 124(31%) males were interviewed; 44% had no independent source of livelihood and 51% were widowed. The majority 376(92.5%) of the respondents had been sick within the last three months, preceding the study with 111(27.8%) being sick all the time. The prevalent diseases included musculoskeletal (80%), respiratory (68%), sight (44%) and dental conditions(40%). Three hundred and sixteen (79%) of the respondents were functionally independent in activities of daily living. One hundred and sixty one (40.3%) were satisfied with their current way of life while (63%) perceived themselves as healthy, 24.8% of the respondents lived alone. The reported social problems included:- economic dependency (96%), poor housing (76%), loneliness (60%) and feeling not needed (42%) of the respondents. Only 26% were on treatment, lack of money hindered health care access to 73% of the respondents (p<0.001). Sixty two per cent of the respondents were buying over-the-counter drugs. Walking was under taken by 217(67%) as a physical exercise, and (26%) of the respondents consumed addictive drugs. The focus groups criticized the lack of health facilities for the elderly in the community.

Conclusion:The effects of ageing, low economic status and inadequate access to health care contributed to the elderly poor health status. The use of over-the-counter drugs was indicative of the inefficient health facilities in meeting the health needs of the elderly. The study points out the need to formulate policies that will target on the health needs of the elderly.

PREVALENCE AND AWARENESS OF OBESITY AMONG PEOPLE OF DIFFERENT AGE GROUPS IN EDUCATIONAL INSTITUTIONS IN MOROGORO, TANZANIA

C.N.M. Nyaruhucha, BSc, MSc, PhD, Senior Lecturer

J.H. Achen, BSc

J.M. Msuya, BSc, MSc, PhD, Senior Lecturer

N.B. Shayo, BSc, MSc, PhD, Associate Professor

K.B.M. Kulwa, BSc, MSc, Assistant Lecturer, Department of Food Science and Technology, Sokoine University of Agriculture, P.O. Box 3006, Morogoro, Tanzania

Request for reprints to: Dr. C.N.M. Nyaruhucha, Department of Food Science and Technology, Sokoine University of Agriculture, P.O. Box 3006, Morogoro, Tanzania

ABSTRACT

Objective:To determine the prevalence rates and level of awareness of obesity among people of different age groups in Morogoro Municipality, Tanzania.

Design:A cross-sectional, descriptive study.

Subjects:One hundred adults aged 19-50 years old and 40 pupils aged 14-18 years old.

Setting:Four educational institutions in Morogoro Municipality were included in the study. The four institutions included a primary and a secondary school, a teacher's training college and a university.

Results: The prevalence of obesity among the sampled subjects in Morogoro Municipality was 25 %, whereby 15.7% had a Body Mass Index (BMI) of between 25 and 30, and 9.3% had a BMI of more than 30. Age and occupation of all the subjects, together with marital status of adult subjects, were significantly related with obesity status. Prevalence of obesity increased with the increased age whereby subjects in the 41-50 years had the highest rate (45.4%). Employed subjects had higher rate of obesity (22.2%) than pupils or students. Similarly, married adults had higher rate of obesity (27.8%) than the single ones (4.7%). Unlike the old age group (41-50 years), 70% of the youngest subjects were not aware about the harmful effects of obesity. On the other hand, more than two thirds of all the subjects could not associate excess body weight with chronic non-communicable diseases such as coronary heart disease, high blood pressure and breathing problems.

Conclusion:Results of the current study indicate that obesity is increasingly becoming a public health problem in Morogoro Municipality, and probably in many other places in Tanzania. There is need for more public awareness on the effect of obesity on people's health through information, education and communication. It would be of great importance if such interventions were introduced at early age of life, for example by inclusion in school curricula.

HUMAN GROUP C ROTAVIRUSES IDENTIFIED IN KENYA

J.M. Mwenda, MPhil, PhD, Principal Research Scientist, Institute of Primate Research, P.O. Box 24481, Karen, Nairobi

I. Peenze, Msc,(Med), Principal Medical Technologist, MRC Diarrhoeal Pathogens Research, Unit, P.O. Box 173, Medunsa 0204, Pretoria, South Africa

N.M. Kiulia, Dip., Laboratory Technologist, Institute of Primate Research, P.O. Box 24481, Karen, Nairobi

M. De Beer, Msc(Med), Chief Medical Technologist, MRC Diarrhoeal Pathogens Research, P.O. Box 173, Medunsa 0204, Pretoria, South Africa

E. Omollo, Cert., Laboratory Technologist

M. Galo, Cert., Laboratory Technologist, Institute of Primate Research, P.O. Box 24481, Karen, Nairobi

A.D. Steel, PhD, Professor/Director, MRC Diarrhoeal Pathogens Research Unit, P.O. Box 173, Medunsa 0204, Pretoria, South Africa

Request for reprints to: Prof. A.D. Steele, MRC Diarrhoeal Pathogens Research Unit, P.O. Box 173, Medunsa 0204, Pretoria, South Africa

ABSTRACT

Background:Rotavirus is associated with acute infantile gastro-enteritis in infants and young children worldwide. Rotavirus is associated with the high cases of morbidity and mortality and it is estimated that up to 650,000 deaths in young children occur annually in the less developed countries. Approximately a quarter of these deaths occur in African children yet minimal data exist on the circulating rotavirus strains in Africa.

Objective:To characterise the circulating rotavirus strains in Kenya.

Design:A prospective study to investigate rotavirus infection in infants and young children with acute diarrhoea in different areas of Kenya. Between September 2001 and February 2002, 119 faecal specimens were collected from children aged between 1 and 60 months with acute infantile gastro-enteritis.

Setting: Faecal samples were collected from clinics around Nairobi and its suburbs including Karen, Ngong, Ongata Rongai

Subjects and Methods:Faecal samples were collected from 119 infants and young children with diarrhoea and were analysed by commercial ELISA and polyacrylamide gel electrophoresis (SDS-PAGE) to identify possible non-group A rotaviruses. Extraction of any potential rrotavirus double-stranded RNA from faeces amd characterisation by SDS-PAGE showed the presence of human group C rotaviruses.

Results:Examination of these samples with a commercial ELISA assay for the presence of group A rotavirus antigen showed that 13 specimens (11%) were positive. An analysis of all stool specimens was performed by polyacrylamide gel electrophoresis to identify possible non-group A rotaviruses. Extraction of any potential rotavirus double-stranded RNA from faeces and characterisation by SDS-PAGE showed the presence of human group C rotaviruses.

Conclusion:This is the first report of group C rotaviruses in Kenya. Further studies are underway to continue the surveillance of rotavirus strains in Kenya; as this information will be useful in planning rotavirus vaccine trials in Africa.

DETERMINANTS OF DIARRHOEAL DISEASES: A COMMUNITY BASED STUDY IN URBAN SOUTH WESTERN ETHIOPIA

A. Mekasha, MD, MSc Associate Professor, Department of Paediatrics and Child Health, Addis Ababa University P.O. Box 405, Addis Ababa, Ethiopia

A. Tesfahun, MD, MPH, Assistant Professor, Department of Community Health Jimma University Jimma, Ethiopia

Request for reprints to: Prof. A. Mekasha, Department of Paediatrics and Child Health, Addis Ababa University, P.O Box 405, Addis Ababa, Ethiopia

ABSTRACT

Objectives:To identify the determinants and describe the extent of diarrhoeal diseases among under-five children in urban Ethiopia.

Design:Community based, cross-sectional study.

Setting:Jimma, a town in south western Ethiopia, is an urban area with multi-ethnic population. The town is divided into 20 kebelles. Each kebelle has a population of about 5000 people

Subjects:Six hundred and five children under the age of five years were selected by random sampling. There were 142 children with diarrhoeal diseases in selected households. All those without diarrhoea were taken as controls.

Results:The incidence at diarrhoeal diseases was 5.48 episodes per child per year. The incidence of persistent diarrhoea was 7.75%. About 24.5% of the acute diarrhoeal diseases (ADD) culminated to persistent diarrhoea. Well source of water, lack of complete immunization, attack of measles and acute respiratory infecions (ARI) in the previous two weeks were found to be significantly associated with occurrence of diarrhoeal disease; however, only ARI and well water were retained in the logistic regression analysis.

Conclusion:The incidence of diarrhoeal diseases and the progression to persistent diarrhoea are very high. Many of the socio-environmental factors did not appear as significant determinants independently. The implication of this is that in a homogenous and economically deprived society improvement in a single factor does not reduce the problem of diarrhoeal diseases. Hence, an inter-sectoral approach is recommended to control diarrhoeal diseases.

KNOWLEDGE, ATTITUDES, AND PRACTICES OF PRIVATE MEDICAL PRACTITIONERS ON TUBERCULOSIS AMONG HIV/AIDS PATIENTS IN ELDORET, KENYA

S.O. Ayaya, MBChB, MMed, FDERM, Lecturer, Department of Child Health and Paediatrics, Moi University, P.O. Box 6121, Eldoret, Kenya

J. Sitienei, MBChB, Dip.(RIT) Medical Officer-in-Charge, National Leprosy and Tuberculosis Program, P.O. Box 5542, Eldoret, Kenya

W. Odero, MD, PhD, Associate Professor and Dean, Institute of Public Health, Moi University, P.O. Box 4606, Eldoret, Kenya

J. Rotich, BSs, Senior Lecture, Department of Preventive Medicine and Epidemiology, Moi University, P.O. Box 4600, Eldoret, Kenya

Request for reprints to: Dr. S.O. Ayaya, Department of Child Health and Paediatrics, Faculty of Health Sciences, Moi University, P.O. Box 4600, Eldoret, Kenya

ABSTRACT

Background:Tuberculosis (TB) is one of the major communicable diseases afflicting mankind today. Its prevalence is increasing with increase in HIV infection. It is important that doctors be able to correctly diagnose and institute proper management of patients with TB.

Objectives: To determine the knowledge, attitudes, and practices (KAP) of private medical practitioners in Eldoret on the management of TB.

Design: Cross-sectional descriptive qualitative study.

Setting:Private medical practitioners’ clinics and the outpatient departments of private hospitals in Eldoret town, western, Kenya. Eldoret is a cosmopolitan town 350-km north west of Nairobi. It is the main town in the north Rift Valley with such infrastructure as roads, international airport, and banks.

Subjects: Private medical practitioners in Eldoret.

Results:Fifty three out of 70 private doctors were interviewed. Of these 84.9% were male. Only 5.7% knew that sputum for AAFBs is collected on spot, early morning, and spot, whereas 69.8% and 13.2% said it should be collected on three and six consecutive early mornings respectively. Sputum and chest X-ray were the most common investigations used to diagnose TB. Few doctors knew that the clinical features considered as suspicious for TB in children were failure to thrive (FTT) (20.6%), contact with open TB case (12.8%), and cough for more than two or more weeks (7.8%). Others wrongly considered cough for four or more weeks (9.2%). Features correctly considered of diagnostic value by a few of the private doctors in paediatric TB were: chest Xray (19.8%), FTT (8.7%), positive sputum for AAFBs (8.7%), and history of contact with TB case (8.7%). A small number of doctors based their diagnosis on chest Xray (38%), AAFBs (19%), and Keith-Jones criteria (6.3%). There were 16 regimes mentioned and used for the treatment of TB. The NLTP recommended regimes such as 2RHZ/4RH, 2RHZE/6HE, 2RHZ/6HE and 2SHRZE/1RHZE/5HRE, were used by 9(19.6%), 2(4.3%), 0% and 0% of the doctors respectively. The rest used unrecommended regimes and no doctor used the re-treatment regime of 2SHRZE/1 RHZE/5RHE. Similar regimes were used for the HIV as for the non-HIV-infected patients. None of the interviewees had appropriate knowledge on all the areas of diagnosis, treatment, case recording, and follow up.

Conclusion:Most doctors were not aware of the correct diagnosis and treatment of TB and many used unrecommended treatment regimes. They were generally unfamiliar with the recording system of TB cases. Most doctors did not know the definitions of the various re-treatment cases. Continuing medical education on clinical management of TB patients is needed for doctors in private practice.

LOW DOSE INTRAVAGINAL MISOPROSTOL VERSUS INTRACERVICAL BALOON CATHETER FOR PRE-INDUCTION CERVICAL RIPENING

T.O. Tabowei, MBBS, FMCOG, FWACS

V.O. Oboro, MBChB, FMCOG, FWACS, Department of Obstetrics and Gynaecology, Zonal General Hospital, Kwale, Delta State, Nigeria

Request for reprints to: Dr. V.O. Oboro, Department of Obstetrics and Gynaecology, LAUTECH College of Health Sciences, P.M.B. 4400, Osogbo, Osun State, Nigeria

ABSTRACT

Background:The efficacy and safety of low dose misoprostol as a ripening agent compared to the widely used balloon catheter in developing countries is undetermined.

Objective:To compare the safety and efficacy of a low dose intravaginal misoprostol and intracervical Foley’s catheter for cervical ripening.

Design:A prospective randomized controlled trial.

Setting:Zonal General Hospital, Kwale, Nigeria from June 1, 1998 to May 30, 2001.

Methods:Candidates for pre-induction cervical ripening were randomized to receive either 250 mcg of intravaginal misoprostol every four hours (n = 60) or intracervical Foley’s catheter (n = 61).

Main outcome measures:Failure to achieve cervical ripening within 24 hours, need for augmentation, maternal and foetal complications.

Results: Failure to achieve cervical ripening within two hours was reduced with misoprostol (Relative Risk [RR] 0.63, 95% Confidence Interval [CI] 0.43 - 0.92). Need for oxytocin augmentation was less in the misoprostol group (RR 0.76, 95% CI 0.64 to 0.91). No significant differences existed in rates for uterine hyperstimulation, Caesarean section, maternal and neonatal morbidity.

Conclusion:Intravaginal misoprostol in a low dose was compared to intracervical balloon catheter for pre-induction ripening of the cervix.

CD4T LYMPHOCYTE SUBSETS AND DISEASE MANIFESTATION IN CHILDREN WITH AND WITHOUT HIV BORN TO HIV-1 INFECTED MOTHERS

E.P. Makokha, BSc, MSc, PhD, Lecturer, Department of Immunology, Faculty of Health Sciences, Moi University, P.O. Box 4606, Eldoret, Kenya

M. Ogolla, MBChB, MMed, Catholic Relief Services, P.O. Box 48932, Nairobi

A.A. Orago, BSc, MSc, Professor, Centre for Complimentary Medicine and Biotechnology, Kenyatta University, P.O. Box 43844, Nairobi, Kenya

D.K. Koech, BSc, MSc, PhD, Chief Research Officer

S. Mpoke, BSc, PhD, Senior Research Officer

F. Esamai, MBChB, MMed, MPH, PhD, Professor, Department of Child Health and Paediatrics, Faculty of Health Sciences, Moi University, P.O. Box 4606, Eldoret, Kenya

E.M. Songok, BSc, MSc, Research Officer

N. Kobayashi, MD, Short-term Japanese Expert

F.A. Okoth, MBChB, MMed, Chief Research Officer

P.M. Tukei, MBChB, MSc, Chief Research Officer, Kenya Medical Research Institute, P.O. Box 54840, Nairobi, Kenya

Request for reprints to: Dr. E.P. Makokha, Department of Immunology, Faculty of Health Sciences, Moi University, P.O. Box 4606, Eldoret, Kenya

ABSTRACT

Objective:To understand the natural history of HIV-1 infection in children in terms of evolution of childhood clinical manifestations versus the immune status, we prospectively studied children with and without maternally transmitted HIV-1 infection born to mothers infected with HIV-1 for two years between March 1998 and March 2000.

Design:A prospective cohort study.

Setting:An institutional children’s home.

Subjects:Fifty nine children (26 males and 33 females) with and without maternally transmitted HIV-1 infection born to mothers infected with HIV-1 and adopted in institutional children home.

Methods:HIV-1 status of children under nine months was confirmed by polymerase chain reaction (PCR). ELISA for HIV-1 antibody in serum/plasma was used to confirm HIV-infection status for children aged £18 months. Children were visited every three months between March and June 2000. At every visit blood was collected for total white cell count, haemoglobin and CD4+ and CD8+ T cell counts. The institutional doctor routinely examined children and treated all ailments. Clinical data were recorded.

Measures: HIV-DNA, anti-HIV antibodies, total white blood count, total T cell counts, CD4 and CD8 T cell subset counts, frequency of childhood manifestations of infection.

Results:The children were aged between 4.5 and 13 years. The baseline haematological and immunological profiles (mean, mode) were: HIV-1 sero-converters (WBC 7151,7150; HB 11.6, 12.0; CD4+ 686, 795; CD8+ 2168, 1507) and HIV-1 de-seroconverters (mean, mode) were: (WBC 8386, 7150; HB 11.7, 12.8; CD4+ 735, 795; CD8+ 2168, 1507). The commonest causes of illnesses among the HIV-1 children were URTI (85.3%), TB(56.1%), pneumonia (56.2%), tonsillitis (34.1%), parotiditis (28%) and acute otitis media (25%). The distribution of clinical manifestations was similar between the two categories of children, except URTI, whose prevalence was significantly increased among HIV-1 infected children (p-value=0.006). Among the HIV-1 infected children, only TB, parotiditis, and acute otitis media (AOM) were significantly associated with decreased CD4+ T cell count (p<0.05) resulting from HIV infection.

Conclusions: HIV infection in children predisposes them to common childhood infections that can be used as markers of immune decline. TB, AOM, URTI may be early indicators of suspicion that would enable selective screening for HIV infection in children.

MAXILLARY INCISOR ROOT FORMS IN ORTHODONTIC PATIENTS IN NAIROBI, KENYA

P M. Ng’ang’a, BDS, MSD, Ph.D., Senior Lecturer, Department of Paediatric Dentistry and Orthodontics, Faculty of Dental Sciences, University of Nairobi, P.O. Box 19676, Nairobi, Kenya

R.N. Ng’ang’a, BDS, Lecturer, Department of Community Oral Health, Kenya Medical Training College, P.O. Box 30195, Nairobi, Kenya

Request for reprints to: Dr. P. M. Ng’ang’a, Department of Paediatric Dentistry and Orthodontics, Faculty of Dental Sciences, University of Nairobi, P.O. Box 19676, Nairobi, Kenya

ABSTRACT

Objective:To evaluate, radiographically, the root forms of maxillary incisors in a sample of patients seeking orthodontic treatment in Nairobi, Kenya.

Design:A retrospective study of maxillary incisor root forms based on periapical radiographs.

Setting: A private dental clinic in Nairobi, Kenya.

Materials and Methods:The study comprised 393 maxillary incisors in 100 consecutive subjects (51 boys, 49 girls) aged 9-24 years. Intra-oral periapical radiographs of the incisors were evaluated. An index was used to categorise the roots as follows: 0=normal, 1=short, 2-blunt, 3=apical bend, 4=pippete apex.

Results:Normal root form was recorded in 60%, short in 12.5%, blunt in 7%, apicalbend in 13%, and pippete-apex in 7% of the roots. Sixty nine percent of the pippeteapex roots were in central incisors and 94% of the roots with apical bend were in lateral incisors. Seventy three percent of short roots were in females.

Conclusion:Based on evidence from previous studies on risk of root resorption which indicates that pipette and blunt roots are the forms mostly involved in this phenomenon, the present data imply that about 14% of the roots may have been at risk of moderate to severe resorption during fixed orthodontic treatment.

INFLUENCE OF SEMINAR AND MAILED GUIDELINES ON KNOWLEDGE OF SCHOOL TEACHERS REGARDING EMERGENCY TREATMENT FOR DENTAL INJURIES

F.K. Kahabuka, DDS, MSc, PhD, Senior Lecturer, Faculty of Dentistry, Department of Preventive and Community Dentistry, Muhimbili University College of Health Sciences, P.O. Box 65014, Dar es Salaam, Tanzania

M. van’t Hof, BSc, PhD

Professor, W. Willemsen, DDS, PhD, Senior Lecturer

R. Burgersdijk, DDS, PhD, Professor, Medical Faculty, College of Dental Sciences, University of Nijmegen, Nijmegen, The Netherlands

Request for reprints to: Dr. F.K. Kahabuka, Faculty of Dentistry, Department of Preventive and Community Dentistry, Muhimbili University College of Health Sciences, P.O. Box 65014, Dar es Salaam, Tanzania

ABSTRACT

Objective: To evaluate the influence of two different modes for delivering guidelines on school teachers’ knowledge on emergency treatment for dental injuries.

Design: Cross sectional questionnaire study.

Setting: Primary schools in Dar es Salaam city council in Tanzania.

Participants:Primary school teachers.

Intervention:Provision of guidelines by mail or through seminar or no guidelines (control).

Main outcome measures:Knowledge on emergency management of dental injuries

Results: The teachers did not have adequate knowledge on the emergency management of traumatised teeth. Significant differences were observed between the study groups. Teachers from the seminar group were likely to re-implant an avulsed tooth (five times more likely than the control group) or otherwise would transport it in the recommended medium. No significant differences were observed between the groups on their willingness to take the avulsed tooth to a doctor or dentist or on the method or liquid they would use to clean a dirty avulsed tooth.

Conclusion:Compared to provision of information through mailed guidelines, seminar discussions better improved the school teachers’ knowledge regarding emergency treatment for dental injuries.

RETAINED SECOND TWIN: EXPERIENCE FROM ILE-IFE, NIGERIA

O.C. Ezechi, MBBS, MPA, FWACS, FMCOG

O.B. Fasubaa, MBChB, FWACS., Department of Obstetrics and Gynaecology, Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Osun State Nigeria

B.E.K. Kalu, MBBS, FWACS, FMCOG, Department of Obstetrics and Gynaecology, Havana Specialist Hospital, 115 Akerele Extension Surulere, Lagos, Nigeria

Request for reprints to: Dr. O.C. Ezechi, Department of Obstetrics and Gynaecology, Havana Specialist Hospital, 115 Akerele Extension Surulere, Lagos, Nigeria

ABSTRACT

Background: Retained second twin contributes significantly to perinatal morbidity and mortality, as well as maternal morbidity and mortality, usually arising as a result of intervention to salvage the retained foetus.

Objective: To review the current incidence, management, fate and outcome of both the retained foetus and its mother, with a view to proffering solution.

Design: Retrospective review over a 12 year period from January 1988 to December 1999.

Setting:Obafemi Awolowo University teaching hospital, Ile Ife, Nigeria.

Subjects:All cases of retained second twin managed during this period.

Main outcome measures:Causes, sources of referral, perinatal and maternal complications.

Results:The incidence is still high (7.9%). Majority of the patients were referred from rural centers (49.6%) and in poor fetal conditions (41.9%). The fetal survival in patients that presented within two hours of delivery of the first twin was 74.2%. The perinatal and maternal mortality were 47.3% and 3.9% respectively.

Conclusion: The incidence and associated maternal and fetal complications of retained twin is still rather high. Therefore, irrespective of the antenatal course and early labour findings, the conduct of twin deliveries must be in a well-equipped health institution with adequate staff. There should also be an efficient referral system for occasional emergencies from the peripheral centres.

GIANT FAT CONTAINING BREAST MASSES: REPORT OF SIX CASES

R.M Hanna, MD FRCR

M.H. Dahniya, DMRD, FRCR

S.D. Ashebu, FWACS, Department of Diagnostic Radiology and Imaging, Al-Sabah Hospital, P.O. Box 25415 Safat 13115, Kuwait

Request for reprints to: Dr. R.M. Hanna, Department of Diagnostic Radiology and Imaging, Al-Sabah Hospital, P.O. Box 25415, Safat 13115, Kuwait

SUMMARY

Six patients with giant fat containing breast masses encountered over a 20 year period are presented including a brief review of the literature. These benign tumours especially the giant varieties are rare but are likely to be increasingly diagnosed because of the widespread use of mammography.