Semen parameters, including WHO and strict criteria morphology, in a fertile and subfertile population: an effort towards standardization of in-vivo thresholds

In this study, the semen analysis results of a fertile population were compared with those from a subfertile population, in order to establish normal cut-off values for the standard semen parameters with the aid of receiver operating characteristic (ROC) curve analysis. The fertile group comprised healthy males (n = 107) without any history of fertility problems, the partners of whom had had a spontaneous pregnancy within one year of unprotected intercourse and were pregnant at the time of the male's inclusion into the study. A total of 103 males from couples attending the infertility clinic, and with an initial sperm count of <20x10(6)/ml were recruited to form the subfertile population. The best discriminating parameter between the two populations was sperm morphology evaluated according to WHO criteria at a cut-off point of 31% normal spermatozoa. The other cut-off values were at 8% for the acrosome index, 45% for motility, and 4% normal spermatozoa for strict criteria. Recalculating the ROC curve cut-off values based on an assumed 50% prevalence of subfertility in an assisted reproductive setting, the cut-off points were reduced to 21% and 3% normal spermatozoa for WHO and strict criteria respectively. For motility, the new cut-off value was at 20% motile spermatozoa, for motility quality at 3.5 (on a scale of 1-6), the acrosome index at 3% normal acrosomes, and the teratozoospermia index at 2.09.

Stepwise regression analysis to study male and female factors impacting on pregnancy rate in an intrauterine insemination programme

The aim of this study was to evaluate the impact of male and female factors on the pregnancy rate in an intrauterine insemination (IUI) programme. Data on 522 cycles were retrospectively studied. All patients 39 years or younger were included in the study where data were available on male and female diagnosis, as well as on ovulation induction methodology. Regression analysis was possible on 495 cycles to study different factors affecting the pregnancy rate per treatment cycle. Logistic regression identified variables which were related to outcome and were subsequently incorporated into a statistical model. The number of follicles was found to have a linear association with the risk ratio (chance) of pregnancy. The age of the woman was also found to have a linear (negative) association with pregnancy. The percentage motility and percentage normal morphology (by strict criteria) of spermatozoa in the fresh ejaculate were the male factors that significantly and independently predicted the outcome. Percentage motility > or = 50 was associated with a risk ratio of pregnancy of 2.95 compared to percentage motility < 50. Percentage normal sperm morphology > 14% was associated with a risk ratio of pregnancy of 1.8 compared to percentage normal morphology < or = 14%. Female patients with idiopathic infertility were divided into three groups according to normal sperm morphology. The pregnancy rate per cycle was 2.63% (1/38) for the P (poor) pattern group (0-4% normal forms), 11.4% (17/149) for the G (good) pattern group (5-14%), and 24% (18/75) for the N (normal) pattern group (> 14% normal forms). A female diagnosis of endometriosis or tubal factor impacted negatively on the probability of pregnancy (risk ratio of 0.17), compared with other female diagnoses. Male and female factors contribute to pregnancy outcome, but the clinician can influence prognosis by increasing the number of follicles, especially in severe male factor cases.

Red palm oil as a source of beta-carotene in a school biscuit used to address vitamin A deficiency in primary school children

The effect of a biscuit with red palm oil as a source of beta-carotene was compared with the effect of a biscuit with beta-carotene from a synthetic source on the vitamin A status of primary school children in a randomised controlled trial. Children aged 5-11 years (n = 265) were randomly assigned to one of three groups: (1) placebo biscuit; (2) biscuit with synthetic beta-carotene as a vitamin A fortificant; and (3) biscuit with red palm oil as a source of beta-carotene. The two non-placebo biscuits were designed to provide 34% of the RDA for vitamin A per serving (4 x 15 g biscuits). The biscuits were distributed daily during the school week and compliance was closely monitored and recorded. Children were assessed at baseline and after 6 months of intervention. Mean serum retinol in all three groups increased significantly compared to baseline (P < 0.0001). The prevalence of low serum retinol levels (< 20 micrograms/dL) dropped from 50 to 24.4% in the control group, from 48.2 to 16.9% in the synthetic beta-carotene group, and from 50.6 to 22.8% in the red palm oil group. There was no significant treatment effect compared to the control group in either the synthetic beta-carotene or red palm oil group. The increase in the control group was probably due to a school feeding scheme (providing 33% of the RDA for vitamin A) introduced during the latter part of the study. Our results were thus confounded and the 'true' effect of the red palm oil biscuit on vitamin A status could not be established. The study has, however, shown that red palm oil can be incorporated in a biscuit and that the end product with regard to taste and appearance was well accepted by the school children. A follow-up study in a school where there is no school feeding is indicated.

Do plastic adhesive drapes prevent post caesarean wound infection?

We conducted a prospective randomized controlled double-blind trial at a regional referral centre for the Eastern Cape area, (Livingstone Hospital) to determine whether the use of plastic adhesive drapes intraoperatively would prevent Post Caesarean Section Wound Infection. A total of 620 patients undergoing Caesarean section (CS) were enrolled for randomization in the trial. Fifteen patients were excluded, while 305 received drapes (test group) and 300 did not (control group). Two patients in the control group were subsequently excluded. The primary outcome measure was the presence of Post Caesarean Wound Infection. A secondary outcome measure was the number of days in hospital post operation. The study and control groups were comparable at entry. Results show that 34 patients in the test group (N= 305) developed wound sepsis (11.1%) compared with 30 in the control group (N= 298) (10.1%) (difference not significant; Fisher's exact test 0.6933). Average days spent in hospital postoperatively were similar for both test (infected cases: mean 10.56 SD 3.84; non-infected cases: mean 5.21 SD 1.3) and control groups (infected cases: mean 10.18 SD 3.81; non-infected cases: mean 5.2 SD 0.93) (NS). We concluded that the use of plastic adhesive skin drapes did not avert PCWS or decrease the length of post operative stay in hospital for septic cases.

A study of semen parameters with emphasis on sperm morphology in a fertile population: an attempt to develop clinical thresholds

The aim of the study was to determine the semen parameters of a proven fertile population and to compare these parameters with that of a subfertile group in the same region. Sixty-nine fertile male patients were studied and compared with 93 patients recruited at an infertility clinic. A sub-sample of patients was matched according to age. Sixty-one were studied in the fertile group and 62 in the infertile group. Receiver operator characteristics analysis was done on the sub-sample. The threshold value of the progressive motility was 42% and it was the best parameter with sperm morphology to distinguish between the two groups. At 69% sensitivity and 67% specificity the sperm morphology threshold was 12% normal forms. If the positive and negative predictive value was used to screen the general population to identify the subfertile group, a 5% normal morphology threshold was indicated with 14% progressive motility, 30% motility and a concentration of 9x10(6)/ml or lower. The negative predictive values of the parameters were good and achieved 90% in most cases. The sensitivity of the semen parameters at the reported thresholds was poor and indicated a large overlap in the distributions of these variables in the fertile and infertile groups. To distinguish between the fertile and subfertile population, the most significant finding of this study was the progressive motility with a threshold level of 14%. The cut-off value of the sperm morphology (5%) in vivo was consistent with the previous publications in assisted reproduction programmes for sperm morphology.

Iodine concentration in household salt in South Africa

OBJECTIVE

To determine the iodine concentration in household salt, the coverage of adequately iodized salt, the use of non-iodized agricultural and producers' salt, and the usefulness of salt as a carrier of iodine, and to relate these observations to socioeconomic status in South Africa.

METHOD

The iodometric titration method was used to analyse 2043 household salt samples collected using a national, multistage, stratified, cluster survey.

FINDINGS

The national mean and median iodine concentrations of household salt were 27 mg/kg (95% confidence interval (CI): 25-29 mg/kg) and 30 mg/kg (range = 0-155 mg/kg), respectively. There was considerable variation within and between geographical areas. Coverage of adequately iodized household salt, i.e. iodized at > 15 mg/kg, was 62.4% of households (95% CI: 58.8-66.0%) two years after the introduction of compulsory iodization at a level of 40-60 mg/kg. A total of 7.3% of households used non-iodized agricultural salt and salt obtained directly from producers. People at the lower end of the socioeconomic spectrum were more likely to suffer the consequences of using under-iodized salt because more of them used agricultural or coarse salt than did people in the higher socioeconomic categories. The iodine concentration in salt was lower in rural areas than in urban and periurban areas.

CONCLUSIONS

The consequences of using under-iodized or non-iodized salt were most likely to be experienced in the country's three northern provinces, among people in the low socioeconomic categories, and in rural households. Since 95.4% of households in South Africa use salt regularly and 2.9% use it occasionally, the national iodization programme has the potential to meet the iodine requirements of the population. However, this can only be achieved if the primary reasons for the inadequate iodization of salt are eliminated and if special attention is given to vulnerable groups.

Mapping of IS6110 flanking regions in clinical isolates of Mycobacterium tuberculosis demonstrates genome plasticity

Southern hybridization was used in combination with IS6110 insertion-locus-specific probes in a comparative study to determine the structure of chromosomal domains flanking IS6110 elements in clinical isolates of Mycobacterium tuberculosis. The resulting restriction fragment length polymorphism (RFLP) data demonstrated three mutational mechanisms responsible for the polymorphisms observed: IS6110 insertion, chromosomal mutation and deletion. The frequency of IS6110 insertion within many of the chromosomal regions demonstrates that preferential integration regions are common in M. tuberculosis. Mapping the IS6110 insertion positions and chromosomal deletions in relation to the M. tuberculosis H37Rv and M. bovis BCG genome sequences reveals numerous disruptions of predicted open reading frames (ORFs). A phylogenetic tree, based on the mutational data, showed a number of independently evolving lineages of M. tuberculosis, while analysis of the mutational events occurring at each branch point suggests both divergent and convergent evolution. A significant positive correlation was demonstrated between the mutation rate and the frequency of occurrence of different isolates in families of strains, suggesting that evolution may impact on strain 'fitness' or that strain proliferation may increase the chance of mutation. We conclude that the genome of clinical isolates of M. tuberculosis continues to evolve.

A randomised controlled trial of lay health workers as direct observers for treatment of tuberculosis

SETTING

Study conducted in a suburb of Cape Town, South Africa.

OBJECTIVE

Comparison of successful tuberculosis treatment outcome rates between self supervision, supervision by lay health worker (LHW), and supervision by clinic nurse.

METHODS

Open, randomised, controlled trial with intention-to-treat analysis.

RESULTS

All groups (n = 156) achieved similar outcomes (LHW vs. clinic nurse: risk difference 17.2%, 95% confidence interval [CI] -0.1-34.5; LHW vs. self supervision 15%, 95%CI -3.7-33.6). New patients benefit from LHW supervision (LHW vs clinic nurse: risk difference 24.2%, 95%CI 6-42.5, LHW vs. self supervision 39.1%, 95%CI 17.8-60.3) as do female patients (LHW vs. clinic nurse 48.3%, 95%CI 22.8-73.8, LHW vs. self supervision 32.6%, 95%CI 6.4-58.7).

CONCLUSIONS

LHW supervision approaches statistically significant superiority, but fails to reach it most likely due to the study's limitation, the small sample size. It is possible that subgroups (new and female patients) do well under LHW supervision. LHW supervision could be offered as one of several supervision options within TB control programmes.

Short-term effectiveness of mandatory iodization of table salt, at an elevated iodine concentration, on the iodine and goiter status of schoolchildren with endemic goiter

BACKGROUND

Goiter rates and iodine deficiency usually show marked improvement in efficacy studies of mandatory iodization of salt, but little is known about the short-term effectiveness of mandatory iodization.

OBJECTIVE

The aim of the study was to evaluate, after 1 y, the effectiveness of mandatory iodization of salt at an iodine concentration higher than that occurring under optional iodization on the goiter rates and iodine status of schoolchildren living in an endemically goitrous area.

DESIGN

Goiters, measured by palpation, and urinary iodine concentrations of children in grades 4-7 in 4 schools in a known goitrous area in South Africa were assessed before and 1 y after the introduction of mandatory iodization at a higher iodine concentration than occurred with optional iodization. Estimates of the iodine concentration of iodized salt and the proportion of households using iodized salt were also made.

RESULTS

Iodine concentration in table salt and household use of iodized salt improved within 1 y. Goiter rates, which varied at baseline from 14. 3% to 30.2% in the 4 schools, remained unchanged, with an overall mean (+/-SE) prevalence of 25.6 +/- 2.5% at baseline and of 27.5 +/- 2.7% 1 y later. The distribution of urinary iodine concentrations in the 4 schools improved substantially from the baseline deficient range. The overall median urinary iodine concentration increased from 0.17 to 1.47 micromol/L.

CONCLUSIONS

Mandatory iodization of salt virtually eradicated iodine deficiency within 1 y in South African schoolchildren, but the goiter rate in these children did not decline. Measurement of goiters by palpation may not be appropriate in short-term evaluations of mandatory iodization programs.

Risk factors for developing tuberculosis in HIV-1-infected adults from communities with a low or very high incidence of tuberculosis

OBJECTIVE

To estimate the incidence rate of tuberculosis in HIV-1-infected adults resident in a region with a high tuberculosis prevalence and to identify clinical and laboratory parameters associated with increased risk of developing tuberculosis.

METHODS

Adult patients going to the University of Cape Town HIV clinics between January 1986 and May 1996. The following variables were assessed for the risk of developing tuberculosis: ethnicity, employment and education status, World Health Organization (WHO) clinical stage, erythrocyte sedimentation rate (ESR), CD4+ count, and total lymphocyte count. Tuberculin skin test data were not available.

RESULTS

There were 198 prevalent and 144 incident cases of tuberculosis in the cohort of 1206 patients. The incidence rate of tuberculosis risk was 10.4/100 person years. WHO clinical stages 3 and 4 (risk ratio [RR], 3.4; 95% confidence interval [CI], 1.8-6.4), ESR >75 mm/hour (RR, 3.5; CI, 1.8-6.5) and being a member of a high-prevalence tuberculosis community (RR, 2.5; CI, 1.2-5.1) were independently associated with the risk of developing tuberculosis.

CONCLUSIONS

HIV-infected adults in Cape Town are at high risk of developing tuberculosis irrespective of tuberculin skin testing. The risk increases markedly with HIV disease progression. Patients at extremely high risk can be identified on the basis of demographic and clinical features. Such individuals would be suitable for targeted tuberculosis prophylaxis.

Modifiable risk factors for Type 2 diabetes mellitus in a peri-urban community in South Africa

AIMS

To investigate the prevalence of Type 2 diabetes mellitus (DM) and its risk factors in a working class peri-urban community in South Africa.

METHODS

A cross-sectional descriptive study was conducted in 1996, where all persons aged 15 years and older, who were resident in randomly selected houses in Mamre, 55 km from the centre of Cape Town, were sampled. Subjects underwent a 75-g oral glucose tolerance test. Socio-demographic and anthropometric data were obtained and physical activity was assessed using a 7-day activity recall questionnaire. The 1985 WHO criteria were used to define diabetes.

RESULTS

The response rate was 64.5% (n = 974). The participants comprised 56% women, 44% men, mean age 37.6 (range 15-86) years. The crude prevalence of Type 2 DM was 7.1% and impaired glucose tolerance (IGT) 8.0%. The age-adjusted prevalence of Type 2 DM was 10.8% (95% confidence interval (CI) 8.2-13.5%) and IGT 10.2% (95% CI 7.7-12.8%). Regression analysis indicated that age (risk ratio (RR) 7.40, 95% CI 3.45-15.86), waist circumference (RR 4.53, 95% CI 2.04-10.05), low total energy expenditure (RR 1.75, 95% CI 1.07-2.56) and family history of diabetes (RR 2.31, 95% CI 1.42-3.77) were independent risk factors for Type 2 DM, while sex, obesity and regular alcohol consumption were not.

CONCLUSIONS

This previously unstudied community has an intermediate prevalence on the international scale of Type 2 DM, which is linked to potentially modifiable risk factors.

Effects of a prudent diet containing either lean beef and mutton or fish and skinless chicken on the plasma lipoproteins and fatty acid composition of triacylglycerol and cholesteryl ester of hypercholesterolemic subjects11This study was sponsored by the Meat Board of South Africa

In this two-phase crossover study, 39 hypercholesterolemic subjects followed a prudent diet with either lean red meat or fish and skinless chicken (treatment groups), and 13 subjects (reference group) followed their habitual diet. Fasting blood samples were analyzed for plasma total cholesterol, triacylglycerol (TAG), high density lipoprotein cholesterol (HDL-C), low density lipoprotein one- and two-cholesterol, apolipoprotein-B, very low density lipoprotein cholesterol, and very low density lipoprotein TAG, and fatty acid composition of plasma TAG and cholesteryl ester (CE). Body mass and blood pressure were determined. Seven-day dietary records were kept once at baseline and twice during the treatment periods. Significant differences were observed in dietary intake between the baseline and treatment diets and between the two treatment diets. HDL-C (P < 0.05) and diastolic blood pressure (P < 0.01) were higher in patients on the red meat diet than in those on the chicken-fish diet. No other significant differences in lipoproteins were observed between the effects of the two treatment diets. The linoleic acid (%), eicosapentaenoic acid (%), and the eicosapentaenoic acid/arachidonic acid ratios in TAG and CE were higher (P < 0.01) in subjects on the chicken-fish diet than in those on the red meat diet. In conclusion, this study showed that the effect of two lipid-lowering diets containing either lean red meat or skinless chicken and fish on the atherogenic lipoproteins did not differ significantly. A prudent diet with skinless chicken and fish, however, had a more favorable effect on the fatty acid composition of the plasma TAG and the CE than did the lean red meat diet.

Rectal bleeding in general practice patients

OBJECTIVE

To determine the prevalence of observed rectal bleeding in general practice patients, the health seeking behaviour of those with rectal bleeding, and what rectal bleeding 'means' to patients in terms of perceived health risk.

METHOD

Self administered questionnaire survey of general practice patients aged 50 years and over in northern Tasmania recruited as they visited their general practitioner (GP).

RESULTS

The reported lifetime prevalence of rectal bleeding in our sample was 33% (299 of 903 respondents). It was more common in younger people, becoming less common with increasing age. Many respondents do not examine for bleeding. Only 45% of respondents with rectal bleeding consulted their GP about the most recent bleed. Patients were more likely to consult if they reported blood in the toilet pan and if they sought advice from a family member. There were significant differences between the meaning of bleeding for GP consulters and non consulters. This may have important implications for health education.

CONCLUSION

Colorectal cancer (CRC) is a common problem managed by a combination of screening and case finding. With the high prevalence of rectal bleeding and low consultation rates for this problem there is potential to enhance the effectiveness of early detection of CRC through general practice based public health and education campaigns.

Repeatability and variance analysis on multiple computer-assisted (IVOS) sperm morphology readings

The repeatability of the Hamilton Thorne Research IVOS (version 10) semen analyser (dimension specific software, version 3) in the evaluation of sperm morphology according to strict criteria was investigated in this study. The repeat measures investigated were cell-cell (300 cells, 3 x each), intraslide (20 slides, 3 x each) and interslide (30 samples, 3 slides each), and their normal sperm morphology outcomes were recorded. Semen samples with varying normal sperm morphology percentages were obtained and sperm morphology slides prepared. The slides were stained with Diff-Quik stain. Agreements between evaluations were determined using the kappa statistic and average coefficients of variation. The predictive probability for an abnormal cell given a prior abnormal cell outcome was 91%, and 89% for a similar prediction of a normal cell. The predictive probabilities for an abnormal or a normal cell given two prior abnormal or two prior normal cell outcomes were 95% and 94%, respectively. No significant bias was obtained between the repeat probabilities for normal and abnormal sperm cells. The average coefficients of variation for the intraslide trial were 9.73% and 8.30% when 100 and 200 sperm cells were evaluated, respectively. The average coefficient of variation for the interslide trial was 15.39%. The technical importance of good sample and slide preparation technique has once again been highlighted by this study. A uniform (spatial homogeneity), high concentration (5-10 cells per computer screen) smear must be made and the cells stained with optimal intensity (maximum contrast). In a trial in which 2000 cells were evaluated, 19 objects (0.95%) were identified as spermatozoa, but were debris. The automated semen analysing system (IVOS) used in this study was shown to maintain a level of repeatability, precision and accuracy acceptable for the application of the system in a routine semen analysis situation.

Hypertension management of medical aid patients attending private practices

OBJECTIVES

The study aimed to describe the treatment status of hypertensive patients and the prescribing patterns of private medical practitioners treating medical aid scheme patients with hypertension.

METHOD

Data on hypertensive patients belonging to medical aid schemes were provided to the drug utilisation review consultancy, Quality Health Services (QHS), by private medical practitioners. The data were computerised and included the age and gender of the patient, the diastolic and systolic blood pressure (BP), the medication prescribed for the condition and the qualifications of the reporting doctor. All the prescribed drugs were categorised into 12 drug classes and combination preparations had each constituent categorised. The level of BP allowed the degree of BP control to be described as controlled (< 140/90 mmHg), borderline (140/90-< 160/95 mmHg) and uncontrolled (> or = 160/95 mmHg).

RESULTS

Included in the study were 11,696 hypertensive patients (46.3% male and 53.7% female) and the 3,503 doctors who cared for them. The systolic BP showed an age-related increase, but the diastolic BP did not. The level of BP control was high, with less than a quarter of patients having uncontrolled hypertension. The most frequently prescribed drug class was angiotensin-converting enzyme (ACE) inhibitors (32.2%). Beta-blockers accounted for 20.8% and calcium antagonists for 14% of all prescriptions. Thiazide and thiazide-like diuretics on their own accounted for only 7.8% of prescriptions. However, a further 13.8% of prescriptions contained this class of diuretics in combination with other drug classes. Diuretics of all classes taken on their own or in combination were used by 33.9% of patients.

CONCLUSIONS

Good levels of hypertension control were reported for hypertensive patients by their private practitioners. Almost half of all prescriptions were for the newer and more costly antihypertensive drugs (ACE inhibitors and calcium antagonists), although their effectiveness in reducing long-term complications of hypertension is still unproven. Furthermore, these prescribing patterns do not conform to those recommended by the Southern African Hypertension Society's hypertension management guidelines.

Clinical value of using an automated sperm morphology analyzer (IVOS)

OBJECTIVE

To determine the clinical value of automated normal sperm morphology outcomes.

DESIGN

Prospective clinical study.

SETTING

Clinical and research assisted reproduction laboratory.

PATIENT(S)

Two hundred seven GIFT cycles.

INTERVENTION(S)

The wife was induced to superovulate, laparoscopically aspirated, and the gametes were transferred laparoscopically. The husband's sperm morphology was evaluated with use of a sperm morphology analyzer using the strict criteria classification system.

MAIN OUTCOME MEASURE(S)

Normal sperm morphology, IVF, and pregnancy outcomes.

RESULT(S)

The logistic regression model showed that normal sperm morphology was significantly associated with fertilization in vitro, as dependent (age) and independent variables. Analyzing the fertilization rates across the 5% normal sperm morphology cutoff point, a fertilization rate of 39.39% (< or = 5%) compared with 62.92% (>5%) was obtained. The logistic regression model showed that normal sperm morphology was also a significant predictor of pregnancy when allowing for the number of oocytes transferred and female age. Analyzing the pregnancy rates across the 5% normal sperm morphology cutoff point, pregnancy rates of 15.15% (< or = 5%) and 37.36% (>5%) were obtained.

CONCLUSION(S)

Normal sperm morphology as evaluated by the automated semen analyzer (IVOS) was shown to adhere to the same fertility cutoff point (5%), as determined by the manual evaluation of sperm morphology. Automated normal sperm morphology outcomes also were found to be significant predictors of IVF and pregnancy in a GIFT program.

Assessment of interlaboratory and intralaboratory sperm morphology readings with the use of a Hamilton Thorne Research integrated visual optical system semen analyzer

OBJECTIVE

To evaluate the level of variance produced in a multicenter study with the use of a computer-assisted sperm morphology analyzer.

DESIGN

A multicenter, prospective, blinded study.

SETTING

Assisted reproduction research laboratories.

PATIENT(S)

Semen samples produced for assisted reproductive procedures.

INTERVENTION(S)

Hamilton Thorne Research (Beverly, MA) integrated visual optical system semen analyzers were used at five different centers to evaluate the same set of 30 slides that were prepared and numerically coded at Tygerberg Hospital in Tygerberg, South Africa.

MAIN OUTCOME MEASURE(S)

The percentage of normal sperm.

RESULT(S)

Interlaboratory coefficients of variation (CVs) ranged between 16.31% and 23.09%. One of the participating laboratories produced an approximately 14% (-6.5-7.7) limits of agreement analysis, with a CV of 11.36%, for its duplicate readings. The use of a 10% normal sperm morphology cutoff point to determine discordance levels produced rates ranging between 10% and 23.3% for the interlaboratory and intralaboratory readings. This level of discordance equates with < or = 7 of the corresponding readings from two laboratories falling into a different normal sperm morphology group (< or = 10% or >10%).

CONCLUSION(S)

The magnitudes of variation produced by the readings performed in our study reached the same level as for the manual evaluation of sperm morphology. A < 10% CV can be obtained if the correct quality control measures are implemented.

Impact after 1 year of compulsory iodisation on the iodine content of table salt at retailer level in South Africa

The short-term effectiveness of introducing compulsory iodisation through revised health legislation, evaluated in terms of the iodine content of iodised table salt, was investigated in three of the nine provinces in South Africa. Shortly before the introduction of compulsory iodisation of table salt in December 1995, iodised at a higher level than before, 187 iodised salt samples were purchased at retailers in 48 magisterial districts situated in the three provinces of Western and Eastern Cape and Mpumalanga for analysis of the iodine content using the titration method. In a follow-up 1 year later 287 iodised salt samples were obtained from the same retailers for iodine determination. The mean iodine content of iodised salt increased significantly from 14 to 33 ppm. However, large variation in the iodine content of iodised table salt among and within salt brands existed at follow-up, and the mean iodine content was lower than the legal specification of 40 to 60 ppm. Only 24% of the samples were found within the range required by the law at follow-up compared to 42% before revising the salt legislation. Despite the introduction of compulsory salt iodisation, the mean retail price of iodised salt remained the same between 1995 and 1996 for a 500 g package of salt. Further refinement of the iodisation process is necessary to improve the accuracy of iodisation and decrease the variation in iodine content. This study nevertheless showed that the introduction of compulsory iodisation and elevating the legally specified iodine level of table salt resulted in a significantly elevated mean iodine level of iodised salt within 1 year, without any additional cost to the consumer.

An assessment of care provided by a public sector STD clinic in Cape Town

A study was undertaken in a Cape Town public sector STD clinic to evaluate the content and quality of care provided since it has been recognized that appropriate improvements in the management of conventional sexually transmitted diseases (STDs), including provision of correct therapy, health education, condom promotion and partner notification, could result in a reduced incidence of HIV infection. Our objectives were to assess patients' needs for health education and to assess the quality of STD management in terms of health education, condom promotion, partner notification, the validity of the clinical diagnoses and the adequacy of the treatments prescribed. The study subjects were sampled systematically, according to their gender. Patients included in the study were given a standardized interview and their clinical records reviewed. Specimens were collected for laboratory investigations. For each STD detected, the treatment was defined as adequate if drugs currently known to be active against that infection were prescribed. One hundred and seventy men and 161 women were included in the study (median age: females 22 years, males 26 years). While almost all patients believed their STD may have been caused by unprotected sexual intercourse, many also believed it may have been caused by other factors, such as bewitchment with traditional medicine. Only 21% of male and 37% of female patients received any education about STD transmission during the clinic visit, and only 25% of male and 36% of female patients received education about condom use. As a result of the low sensitivity of the clinicians' diagnoses, 16% of men and 61% of women left the clinic with at least one infection inadequately treated. The majority of patients were not receiving education for the prevention of STDs including HIV. Many were not receiving adequate treatment for their infections. The introduction of a syndromic management protocol in this setting would substantially reduce the proportion of inadequately-treated patients. However, syndromic protocols, and the means by which they are implemented, need to take into account problems with the clinical detection of genital ulcerative disease and candidiasis in women.

Randomised controlled trial of self-supervised and directly observed treatment of tuberculosis

BACKGROUND

Tuberculosis is a major public-health problem in South Africa, made worse by poor adherence to and frequent interruption of treatment. Direct observation (DO) of tuberculosis patients taking their drugs is supposed to improve treatment completion and outcome. We compared DO with self-supervision, in which patients on the same drug regimen are not observed taking their pills, to assess the effect of each on the success of tuberculosis treatment.

METHODS

We undertook an unblinded randomised controlled trial in two communities with large tuberculosis caseloads. The trial included 216 adults who started pulmonary tuberculosis treatment for the first time, or who had a second course of treatment (retreatment patients). No changes to existing treatment delivery were made other than randomisation. Analysis was by intention to treat. Individual patient data from the two communities were combined.

FINDINGS

Treatment for tuberculosis was more successful among self-supervised patients (60% of patients) than among those on DO (54% of patients, difference between groups 6% [90% CI -5.1 to 17.0]). Retreatment patients had significantly more successful treatment outcomes if self-supervised (74% of patients) than on DO (42% of patients, difference between groups 32% [11%-52%]).

INTERPRETATION

At high rates of treatment interruption, self-supervision achieved equivalent outcomes to clinic DO at lower cost. Self-supervision achieved better outcomes for retreatment patients. Supportive patient-carer relations, rather than the authoritarian surveillance implicit in DO, may improve treatment outcomes and help to control tuberculosis.

Multicenter study on reproducibility of sperm morphology assessments

Sperm morphology has always been considered an important tool in evaluating a man's fertilizing potential. The objective of this multicentric study was to evaluate intra- and interindividual variability and between-laboratory variation using the same or different criteria of sperm morphology assessment. Semen samples were obtained from 20 males and 32 smears were made of all samples. Eighty coded smears (4 per patient) were sent to 8 laboratories for morphology assessment. The centers applied different classification systems (strict criteria, WHO 1987, Düsseldorf criteria) and participants were asked to analyze the 80 smears twice, with an interval of 1 week between each participant's two analyses. Intraclass correlations between repeats showed that sperm morphology can be assessed with acceptable within observer reproducibility. Expected increases in imprecision were observed up to coefficients of variation of >30% with decreasing morphology scores, regardless of the classification system used. Agreement in correct classification of samples as normal/abnormal was obtained in 80% of cases. Differences in reproducibility between slides may reflect an important source of heterogeneity due to smear preparation. These results emphasize the importance of external quality control systems to improve the value of sperm morphology assessments in the investigation of the male partner in a subfertile couple.

Familial hypercholesterolemia: potential diagnostic value of mutation screening in a pediatric population of South Africa

Three founder-related low-density lipoprotein receptor (LDLR) gene mutations, D154N, D206E and V408M, cause familial hypercholesterolemia (FH) in approximately 90% of South African Afrikaners. Two hundred and twenty-one South African children, from 85 affected families, were screened for the specific mutation identified previously in the index case. Sixty boys and 56 girls were heterozygous for mutation D154N (FH3), D206E (FH1) or V408M (FH2). Total and LDL cholesterol (LDLC) levels were similar among the children heterozygous for the three founder mutations, and mean values were significantly higher compared to those without a known mutation (p < 0.0001). Plasma cholesterol levels overlapped considerably between the different groups, suggesting that modifiable lifestyle factors remain important in children with FH. This study demonstrates the potential diagnostic value of mutation screening in a pediatric population with an enrichment of particular gene mutations.

Significance of antisperm antibodies in female serum in a gamete intrafallopian transfer program

The influence of antisperm antibodies in the female serum on fertilization and pregnancy rate in patients undergoing GIFT was assessed. A study group of 52 couples (69 cycles) with significant levels of antisperm antibodies in the female serum were compared to a control group of 749 couples (1185 cycles). Maternal serum or donor serum was used as growth medium supplement. The TAT test was performed for the detection of antisperm antibodies in the serum. Antisperm-antibody presence in female serum was associated with similar fertilization and pregnancy rates in a GIFT program compared to the control group. The type of serum used as growth medium supplement did not affect statistically the fertilization or pregnancy rate.

Hypertension care at a Cape Town community health centre

OBJECTIVES

To describe the demographic profile of hypertensive patients and the quality of care for hypertension at a Cape Town community health centre (CHC).

DESIGN

Prospective, descriptive study.

SETTING AND SUBJECTS

Medium-sized CHC, attended by 1,098 hypertensive patients during a 1-year period from 1 January 1992.

OUTCOME MEASURES

Default rate--proportion of due visits not attended. Loss to follow-up--proportion of patients persistently defaulting or not responding to recall. Frequency of blood pressure measurement--per 12 due visits. Compliance--proportion of patients collecting > or = 75% of antihypertensive drugs. Blood pressure control--mean blood pressure of aggregated readings; and proportion controlled (< 160/95 mmHg) on the basis of all blood pressure readings and mean blood pressures of individual patients with two or more readings during the study period.

RESULTS

More than half (51.6%) of the hypertensive patients were aged > or = 65 years; 81.7% were female. The default rate was between 11.9% and 19.4%. Compliance was high (76.9%). Loss to follow-up was 8.1%. Blood pressure was recorded a mean of 4.0 times per 12 due visits. There were no significant gender differences with regard to these measures. Mean blood pressure was 158.3/89.6 mmHg. Over half (56.7%) of all individual readings over the year were uncontrolled and 51.4% of patients were found to be uncontrolled when categorised by their mean blood pressure. Control was significantly poorer among women > or = 65 years.

CONCLUSION

We found better compliance, more frequent blood pressure measurement, and lower defaulting and loss to follow-up compared with previous South African studies in similar settings. Despite this, blood pressure control was mediocre. Possible explanations for this are discussed. The low proportion of male hypertensives attending the CHC suggests that the accessibility or acceptability of care is poor for this group. The study illustrates the potential for research in this setting and for the use of computers to monitor the quality of primary care.

Improving cost-effectiveness of hypertension management at a community health centre

OBJECTIVES

To describe the pattern of prescribing for hypertension at a community health centre (CHC) and to evaluate the impact of introducing treatment guidelines and restricting availability of less cost-effective antihypertensive drugs on prescribing patterns, costs of drug treatment and blood pressure (BP) control.

DESIGN

Before/after intervention study.

SETTING

Medium-sized CHC in the Cape Flats area of Cape Town.

SUBJECTS

1,084 hypertensive patients attending the CHC, who had at least two prescriptions for antihypertensive drugs during a 1-year period starting on 1 January 1992.

INTERVENTIONS

1. Implementation of stepped-care guidelines for hypertension, specifying treatment with more cost-effective drugs and minimising drug treatment. 2. Reducing availability for routine prescribing by CHC doctors of 10 less cost-effective antihypertensive drugs or drug combinations.

OUTCOME MEASURES

1. Mean number of drugs prescribed per patient. 2. Proportion of prescriptions for: each major class of antihypertensive drug; restricted availability and freely prescribable drugs; and more and less cost-effective drugs. 3. Mean monthly cost of drugs prescribed per patient. 4. Mean blood pressure and proportion of BP readings controlled (< 160/95 mmHg) or uncontrolled (> or = 160/95 mmHg).

RESULTS

A mean of 1.7 active drugs was prescribed per patient per visit. The most frequently prescribed drugs were thiazide-like diuretics (44.8%), centrally acting agents (28.4%) and b-blockers (13.2%). Mean monthly drug costs per patient decreased significantly by R1.99 (24.2%) from R8.24 to R6.25 between the first and last prescription for each patient (exclusive of any reduction due to withdrawal of treatment). This was attributable to reduced prescribing of more expensive drugs withdrawn from routine use and a 51.1% increase in prescribing of the most cost-effective drugs. The overall annual cost-saving of the changes in prescribing for this CHC are estimated at R75 150. Blood pressure control did not change significantly.

CONCLUSION

The pattern of changes in prescribing and drug costs was consistent with a causal effect of the interventions. The study demonstrates the potential for improving cost-effectiveness of hypertension care in primary care in South Africa and the potential for research in this setting.

Cervical cytology in menopausal women at high risk for endometrial disease

The objective of this study was to evaluate the value of cervical cytology in the diagnosis of endometrial disease in women after menopause. In 128 consecutive menopausal women presenting with uterine bleeding (116) or in whom endometrial cells were found on a previous cervical cytology smear (12), an endo- and ectocervical smear was taken before hysteroscopy with curettage. The results of the cervical cytology were compared with the endometrial histology. Mean age was 59 years. The average duration of menopause was 10 years. Endometrial carcinoma was diagnosed by endometrial sampling in six women. In two of these cases cervical smears did not contain endometrial cells. The presence of endometrial cells on ectocervical cytology showed a sensitivity of 67% and a specificity of 78% for endometrial carcinoma vs 80% and 76%, respectively, for endocervical cytology. The positive predictive value for endometrial malignancy of the presence of endometrial cells on cervical cytology ranged between 17% and 13%. The presence of 'atypical' endometrial cells on cervical smear was associated with endometrial malignancy in almost half the cases. Cervical cytology is of limited value in the diagnosis and the management of postmenopausal endometrial disease.

Predictive value of normal sperm morphology: a structured literature review

The aim of the study was to conduct a structured review of the literature published on the use of normal sperm morphology, as an indicator of male fertility potential in the in-vitro fertilization (IVF) situation, and to establish the universal predictive value of this semen parameter. Published literature in which normal sperm morphology was used to predict fertilization and pregnancy, during the period 1978-1996, was reviewed. A total of 216 articles were identified by the sourcing methodology, but only 49 provided data that could be tabulated and analysed. Of these, only 18 provided sufficient data for statistical analysis. Fifteen studies used the strict criteria to evaluate sperm morphology, two used World Health Organization (WHO) guidelines and one used both the strict criteria and the WHO guidelines. All the studies (n = 10) using the 5 and 14% normal sperm morphology thresholds (strict criteria) produced positive predictive values for IVF success. In the prediction of pregnancy, 82% (9/11) and 75% (6/8) of the studies produced positive predictive values when using the 5% and 14% thresholds respectively. Aggregating the data produced around the 5% normal sperm morphology threshold (strict criteria), the overall fertilization rates were 59.3% (1979/3337; per oocyte) for the < or = 4% group and 77.6% (10345/13327; per oocyte) for the >4% group, and the overall pregnancy rates were 15.2% (60/395; per cycle) and 26.0% (355/1368; per cycle) respectively. The no-transfer rates across the 5% threshold were 24.0% (86/359; per cycle) in the < or = 4% group compared to 7.4% (80/1088; per cycle) in the >4% group. The inclusion of an accurately evaluated normal sperm morphology count as an integral part of the standard semen analysis makes this analysis still the most cost-effective means of evaluating the male factor.

Methodological issues in the South African incomplete abortion study

In 1994, a national hospital-based study was undertaken of cases of incomplete abortion presenting to public hospitals in South Africa. Data were collected for all women admitted to a random sample of hospitals with incomplete abortion during a two-week period. The WHO protocol for such studies was used as a basis for developing the methods to describe the epidemiology of incomplete abortion and hospital management of cases. Attempts were made to estimate the proportion of cases that might have been induced. This report focuses on methodological issues arising from the study that have implications for future research. The findings demonstrate that only a small proportion of the women acknowledged having had an induced abortion and that only a few of those who did showed evidence of interference with pregnancy. Clinical opinion of sepsis and the likelihood of induction were found to be highly unreliable. These findings considerably reduce the usefulness of the WHO-protocol method of estimating the likely origin of incomplete abortions. Results presented in terms of three partially overlapping descriptive categories are judged to better reflect the limitations of the data collected.

Macronutrient intake and cardiovascular risk factors in older coloured South Africans

A cross-sectional analytical study was undertaken to investigate the macronutrient intake and cardiovascular risk factor profile of community-dwelling older coloured (mixed descent) South Africans. A sample of 200 subjects aged 65 years and above in Cape Town was randomly drawn using a two-stage cluster design. Trained field workers interviewed subjects to obtain demographic, dietary and life-style data, to draw fasting blood samples for the analysis of plasma lipids, and to take anthropometric measurements. Nutrient intake was assessed using a validated quantified food frequency questionnaire. Blood pressure was measured according to the guidelines of the American Heart Association. The mean daily energy intake was 7984 (3245) kJ and 6979 (2219) kJ for men and women, respectively. Twenty-nine per cent of the subjects had energy intakes less than two-thirds of the RDA. Dietary fat intake comprised 32.4% of total energy intake, which is in line with the prudent dietary guidelines. The inadequate fibre intake (mean = 17(8) g/day) was attributed to the low consumption of fruit and vegetables. Anthropometric assessment indicated that the women tended towards overnutrition, while the men appeared to be undernourished. Lipid profiles fell within the lower end of the moderate risk band for cardiovascular disease and a high prevalence of hypertension (71.7%) was identified. The survey findings indicate a need for health promotion activities to encourage increased physical activity levels and an increased consumption of vegetables, fruit, wholegrain cereals and low fat dairy products in this population.

Comparison of two staining and evaluation methods used for computerized human sperm morphology evaluations

The purpose of the study was to analyse the agreement between computer analysed (Hamilton Thorne, IVOS Dimensions Version 3) normal sperm morphology and values obtained from 97 slides stained according to the Papanicolaou and Diff-Quik method. Liquefied semen samples were washed once by centrifugation and air dried smears on slides were made, which were stained according to the Papanicolaou and Diff-Quik method and analysed by computer. The paired t-test was used to assess whether any bias existed between the two methods. The limits of agreement were calculated using the Bland and Altman approach and a modification of this approach (mean-dependent limits). A significant bias of 1.6% was obtained in favour of higher normal sperm morphology percentages when using the Diff-Quik method. The standard limits of agreement were -13.4% to 16.6%, whereas the mean-dependent limits of agreement were 1.6% [5.8 + 0.6 (mean percentage normal morphology)]. Statistically, the Diff-Quik and Papanicolaou staining methods produce different normal sperm morphology profiles. These inherent differences may, therefore, require the establishment of new normal sperm morphology thresholds for male fertility, based on clinical data, when using the Diff-Quik staining method in conjunction with computerized analysis.

Management of incomplete abortions at South African public hospitals. National Incomplete Abortion Study Reference Group

OBJECTIVE

The objective of this report was to review and describe the management of incomplete abortion by public sector hospitals.

DESIGN

A descriptive study in which data were collected prospectively from routine hospital records on all women admitted with incomplete abortion to a stratified random sample of hospitals between 14 and 28 September 1994.

SETTING

Public sector hospitals in South Africa.

PATIENTS

Women with incomplete abortions.

MAIN OUTCOME MEASURES

Length of hospital stay, details of medical management, details of surgical management, determinants of the above.

MAIN RESULTS

Data were collected on 803 patients from the 56 participating hospitals. Of these, 767 (95.9%) were in hospital for 1 day or more, and 753 (95.3%) women underwent evacuation of the uterus. Sharp curettage was the method employed in 726 (96.9%) and general anaesthesia was used for 601 (68%) of the women requiring uterine evacuation. Antibiotics were prescribed for 396 (49.5%) and blood transfusions were administered to 125 (17%) women. Statistical analysis showed length of stay to be longer in small hospitals (under 500 beds) and when the medical condition was more severe. Antibiotic usage and blood transfusion were more common with increasing severity and a low haemoglobin level on admission. However, some inappropriate management was identified with regard to both.

MAIN CONCLUSIONS

It is suggested that uncomplicated incomplete abortion can be more effectively and safely managed using the manual vacuum aspiration technique with sedation/analgesia as an outpatient procedure. Attention should be directed at the introduction of this management routine at all types of hospital and to the ensuring of appropriate management of women with complicated abortion.

Urbanization and the risk for chronic diseases of lifestyle in the black population of the Cape Peninsula, South Africa

BACKGROUND

Men and women have experienced differing patterns of urbanization. Men spent more time in the city as migrant labourers, which could be attributed to the influx control legislation during the apartheid years.

OBJECTIVE

To investigate urban exposure among black people of the Cape Peninsula, South Africa, in relation to unhealthy lifestyles and the risk factors for chronic diseases of lifestyle.

METHODS

Blood pressure, height, weight and serum cholesterol were measured in a random sample of 986 persons, aged 15-64 years. Sociodemographic details, urban exposure, dietary intake patterns and personal habits were elicited by questionnaire. An urbanization index (percentage of life spent in a city), the dietary Keys score and body mass index were calculated. Linear regression modelling for cholesterol and hypertension, and multiple correspondence analysis for risk factors and demographic characteristics were performed.

RESULTS

The degree of urbanization had no effect on total serum cholesterol concentrations, which were very low compared with other groups in South Africa. Hypertension was independently related to age, obesity and the degree of urbanization. Smoking patterns were influenced by the degree of urbanization in women only. Correspondence analysis identified groups with clusters of risk factors: formal housing-westernized diet-highly urbanized; male-normal weight-increased exercise-alcohol-smoking; female-obesity-non-smoking; and hypertension-ageing.

CONCLUSIONS

Those who spent larger proportions of their lives in an urban setting tended to have unhealthier lifestyles and higher risk for chronic diseases lifestyle compared with their less urbanized counterparts. Groups to whom intervention should be targeted were also identified.

Autonomic neuropathy in extra-hepatic portal vein thrombosis: evidence for impaired autonomic reflex arc

BACKGROUND/AIMS

Autonomic dysfunction is common in cirrhosis, and may be associated with increased mortality and hyperdynamic circulatory changes. Our aim was to investigate whether autonomic disturbances occur in extrahepatic portal vein thrombosis and their correlation with hemodynamic abnormalities.

PATIENTS AND METHODS

Heart rate variation in response to standing, deep breathing, and Valsalva maneuver, and blood pressure response to sustained handgrip and to standing, were studied in 16 subjects with portal vein thrombosis (10 males, 30.8+/-2.8 years: mean+/-SE), 12 with cirrhosis (7 males, 52+/-2.3 years), and 10 healthy controls (7 males, 30.8+/-3.0 years). Supine resting, and 10- and 30-min standing epinephrine and norepinephrine levels were measured and results correlated with cardiac output.

RESULTS

Autonomic dysfunction occurred in 62% of portal vein thrombosis and 75% of cirrhosis subjects, but in no controls (p<0.02). Similarly, postural hypotension occurred in portal vein thrombosis (-10.25+/-0.65 mmHg, p=0.003) and cirrhosis (-7.42+/-0.82 mmHg, p=0.007) but not in controls. All groups had similar baseline epinephrine and norepinephrine concentrations. Epinephrine increased significantly in controls (45%, p<0.01 and 49%, p<0.02) after 10 of 30 min standing but not in the portal vein thrombosis or the cirrhotic group, and norepinephrine increased after 10 and 30 min standing in cirrhotics (128%, p<0.004 and 130%, p<0.008) and controls (129%, p<0.002 and 116%, p<0.004), but not portal vein thrombosis (34.5% and 39%, NS vs baseline). Portal vein thrombosis and cirrhosis groups had increased cardiac output (4441+/-509 and 3262+/-292) vs controls (1763+/-212 ml/min/m2, p<0.002), but there was no correlation with autonomic neuropathy or with catecholamine levels.

CONCLUSIONS

Autonomic dysfunction and impaired catecholamine response to orthostatic stress occur commonly in portal vein thrombosis and suggest an impairment of the autonomic reflex arc, but changes do not correlate with hemodynamic abnormalities.

Effect of sperm preincubation time on GIFT pregnancy outcome

This investigation was conducted to evaluate the effect of human sperm preincubation time on the pregnancy outcome in gamete intrafallopian tube transfers. This was determined in a retrospective study on gamete intrafallopian transfer patients (ideopathic infertility) using logistic regression with the covariates, preincubation time (< or = 60 and > 60 min) and age (< or = 35 and > 35 years). The study included 485 consecutive gamete intrafallopian transfer cycles in which 3 metaphase II oocytes were transferred. Pregnancy outcome was evaluated by beta hCG levels on days 12 and 16 and was confirmed by the presence of a fetal heart 8 weeks after the procedure by means of sonography. The wife's age and sperm preincubation time were significant covariates in the prediction of ongoing pregnancy. The odds ratio for age (< or = 35 years) was 2.2 in the prediction of ongoing pregnancy, while the age-adjusted odds ratios for preincubation time (< or = 60 min) was 1.9. There was a critical relationship between sperm preincubation time and GIFT success, which confirms the effect of the wife's age on pregnancy. Close coordination is of importance between the clinical scientist and the physician to restrict the preincubation time to 1 h. The sperm preincubation time is a significant factor that has to be considered in the prediction of ongoing pregnancy in GIFT patients.

The prevalence of diabetes mellitus and associated risk factors in elderly coloured South Africans

OBJECTIVE

To determine the prevalence of diabetes and its associated risk factors in elderly coloured South Africans.

RESEARCH DESIGN

Cross-sectional analytical study.

METHODS

A random sample of 200 non-institutionalised coloured (mixed ancestry) subjects aged > or = 65 years of age, resident in urban Cape Town, was drawn by means of a two-stage cluster design. The survey procedure included an oral glucose tolerance test, anthropometric measurements, and physical activity and alcohol intake assessments.

RESULTS

The prevalence of diabetes was 28.7% (95% CI 21.7-35.7%), 25.7% in men and 30.3% in women. The prevalence of impaired glucose tolerance was 15% (95% CI 9.2-20.8%). Upper-segment fat distribution (P < 0.001) and body mass (P < 0.05) were identified as significant risk factors for diabetes. A differential age and sex interaction was evident; in men the association between the identified risk factors and diabetes increased with age, while in women the association was strongest in those aged < 70 years. Body mass index, alcohol intake and physical activity were not significant risk factors.

CONCLUSIONS

The prevalence of diabetes in older coloured South Africans was found to be high. The predicted increase in the proportion of the coloured population aged 65 years and older during the next 4 decades has important implications for the allocation of health resources for management of chronic diseases associated with ageing; diabetes appears to constitute a major health problem in this regard.

Effects of different staining and washing procedures on the results of human sperm morphology evaluation by manual and computerised methods

The purpose of this study was to investigate the effect of different staining and washing procedures on the results of human sperm morphology evaluation by manual and computerised methods. Furthermore, it was intended to find the staining and washing combination which would provide optimal readability for computer-assisted sperm morphology evaluations. In phase one, four staining methods were evaluated for smears prepared from the resulting samples following a two times washing procedure. In phase two, 20 semen samples were used to compare the Diff-Quik and Papanicolaou staining methods, following one and two washes. All manual readings, of Papanicolaou and Diff-Quik stained smears, were comparable with each other, with means between 7.3% and 7.9% normal spermatozoa. All the manual readings were also comparable to the computer readings of the Diff-Quik slides following one and two washes with means of 9.0% and 5.9%, respectively. However, due to the higher computer readings found for the Papanicolaou stained smears, with means of 13.9% and 13.5% following one and two washes, respectively, a statistically significantly difference between overall computer and manual readings was found (Wilks' Lamda, P = 0.0002). Taking all data into consideration, it could be concluded that the one wash Diff-Quik stained smears was the optimal preparation method for computerised sperm morphology evaluation, comparing favourably with manual evaluations.

Vitamin D status of older South Africans

OBJECTIVE

To determine the vitamin D status of older coloured' South Africans who had not sustained a fracture.

DESIGN

Cross-sectional analytic study.

METHODS

A random sample of 200 non-institutionalised subjects in Cape Town aged > or = 65 years was drawn using a two-stage cluster design. Trained fieldworkers interviewed subjects to obtain demographic, dietary and lifestyle data, to draw fasting blood samples for the analysis of serum 25-hydroxyvitamin D (25(OH)D) and other biochemical parameters, and to take anthropometric measurements.

RESULTS

Seventeen per cent of the subjects (95% CI: 11.4-22.6%) had serum 25(OH)D levels in the deficient range for the elderly (< 10 ng/ml); 7.5% (95% CI: 3.6-11.4%) had concentrations in the moderately severe range of deficiency (< 8 ng/ml). Sixty-three per cent of the subjects had raised serum alkaline phosphatase concentrations. Regression modelling showed neither a sex difference in 25(OH)D levels nor a sex-age interaction; however, a negative association with age was found (r = -0.18; P < 0.05). Mean oral vitamin D intake was low (3.6 (SD = 2.7) micrograms and 2.8 (SD = 1.7) micrograms for men and women, respectively), but no association between dietary vitamin D intake and serum 25(OH)D was found.

CONCLUSIONS

The prevalence of suboptimal vitamin D status was high. However, the interpretation of the data, with regard to bone health, is limited by the cross-sectional design of the study. Further investigation is required to determine the potential benefits of intervention in this age group.

A prospective study on the predictive value of normal sperm morphology as evaluated by computer (IVOS)

OBJECTIVE

To evaluate the IVOS (Hamilton Thorne Research Version 2.1 Dimension Program, Beverly, MA) system's ability to predict fertilization in vitro in a prospective study.

DESIGN

Hospital-based academic ART program.

PATIENTS

Eighty patients from the IVF-GIFT program were evaluated. The same semen sample was analyzed on a day-to-day basis by both laboratory (manual method) and the computerized system for percentage normal morphology, concentration/mL, motility, and forward progression. Only patients with two or more metaphase II (MII) oocytes available were allowed into the study and excluded where the male partner had antisperm antibodies or qualified for intracytoplasmic sperm injection (<500,000 motile spermatozoa obtained after glass wool separation).

STATISTICAL ANALYSIS

Logistic regression analysis was used to study predictors of fertilization in vitro.

RESULTS

Three hundred thirty-eight oocytes were obtained from 80 patients of which 239 fertilized. The logistic regression analysis of the manual method (percentage normal morphology) and IVOS indicated that both were predictors of fertilization. Sperm morphology as evaluated by IVOS in patients with <10 x 10(6) motile spermatozoa/mL retrieved after swim-up was a significant predictor of fertilization as was the number of oocytes obtained. Thus, the more oocytes obtained in the lower morphological groups, the better the chance of fertilization. The fertilization rate in the morphology group of 0% to 4% normal forms was 45.6% (37/81) and in the group >14% normal forms was 85.2% (69/81).

CONCLUSIONS

It was shown that in patients where </= 10 x 10(6) motile spermatozoa were obtained, the role of morphology (evaluated by IVOS) as well as the number of oocytes were important predictors of fertilization. The computer can assist to identify these patients with a poor prognosis for fertilization.

Slide preparation and staining procedures for reliable results using computerized morphology

The purpose of this study was to standardize slide preparation and staining procedures to improve the efficiency and effectivity of the IVOS system on normal sperm morphology readings with regard to the strict criteria. Semen samples from patients attending the Reproductive Biology Unit, Tygerberg Hospital, were used. In experiment 1, five different Diff-Quik staining procedures, including the standard procedure, were evaluated on each of 22 patients and the effect of slide preparation within 1 h or more than 5 h after collection and the effect of immediate fixation versus fixation after 24 h were observed. In experiment 2, the manual evaluation time per slide (n = 20) by two technicians was compared with the time taken by computer. In experiment 1 the median % normal for the 5 different staining procedures was 6, 6.5, 9.5, 8.5, and 5.5%. No significant difference was found between the different staining procedures (p = .60, nonparametric Friedman test). In experiment 2 the mean time for manual assessment by two technicians was 3 min:6 s and 3 min:53 s per slide as compared to 4 min:39 s by computer. For experiment 1, slides can be prepared immediately or after 5 h. Fixation time also does not interfere with the computer's ability to identify normal forms. For experiment 2, the IVOS system is competitive regarding assessment time. Standardization of optimum staining procedures is important to ensure repeatability and comparability. Therefore, slides should be prepared immediately after liquefaction and fixed immediately after air drying.

Comparison of motility characteristics and normal sperm morphology of human semen samples separated by percoll density gradient centrifugation

The aim of this study was twofold: to investigate the ability of Percoll gradient centrifugation (52, 68, 84%) to fractionate semen samples according to motility quality and percentage normal morphology and to determine whether there is an association between sperm motility quality and percentage normal morphology. Sperm motility was evaluated using a Hamilton Thorn analyzer and normal sperm morphology was manually assessed according to the strict criteria (< or = 4, 5-14, and >14%). The majority of motility parameters and the percentage normal morphology were found to be significantly improved in the 84% Percoll fraction. The greatest effect was on the < or = 4% group, shifting the mean normal morphology percentage from 2.6 to 5.2%. Curvilinear velocity (VCL) and average path velocity (VAP) were the only two motility parameters that were significantly associated with the percentage normal morphology. Using a combined VCL, VAP vector the >14% group was found to have a significantly different value as compared to the 5-14 and < or = 4% groups. Percoll (discontinuous) gradient centrifugation can therefore play a significant role in the improvement of semen samples for use in assisted reproduction procedures. The VCL, VAP vector identified may also serve as an additional tool in the prediction of the fertility potential of sperm samples.

Comparison between swim-up and glass wool column filtration of human semen in a gamete intrafallopian transfer program

This study compared swim-up and glass wool filtration in both pregnancy outcome and fertilization of excess oocytes in patients undergoing gamete intrafallopian transfer. Gamete intrafallopian transfer patients were retrospectively included in the study group (n = 52). The criteria for inclusion were as follows: Semen had to have been prepared by means of glass wool filtration and at least 2 metaphase II oocytes had to have been transferred. Each patient from this group was then carefully matched with another patient according to specific criteria (number of metaphase II oocytes aspirated and transferred, normal sperm morphology, wife's age, the absence of anti-sperm antibodies, semen preparation by means of the swim-up procedure). Fourteen patients were matched with themselves (groups A1 and A2) and 38 patients were matched with another patient (groups B and C). The results indicate that there was no significant difference in the fertilization and pregnancy probabilities of sperm prepared by means of glass wool filtration or swim-up procedure. The comparative pregnancy rates for the groups were A1 (7.1%) versus A2 (7.1%) and B (28.9%) versus C (31.6%). Factors other than fertilization and pregnancy potential may have a greater influence on choosing the optimum sperm preparation procedure.

Endopap-versus Pipelle-sampling in the diagnosis of postmenopausal endometrial disease

OBJECTIVE

To evaluate the accuracy of Endopap- and Pipelle-sampling in the diagnosis of postmenopausal disease.

STUDY DESIGN

Observational study in the setting of a University Hospital. One hundred and six consecutive postmenopausal women presenting with uterine bleeding or endometrial cells on cervical cytology underwent an Endopap sampling as well as a Pipelle biopsy. Thereafter, 89 of those women underwent a hysteroscopy and curettage (n = 71) or a hysterectomy (n = 18). The diagnostic accuracy of Pipelle and Endopap was assessed against the final diagnosis.

RESULTS

Endometrial carcinoma was found in five cases (6%), benign disease in 34 (38%). The sensitivity of Endopap and Pipelle for the detection of endometrial disease was 56 and 51%, respectively, with a specificity of 94 and 100%, respectively. The sensitivity for endometrial carcinoma was 80% for Endopap and 100% for Pipelle.

CONCLUSIONS

Our data tend to favor Pipelle against Endopap as diagnostic tool in endometrial disease in symptomatic postmenopausal women.

Re-evaluation of the "week-end effect" data: possible role of urinary copper and phosphorus in the pathogenesis of renal calculi

Early morning urinary concentrations of 10 elements which had demonstrated a "week-end effect" in a previous study, were subjected to a normalization procedure thereby allowing a re-assessment of their potential role in urolithiasis. After transformation of each concentration to a weighted proportion of the total concentration on each day, only Cu and P values were significantly different for kidney stone formers and healthy controls on all three days indicating that these elements may play a role in the pathogenesis of renal calculi. The results obtained in this study demonstrate that a more meaningful picture of the possible differences in the urinary concentrations of stone formers and normal controls might emerge if "proportional" rather than "raw" concentrations are compared.

Tuberculosis drug resistance in the Western Cape

OBJECTIVES

Drug resistance is a serious problem in the treatment of tuberculosis and a threat to successful tuberculosis control programmes. Local health workers have expressed concern that the increasing tuberculosis epidemic in the Western Cape is partly attributable to drug resistance. The aim of this study was to determine the prevalence of tuberculosis drug resistance (including multidrug resistance) and to investigate possible relationships between drug resistance and patient demographic characteristics.

DESIGN, SETTING, SUBJECTS, OUTCOME MEASURES

During a defined period, all adult (> or = 15 years) patients with pulmonary tuberculosis (confirmed by culture) from all tuberculosis clinics in the Western Cape were included. Previous tuberculosis treatment history was obtained by interviews, utilising a standardised questionnaire. Acquired drug resistance was determined on cultures from patients with a prior history of tuberculosis treatment, while initial resistance was determined from tuberculosis cases with no history of previous treatment.

RESULTS

Data from 7,266 patients were analysed. After adjusting for missing information by way of a random sample validation study, 32% of patients were found to have a history of previous treatment, 63% indicated no previous treatment, and in 5% the treatment history was unknown. Rates for initial resistance were found to be low at 3,9% for isoniazid, 1,1% for rifampicin and 0,2% for ethambutol. Combined resistance to isoniazid and rifampicin (multidrug resistance) was found to be 1,1% in patients not treated before. Acquired resistance rates were higher at 10,8% for isoniazid, 4,2% for rifampicin, 0,3% for ethambutol and 4,0% for multidrug resistance. Logistic regression analysis of the data indicated that drug resistance was not influenced by population group, gender or age. Patients with a history of tuberculosis treatment were found to be at an increased risk of developing drug resistance (relative risk 2,6). Some regions in the Western Cape had higher proportions of previously treated patients with consequent higher acquired resistance rates.

CONCLUSIONS

Results from this study indicated that drug resistance is currently not a major problem in the Western Cape, rates comparing favourably with those reported from developed countries and being much lower than those for developing countries. Every effort should therefore be made to maintain the status quo and to prevent the emergence of further resistance. The priority for tuberculosis control in the Western Cape should remain to limit transmission of the disease by reducing the infectious pool through improved cure of (especially) smear-positive cases.

Supplemented low-protein diets--are they superior in chronic renal failure?

Twenty-two patients with chronic renal failure were randomly assigned to a conventional low-protein diet containing 0.6 g protein/kg/day or a very-low-protein diet containing 0.4 g protein/kg/day supplemented with essential amino acids; they were followed up for 9 months. There were no significant changes in body mass index, arm muscle area, percentage body fat, serum albumin and transferrin levels in any of the groups; neither was there any difference between the groups in respect of these parameters. Renal function, as measured by the reciprocal of serum creatinine over time, stabilised in both groups during intervention, with no significant difference between the groups. There was however no correlation between changes in renal function and changes in blood pressure, or dietary intake of protein, phosphorus, cholesterol, polyunsaturated and saturated fatty acids. There were also no significant changes and no significant differences between the groups in serum levels of parathyroid hormone and alkaline phosphatase, urine cyclic adenosine monophosphate, tubular reabsorption of phosphate, and the theoretical renal threshold for phosphate. The results of this study suggest that the supplemented very-low-protein diet was not superior to the conventional low-protein diet in terms of its effect on protein-energy status, renal function and biochemical parameters of renal osteodystrophy.

Influence of ethnic and geographic factors on the classic photoparoxysmal response in the electroencephalogram of epilepsy patients

The classic photoparoxysmal response (CPPR) on photic stimulation in the electroencephalogram (EEG) of 128 patients with chronic epilepsy, constituting three different ethnic groups, was investigated. All patients were referred for routine clinical EEG investigation. There was a significantly higher occurrence in whites (2.7%, of 72 of 2,657) as compared with blacks (0.1%, 1 of 848) and subjects of "mixed race" (0.9%, 55 of 5,958). Interictal abnormalities and the range of responses were similar in the two main ethnic groups. There was no evidence of a seasonal association with CPPR. We conclude that genetic rather than environmental factors influence the CPPR.

Combining vaginal ultrasonography and office endometrial sampling in the diagnosis of endometrial disease in postmenopausal women

OBJECTIVE

To investigate the value of the combined use of vaginal ultrasonography and endometrial sampling in the office for the diagnosis of endometrial disease in postmenopausal women.

METHODS

One hundred forty consecutive postmenopausal women presenting with uterine bleeding or endometrial cells on cervical cytology entered the study. Vaginal ultrasonography was used to measure the endometrial thickness, followed by use of the Pipelle endometrial sampler. Pipelle biopsy was not feasible in two patients. The results of hysteroscopy with biopsy or hysterectomy, performed within 6 weeks in all but 12 patients, were considered the final diagnosis. The accuracy of ultrasound and Pipelle was measured against the final diagnosis.

RESULTS

The sensitivity of vaginal ultrasonography for endometrial disease was 98.2 and 82.0% if cutoff points for endometrial thickness of 2 and 4 mm, respectively, were used. All six patients with endometrial carcinoma had endometrial thicknesses exceeding 12 mm. Pipelle endometrial sampling had a sensitivity of 44.6% and a specificity of 98.5% for endometrial disease. All cases of endometrial carcinoma were detected by sampling in the office setting.

CONCLUSION

This study illustrates the value of vaginal scanning in the diagnosis of endometrial disease in symptomatic, postmenopausal women. A 4-mm cutoff point for endometrial thickness seemed appropriate. The sensitivity of Pipelle sampling for endometrial carcinoma was excellent, but relatively weak for other endometrial disease because it failed to detect endometrial polyps and submucous myomas. The combined use of ultrasound and Pipelle sampling offers sufficient diagnostic information for most symptomatic postmenopausal women.