Carl Lombard

Sperm morphologic features as a prognostic factor in in vitro fertilization

To determine whether there is a prognostic value in the percentage normal sperm morphologic features in a human in vitro fertilization (IVF) program, the authors conducted a prospective study in women with bilateral tubal damage. Based on the percentage of morphologically normal spermatozoa, the patients were divided into four groups: group I, normal morphologic features between 0% and 14%; group II, 15% to 30%; group III, 31% to 45%; and group IV, 46% to 60%. One hundred ninety successful laparoscopic cycles were evaluated. In group I, 104 oocytes were obtained, of which 37% fertilized, but no pregnancy resulted; in group II, 81% of 324 oocytes were fertilized, with a pregnancy rate per embryo transfer (ET) of 22%; in group III, 82% of 309 oocytes were fertilized, with a 31% pregnancy rate; and in group IV, 91% of 69 oocytes were fertilized, with a pregnancy rate of 12%. Probability models indicated that there was a clear threshold in normal sperm morphologic features at 14%, with high fertilization and pregnancy rate in the groups with normal sperm morphologic features greater than 14%.

A Fivefold Reduction in the Incidence of Recurrent Ankle Sprains in Soccer Players Using the Sport-Stirrup Orthosis:

A study was undertaken to evaluate the effect of a semi rigid ankle orthosis (Sport-Stirrup) on the incidence of ankle sprains in soccer players during 1 playing season. Senior soccer players were divided into 2 groups: play ers with previous ankle sprains (N = 258) and players without such history (N = 246). The players in these groups were each randomly allocated to either a semi rigid orthosis or a control group at the start of the playing season. All subsequent injuries during the season and the total number of playing hours were documented. There was a significant reduction in the incidence of ankle sprains (injuries/1 000 playing hours) by ankles in the orthosis group with previous sprains (0.14) com pared with the nonbraced group with previous sprains (0.86). The incidence of ankle sprains was significantly higher in the nonbraced group with previous sprains (0.86) compared with the nonbraced group without pre vious sprains (0.46). Thus, in this study, a semirigid or thosis significantly reduced the incidence of recurrent ankle sprains in soccer players with previous history of ankle sprains.

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.

Effect of isoniazid prophylaxis on mortality and incidence of tuberculosis in children with HIV: randomised controlled trial

Objectives To investigate the impact of isoniazid prophylaxis on mortality and incidence of tuberculosis in children with HIV. Design Two centre prospective double blind placebo controlled trial. Participants Children aged ≥8 weeks with HIV. Interventions Isoniazid or placebo given with co-trimoxazole either daily or three times a week. Setting Two tertiary healthcare centres in South Africa. Main outcome measures Mortality, incidence of tuberculosis, and adverse events. Results Data on 263 children (median age 24.7 months) were available when the data safety monitoring board recommended discontinuing the placebo arm; 132 (50%) were taking isoniazid. Median follow-up was 5.7 (interquartile range 2.0-9.7) months. Mortality was lower in the isoniazid group than in the placebo group (11 (8%) v 21 (16%), hazard ratio 0.46, 95% confidence interval 0.22 to 0.95, P=0.015) by intention to treat analysis. The benefit applied across Centers for Disease Control clinical categories and in all ages. The reduction in mortality was similar in children on three times a week or daily isoniazid. The incidence of tuberculosis was lower in the isoniazid group (5 cases, 3.8%) than in the placebo group (13 cases, 9.9%) (hazard ratio 0.28, 0.10 to 0.78, P=0.005). All cases of tuberculosis confirmed by culture were in children in the placebo group. Conclusions Prophylaxis with isoniazid has an early survival benefit and reduces incidence of tuberculosis in children with HIV. Prophylaxis may offer an effective public health intervention to reduce mortality in such children in settings with a high prevalence of tuberculosis. Trial registration. Clinical Trials NCT00330304

Exclusive breastfeeding promotion by peer counsellors in sub-Saharan Africa (PROMISE-EBF): a cluster-randomised trial

BACKGROUND Exclusive breastfeeding (EBF) is reported to be a life-saving intervention in low-income settings. The effect of breastfeeding counselling by peer counsellors was assessed in Africa. METHODS 24 communities in Burkina Faso, 24 in Uganda, and 34 in South Africa were assigned in a 1:1 ratio, by use of a computer-generated randomisation sequence, to the control or intervention clusters. In the intervention group, we scheduled one antenatal breastfeeding peer counselling visit and four post-delivery visits by trained peers. The data gathering team were masked to the intervention allocation. The primary outcomes were prevalance of EBF and diarrhoea reported by mothers for infants aged 12 weeks and 24 weeks. Country-specific prevalence ratios were adjusted for cluster effects and sites. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00397150. FINDINGS 2579 mother-infant pairs were assigned to the intervention or control clusters in Burkina Faso (n=392 and n=402, respectively), Uganda (n=396 and n=369, respectively), and South Africa (n=535 and 485, respectively). The EBF prevalences based on 24-h recall at 12 weeks in the intervention and control clusters were 310 (79%) of 392 and 139 (35%) of 402, respectively, in Burkina Faso (prevalence ratio 2·29, 95% CI 1·33-3·92); 323 (82%) of 396 and 161 (44%) of 369, respectively, in Uganda (1·89, 1·70-2·11); and 56 (10%) of 535 and 30 (6%) of 485, respectively, in South Africa (1·72, 1·12-2·63). The EBF prevalences based on 7-day recall in the intervention and control clusters were 300 (77%) and 94 (23%), respectively, in Burkina Faso (3·27, 2·13-5·03); 305 (77%) and 125 (34%), respectively, in Uganda (2·30, 2·00-2·65); and 41 (8%) and 19 (4%), respectively, in South Africa (1·98, 1·30-3·02). At 24 weeks, the prevalences based on 24-h recall were 286 (73%) in the intervention cluster and 88 (22%) in the control cluster in Burkina Faso (3·33, 1·74-6·38); 232 (59%) and 57 (15%), respectively, in Uganda (3·83, 2·97-4·95); and 12 (2%) and two (<1%), respectively, in South Africa (5·70, 1·33-24·26). The prevalences based on 7-day recall were 279 (71%) in the intervention cluster and 38 (9%) in the control cluster in Burkina Faso (7·53, 4·42-12·82); 203 (51%) and 41 (11%), respectively, in Uganda (4·66, 3·35-6·49); and ten (2%) and one (<1%), respectively, in South Africa (9·83, 1·40-69·14). Diarrhoea prevalence at age 12 weeks in the intervention and control clusters was 20 (5%) and 36 (9%), respectively, in Burkina Faso (0·57, 0·27-1·22); 39 (10%) and 32 (9%), respectively, in Uganda (1·13, 0·81-1·59); and 45 (8%) and 33 (7%), respectively, in South Africa (1·16, 0·78-1·75). The prevalence at age 24 weeks in the intervention and control clusters was 26 (7%) and 32 (8%), respectively, in Burkina Faso (0·83, 0·45-1·54); 52 (13%) and 59 (16%), respectively, in Uganda (0·82, 0·58-1·15); and 54 (10%) and 33 (7%), respectively, in South Africa (1·31, 0·89-1·93). INTERPRETATION Low-intensity individual breastfeeding peer counselling is achievable and, although it does not affect the diarrhoea prevalence, can be used to effectively increase EBF prevalence in many sub-Saharan African settings. FUNDING European Union Sixth Framework International Cooperation-Developing Countries, Research Council of Norway, Swedish International Development Cooperation Agency, Norwegian Programme for Development, Research and Education, South African National Research Foundation, and Rockefeller Brothers Foundation.

Effect of educational outreach to nurses on tuberculosis case detection and primary care of respiratory illness: pragmatic cluster randomised controlled trial

Abstract Objectives To develop and implement an educational outreach programme for the integrated case management of priority respiratory diseases (practical approach to lung health in South Africa; PALSA) and to evaluate its effects on respiratory care and detection of tuberculosis among adults attending primary care clinics. Design Pragmatic cluster randomised controlled trial, with clinics as the unit of randomisation. Setting 40 primary care clinics, staffed by nurse practitioners, in the Free State province, South Africa. Participants 1999 patients aged 15 or over with cough or difficult breathing (1000 in intervention clinics, 999 in control clinics). Intervention Between two and six educational outreach sessions delivered to nurse practitioners by usual trainers from the health department. The emphasis was on key messages drawn from the customised clinical practice guideline for the outreach programme, with illustrative support materials. Main outcome measures Sputum screening for tuberculosis, tuberculosis case detection, inhaled corticosteroid prescriptions for obstructive lung disease, and antibiotic prescriptions for respiratory tract infections. Results All clinics and almost all patients (92.8%, 1856/1999) completed the trial. Although sputum testing for tuberculosis was similar between the groups (22.6% in outreach group v 19.3% in control group; odds ratio 1.22, 95% confidence interval 0.83 to 1.80), the case detection of tuberculosis was higher in the outreach group (6.4% v 3.8%; 1.72, 1.04 to 2.85). Prescriptions for inhaled corticosteroids were also higher (13.7% v 7.7%; 1.90, 1.14 to 3.18) but the number of antibiotic prescriptions was similar (39.7% v 39.4%; 1.01, 0.74 to 1.38). Conclusions Combining educational outreach with integrated case management provides a promising model for improving quality of care and control of priority respiratory diseases, without extra staff, in resource poor settings. Trial registration Current controlled trials ISRCTN13438073.

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.

Psychological distress among women suffering from couple infertility in South Africa: a quantitative assessment

BACKGROUND Recent years have seen a growing interest in the impact of infertility on reproductive health in developing countries. Most of the research which has addressed the psychosocial consequences of infertility in African countries has been qualitative in nature and focused on women. It was the aim of this study to assess psychological distress quantitatively in men suffering from couple infertility living in an urban community in South Africa. METHODS The Symptom Checklist-90-R, a standardized instrument for the measurement of current psychological symptom status, was administered to 120 men upon first presentation to a public health sector infertility clinic (study group) in a tertiary referral centre. The control group comprised 120 men who attended an antenatal clinic with their partner. All men may have previously fathered a child. Raw test scores were converted into standard area T scores and analyzed further. RESULTS Participants in the study group differed in their psychological symptom status when compared with controls. Male partners of infertile couples had significantly elevated mean T scores for all nine primary symptom dimensions as well as the three global markers of distress (P < 0.0001 versus control), but these did not exceed the upper range of normal. CONCLUSIONS When compared with controls, male partners of infertile couples experienced elevated levels of psychological distress, but without, on average, suffering from psychopathology. A comparison with qualitative studies from African countries and with quantitative studies from the Western industrialized world revealed both similarities and differences. Understanding and addressing the male perspective of infertility is an important component of infertility management.

Rising diabetes prevalence among urban-dwelling black South Africans.

Objective To examine the prevalence of and the association of psychosocial risk factors with diabetes in 25–74-year-old black Africans in Cape Town in 2008/09 and to compare the prevalence with a 1990 study. Research Design and Methods A randomly selected cross-sectional sample had oral glucose tolerance tests. The prevalence of diabetes (1998 WHO criteria), other cardiovascular risk factors and psychosocial measures, including sense of coherence (SOC), locus of control and adverse life events, were determined. The comparison of diabetes prevalence between this and a 1990 study used the 1985 WHO diabetes criteria. Results There were 1099 participants, 392 men and 707 women (response rate 86%). The age-standardised (SEGI) prevalence of diabetes was 13.1% (95% confidence interval (CI) 11.0–15.1), impaired glucose tolerance (IGT) 11.2% (9.2–13.1) and impaired fasting glycaemia 1.2% (0.6–1.9). Diabetes prevalence peaked in 65–74-year-olds (38.6%). Among diabetic participants, 57.9% were known and 38.6% treated. Using 1985 WHO criteria, age-standardised diabetes prevalence was higher by 53% in 2008/09 (12.2% (10.2–14.2)) compared to 1990 (8.0% (5.8–10.3)) and IGT by 67% (2008/09: 11.7% (9.8–13.7); 1990: 7.0% (4.9–9.1)). In women, older age (OR: 1.05, 95%CI: 1.03–1.08, p<0.001), diabetes family history (OR: 3.13, 95%CI: 1.92–5.12, p<0.001), higher BMI (OR: 1.44, 95%CI: 1.20–1.82, p = 0.001), better quality housing (OR: 2.08, 95%CI: 1.01–3.04, p = 0.047) and a lower SOC score (≤40) was positively associated with diabetes (OR: 2.57, 95%CI: 1.37–4.80, p = 0.003). Diabetes was not associated with the other psychosocial measures in women or with any psychosocial measure in men. Only older age (OR: 1.05, 95%CI: 1.02–1.08, p = 0.002) and higher BMI (OR: 1.10, 95%CI: 1.04–1.18, p = 0.003) were significantly associated with diabetes in men. Conclusions The current high prevalence of diabetes in urban-dwelling South Africans, and the likelihood of further rises given the high rates of IGT and obesity, is concerning. Multi-facetted diabetes prevention strategies are essential to address this burden.

Mortality of Women From Intimate Partner Violence in South Africa: A National Epidemiological Study

The purpose of this article is to describe mortality of women from intimate partner violence (IPV) in South Africa using a retrospective national study in a proportionate random sample of 25 mortuaries. Homicides identified from mortuary, autopsy, and police records. There were 3,797 female homicides, of which 50.3% were from IPV. The mortality rate from IPV was 8.8 per 100,000 women. Mortality from IPV were elevated among those 14 to 44 years and women of color. Blunt force injuries were more common, while strangulation or asphyxiation were less common. The national IPV mortality rate was more than twice that found in the United States. The study highlights the value of collecting reliable data across the globe to develop interventions for advocacy of which gender equity is critical.