Consensus and Diversity in the Management of Varicocele for Male Infertility: Results of a Global Practice Survey and Comparison with Guidelines and Recommendations

PURPOSE

Varicocele is a common problem among infertile men. Varicocele repair (VR) is frequently performed to improve semen parameters and the chances of pregnancy. However, there is a lack of consensus about the diagnosis, indications for VR and its outcomes. The aim of this study was to explore global practice patterns on the management of varicocele in the context of male infertility.

MATERIALS AND METHODS

Sixty practicing urologists/andrologists from 23 countries contributed 382 multiple-choice-questions pertaining to varicocele management. These were condensed into an online questionnaire that was forwarded to clinicians involved in male infertility management through direct invitation. The results were analyzed for disagreement and agreement in practice patterns and, compared with the latest guidelines of international professional societies (American Urological Association [AUA], American Society for Reproductive Medicine [ASRM], and European Association of Urology [EAU]), and with evidence emerging from recent systematic reviews and meta-analyses. Additionally, an expert opinion on each topic was provided based on the consensus of 16 experts in the field.

RESULTS

The questionnaire was answered by 574 clinicians from 59 countries. The majority of respondents were urologists/uro-andrologists. A wide diversity of opinion was seen in every aspect of varicocele diagnosis, indications for repair, choice of technique, management of sub-clinical varicocele and the role of VR in azoospermia. A significant proportion of the responses were at odds with the recommendations of AUA, ASRM, and EAU. A large number of clinical situations were identified where no guidelines are available.

CONCLUSIONS

This study is the largest global survey performed to date on the clinical management of varicocele for male infertility. It demonstrates: 1) a wide disagreement in the approach to varicocele management, 2) large gaps in the clinical practice guidelines from professional societies, and 3) the need for further studies on several aspects of varicocele management in infertile men.

AhRR methylation contributes to disease progression in urothelial bladder cancer

BACKGROUND

Bladder Cancer (BCa) is the tenth most incidental malignancy worldwide. BCa is mostly attributed to environmental exposure and lifestyle, particularly tobacco smoking. The Aryl Hydrocarbon Receptor Repressor (AhRR) participates in the induction of many enzymes involved in metabolizing carcinogens, including tobacco smoke components. Additionally, studies have shown that smoking demethylates the (AhRR) gene in blood, suggesting AhRR demethylation as a specific serum smoking biomarker.

OBJECTIVE

This study aimed to validate AhRR demethylation as a smoking biomarker in the target tissue and investigate its contribution to bladder carcinogenesis.

METHODS

AhRR percent methylation was tested for its association with patient smoking status and oncogenic outcome indicators, particularly p53, RB1, and FGFR3 activating mutations, muscle-invasiveness, and tumor grade, in 180 BCa tissue-based DNA.

RESULTS

Results showed significantly higher AhRR percent methylation in muscle-invasive compared to non-muscle invasive tumors (42.86% vs. 33.98%; p= 0.011), while lower AhRR methylation was significantly associated with FGFR3 Codon 248 mutant genotype compared to wild-type (28.11% ± 9.44 vs. 37.87% ± 22.53; p= 0.036). All other tested associations were non-statistically significant.

CONCLUSIONS

Although AhRR methylation did not predict smoking status in BCa tumors, it seems to play a role in carcinogenesis and disease progression. Our findings make a basis for further research.

Prognostic significance of microRNA 17-92 cluster expression in Egyptian chronic lymphocytic leukemia patients

BACKGROUND

Abnormal expression patterns of microRNAs (miRs) play an important role in the development and progression of malignancy. Identification of the clinical significance and prognostic value of these small molecules in chronic lymphocytic leukemia (CLL); a disease of heterogeneous biological landscape and clinical course, has always been of tremendous translational value.

AIM

To evaluate the prognostic value of microRNA17-92 cluster members in Egyptian CLL patients.

METHODS

The expression levels of miR17-92 cluster members were evaluated by qRT-PCR, including miR17, miR18a, miR19a, miR19b-1, miR20a, and miR92a-1. Other investigations included serum LDH, serum β2 microglobulin (β2M), CD38 and ZAP70 expression by flow cytometry, fluorescence in situ hybridization (FISH) for 17p deletion, and imaging studies (computerized tomography (CT) scans of neck, chest, abdomen, and pelvis or PET-CT scans).

RESULTS

Overexpression of all members of the miRNA17-92 cluster was detected in CLL patients compared to controls (p =  < 0.001 for all miRs while p = 0.01 for miR19b-1). A significant positive correlation between Hb and miR17 and a significant negative correlation between Hb and miR19b-1 were observed (p = 0.041, 0.017 respectively). A statistically significant positive correlation between miR19b-1 expression and each of the WBCs and absolute lymphocytic count (ALC) was detected (p = 0.023, 0.022 respectively). Moreover, a statistically significant relation between miR19b-1 expression and advanced Binet stages was also found (p = 0.05). Regarding miR18a, a statistically significant positive correlation with LDH level was found (p = 0.003). We also found a significant positive correlation between miR92a-1 and β2M level (p = 0.005), as well as a significant relation between miR17 and negative CD38 expression (p = 0.034). However, no significant relationships between any of studied miRNA expression levels and 17p deletion or response to treatment were observed. Patients who expressed miR19b-1 were significantly indicated to start therapy at diagnosis (p = 0.05). The overall survival of CLL patients included in our study was 90.2% after 1 year from the time of diagnosis. Patients with high expression of miR19a had better OS than those with low expression (p = 0.04).

CONCLUSIONS

Overexpression of all members of the miR17-92 cluster was detected in Egyptian CLL patients. MiR18a, miR19b-1, and miR92a-1 also have an adverse prognostic value while miR17 can be considered a good prognostic marker. High expression of miR19a is associated with better OS.

Slow N-acetylation as a possible contributor to bladder carcinogenesis

Bladder cancer (BCa) is an exophytic tumor that presents as either noninvasive confined to the mucosa (NMIBC) or invading the detrusor muscle (MIBC), and was recently further subgrouped into molecular subtypes. Arylamines, major BCa environmental and occupational risk factors, are mainly metabolized by the genetically polymorphic N-acetyltransferases 1, NAT1 and NAT2. In this study, we investigated the association between N-acetyltransferases genetic polymorphism and key MIBC and NMIBC tumor biomarkers and subtypes. A cohort of 250 males with histologically confirmed urothelial BCa was identified. Tumors were genotyped for NAT1 and NAT2 using real-time polymerase chain reaction (PCR), and characterized for mutations in TP53, RB1, and FGFR3 by PCR-restriction fragment length polymorphism. Pathology data and patients' smoking status were obtained from medical records. Pearson χ² and Fisher exact tests were used to check for associations and interactions. Results show that NAT1 G⁵⁶⁰ A polymorphism is significantly associated with higher muscle-invasiveness (MIBC vs NMIBC; P = .001), higher tumor grade (high grade vs low grade; P = .011), and higher FGFR3 mutation frequency within the MIBC subgroup (P = .042; .027). NAT2 G⁸⁵⁷ A polymorphism is also found to be significantly associated with higher muscle-invasiveness (MIBC vs NMIBC; P = .041). Our results indicate that slow N-acetylation is a contributor to bladder carcinogenesis and muscle-invasiveness. These findings highlight NAT1 as a biomarker candidate in BCa and a potential target for drug development.

CYP2E1 and NQO1 genotypes and bladder cancer risk in a Lebanese population

Urinary bladder cancer incidence in Lebanon ranks among the highest in the world. Cytochrome P450 2E1 (CYP2E1), NAD(P)H quinone oxidoreductase1 (NQO1), and N-Acetyltransferase1 (NAT1), are drug-metabolizing enzymes (DMEs) involved in the metabolism of carcinogens, such as arylamines and heterocyclic amines, implicated in bladder cancer. The present study attempts to investigate the role of these DMEs genetic polymorphism in bladder cancer risk among Lebanese men. 54 cases and 106 controls were recruited from two hospitals in Beirut. An interview-based questionnaire was administered to assess suspected environmental and occupational risk factors. PCR-RFLP was performed on blood-based DNA samples to determine DMEs genotypes. Associations between bladder cancer and putative risk factors were measured using adjusted odds ratios (ORs) and their 95% confidence intervals (CIs). Results showed CYP2E1 c1/c1, NAT1*14A, and smoking, to be risk factors for bladder cancer. No significant differences in frequency distribution of the NQO1 genotypes were found in cases versus controls. The odds of carrying the CYP2E1 c1/c1 genotype were 4 times higher in cases compared to controls (OR=3.97, 95% CI: 0.48-32.7). The odds of carrying at least one NAT1*14A allele were 14 times higher in cases versus controls (OR=14.4, 95% CI: 1.016-204.9). Our study suggests CYP2E1 c1/c1, NAT1*14A, and smoking, as potential risk factors for bladder cancer in Lebanese. Further studies with larger samples must be conducted to confirm these findings.

Plasma leptin concentration in patients with Type 2 diabetes: relationship to cardiovascular disease risk factors and insulin resistance

AIMS

The aim of this study was to evaluate the relationship of obesity, leptin, insulin resistance and C-reactive protein (CRP) with coronary heart disease (CHD) risk factors in patients with Type 2 diabetes mellitus (DM) with CHD compared with those with Type 2 DM without CHD.

METHODS

Leptin, CRP (high sensitivity assay), fasting plasma insulin, glucose, HbA(1c) and full lipid profile were determined in 58 Type 2 diabetic patients with CHD and 87 Type 2 DM patients without CHD.

RESULTS

were compared between those with and without CHD. Univariate correlation as well as logistic regression analyses were used to relate these markers with traditional CHD risk factors.

RESULTS

Leptin showed significant correlations with BMI (r = 0.59; P < or = 0.0001), waist circumference (r = 0.45; P < 0.0001), CRP (r = 0.36; P < 0.0001), and fasting insulin (r = 0.53; P < 0.0001) as well as with systolic (r = 0.23; P = 0.007) and diastolic (r = 0.23; P = 0.007) blood pressure. However, when those with and without CHD were compared only age (P < 0.0001), duration of diabetes (P < 0.001) and degree of microalbuminuria (P = 0.02) were significantly higher in patients with CHD. Leptin (P = 0.49), CRP (P = 0.19) and lipid parameters were not significantly different between the two groups.

CONCLUSION

Our study confirms a relationship between leptin and CRP with CHD risk factors. The lack of significant difference when patients with and without CHD are compared may be due to the potential confounding effects of treatment with aspirin and statins.

Associations of plasma homocysteine concentration in subjects with type 2 diabetes mellitus

We investigated the potential relationship between hyperhomocysteinemia and the presence of coronary heart disease (CHD) and chronic complications in a consecutive series of 358 (156 men) Kuwaiti type 2 diabetic subjects. The median (2.5(th), 97.5(th) percentiles) fasting plasma concentration of total homocysteine (tHcy) in the patients was 10.2 (5.4, 19.1) micromol/l. Fasting tHcy concentration was significantly (p<0.001) higher among men [11.3 (7.1, 24.6) micromol/l] compared to women [8.8 (5.3, 16.3) micromol/l]. Of the 57 patients with a history of CHD and/or electrocardiographic (ECG) evidence of CHD, 9 (16%) had hyperhomocysteinemia (tHcy > or =15 micromol/l) compared to 8.3% (25 of 301) of patients without evidence of CHD. In univariate analysis, plasma tHcy concentration was significantly (p<0.01) higher in those diabetic subjects with history of CHD and/or abnormal ECG. Although hyperhomocysteinemia was more common in patients with microalbuminuria (15%) compared to patients with normoalbuminuria (12%), there was no significant association between hyperhomocysteinemia and the degree of albuminuria. After controlling for age and sex, multiple regression analyses showed significant associations of plasma tHcy concentration with glycated hemoglobin (p<0.05), plasma concentrations of creatinine (p<0.001) and apolipoprotein-B (p<0.05), but not with smoking, neuropathy or retinopathy. It seems that the association of hyperhomocysteinemia with diabetic microvascular complications is mediated by the confounding effect of other factors like age, sex and plasma creatinine concentration. In conclusion, we have found a univariate association between hyperhomocysteinemia and CHD but not with microalbuminuria, neuropathy and retinopathy. Although routine estimation of plasma homocysteine may be useful, the association with cardiovascular disease or microvascular complications in patients with type 2 DM deserves prospective studies.

Association of C-reactive protein with coronary heart disease risk factors in patients with type 2 diabetes mellitus

The assessment of markers of systemic inflammation, such as C-reactive protein (CRP) and interleukin 6 (IL6), could be used to identify persons at high risk of coronary heart disease (CHD). This study evaluates the relationship of CRP and IL6 with CHD risk factors in patients with type 2 diabetes mellitus (DM) with CHD and age and sex matched type 2 DM controls without CHD. CRP, IL-6, total plasma homocysteine (tHcy), lipoprotein (a) [Lp(a)] and sialic acid (SA) were determined in 55 type 2 diabetic patients with CHD and 51 age- and sex-matched type 2 diabetic controls without CHD. Multivariate and logistic regression analyses were used to relate these markers with CHD risk factors. CRP (P=0.02) and tHcy (P=0.03) were significantly higher in patients with CHD compared with the control group even after correction for age and sex. IL6, Lp(a), SA and lipid parameters were not significantly different between the two groups of patients. After adjustment for potential confounders, the odds ratio (OR) for elevated CRP was 2.00 (95% confidence interval [CI], 1.12-3.58) (P=0.02) but the OR for IL6 was 3.41 95% CI, 0.70-17.17 (P=0.14). Partial correlation analyses of CRP and IL6 with other variables showed significant correlation of CRP with tHcy, and SA in patients with CHD only. Our results support the inclusion of CRP (high-sensitivity assay), in the risk assessment of diabetic subjects.

Serum lipoprotein(a) concentration as a cardiovascular risk factor in Kuwaiti type 2 diabetic patients

Serum lipoprotein(a) [Lp(a)], a risk factor for coronary heart disease (CHD) in some nondiabetic populations, is largely under genetic control and varies among ethnic and racial groups. We evaluated serum Lp(a) concentration and its relationship with traditional CHD risk factors (age, sex, smoking, hypertension, dyslipidemia) as well as stage of diabetic nephropathy in 345 type 2 diabetic patients. Lp(a) concentration was skewed with median (2.5th, 97.5th percentiles) of 25.0 (8.1, 75.7) mg/dl. Twenty-three of 55 (41.8%) patients with CHD had increased (>30 mg/dl) Lp(a) compared with 102 of 290 (35.1%) patients without CHD (P=.35). Twelve of 27 (44.4%) female patients with CHD had increased Lp(a) compared to 11 of 28 (39.3%) males (P=.70). Lp(a) was significantly (P<.05) higher in females than males, but the logistic regression analysis showed significant association of Lp(a), LDL-C, and duration of diabetes mellitus (DM) with CHD in male patients only. Although female patients with CHD and macroalbuminuria had significantly (P<.05) higher Lp(a) than normoalbuminuric female patients without CHD, no such association was found in males and no significant association was found between Lp(a) and the degree of albuminuria. Partial correlation analysis controlling for age, sex, and BMI showed significant correlation of Lp(a) with total cholesterol only (P=.03) and no correlation was found with other lipid parameters. Multiple regression analysis did not show significant associations of Lp(a) with standard CHD risk factors, HbA(1c), and plasma creatinine. This study is in agreement with studies in other populations, which showed that Lp(a) may not be an independent risk factor for CHD in patients with DM. However, as Lp(a) could promote atherogenesis via several mechanisms, follow-up studies in our patients will confirm if increased Lp(a) concentration can partly account for the poorer prognosis when diabetic patients develop CHD.

Recurrent pyelonephritis without vesicoureteral reflux: is there a role for an antireflux procedure?

PURPOSE

To evaluate the results of an endoscopic antireflux procedure in women with recurrent acute pyelonephritis and no evidence of vesicoureteral reflux (VUR) on voiding cystograms.

PATIENTS AND METHODS

From 1989 to 1999, 603 female patients were hospitalized for acute pyelonephritis with unilateral loin pain, chills, fever, and a positive urine culture. Of these patients, 48 (8%) had recurrent episodes of acute pyelonephritis and underwent a thorough diagnostic work-up including intravenous urography or renal CT scan, cystoscopy, and voiding cystourethrography (VCUG). Vesicoureteral reflux was demonstrated in 21 patients, who were then offered an antireflux procedure, either surgical or endoscopic. Another 27 patients had no reflux on VCUG; in 15 cases, the upper urinary tract was normal, and the ureteral orifices did not show any abnormality on cystoscopy. The other 12 patients in this group with a normal VCUG had one or more abnormal findings normally associated with VUR: renal scarring in five and ureteral duplication in two. Golf-hole ureteral orifices were noted in two patients. The intravesical ureter was short (< 5 mm) in five patients. In spite of the normal VCU, we offered these patients endoscopic treatment of VUR by submeatal injection of Teflon or microparticulate silicone (Macroplastic). The median follow-up before treatment was 4 years (range 1-15.3 years); 0.3 episodes of acute pyelonephritis per patient-month of follow-up were noted. The frequence of preoperative and postoperative episodes of acute pyelonephritis was compared with Wilcoxon's paired analysis. The median postoperative follow-up was 3.9 years (range 1.1 months-10.2 years).

RESULTS

There were no significant postoperative complications. One patient had two episodes of acute pyelonephritis during pregnancy. On the whole, 11 patients (91%) were free of recurrent pyelonephritis after treatment. Overall, 0.003 episodes of acute pyelonephritis per patient-month of postoperative follow-up were observed. The result was statistically significant (P < 0.01).

CONCLUSION

Recurrent acute pyelonephritis is frequently related to VUR. Intermittent reflux can be difficult to demonstrate on voiding conventional or nuclear cystograms but can be suspected in the presence of ureteral duplication, renal scarring, or abnormal ureteral orifices. Adult patients with recurrent episodes of upper urinary tract infection and normal cystograms should be considered for an endoscopic antireflux procedure in the presence of anatomic abnormalities commonly associated with reflux.

The status of rubella immunity among pregnant women in Kuwait: screening in childbearing age should be reintroduced

The objective of this study was to investigate the immunity against rubella in the obstetric population in Kuwait by testing 600 pregnant women at a prenatal clinic, using the haemagglutination inhibition technique. In addition, a comparison was made between this study and one done in 1978 at the same clinic; its relation to the vaccination programme is also discussed. 7.7% of the population under study were non-immune. Statistically significant effect was demonstrated for maternal age but not for parity and nationality. Though it has been almost 20 years since an intense rubella vaccination programme was implemented, the percentage of non-immune pregnant women has not decreased. In Kuwait, termination of pregnancy for congenital rubella syndrome is prohibited. As a result, it is recommended that women be screened and vaccinated at the time of marriage.

Apolipoproteins A-I and B in Kuwaiti children

To assess the relation of apolipoproteins (Apos) A-I and B (the carrier proteins for high and low density lipoprotein cholesterol, respectively) with the degree of obesity, body fat distribution, serum lipids, glucose and insulin levels, a case-control study was carried out and included 460 Kuwaiti obese children, 6-13 years old, matched by age and sex to 460 normal-weight controls. Obese children were ascertained in a representative cross-sectional study of 2,400 school children. The Apo A-I levels were not different between obese and non-obese boys, while they were significantly lower in obese girls (p < 0.01). The Apo B mean concentrations were significantly higher in obese boys and girls (p < 0.001), while the Apo A-I:B ratio was significantly lower in obese children (p < 0.001). Apo A-I levels were positively correlated with total cholesterol, high- and low-density lipoprotein cholesterol, but were not correlated with very low-density lipoprotein cholesterol, triglycerides, insulin, glucose or insulin:glucose ratio. Apo B levels were negatively correlated with high-density lipoprotein cholesterol and positively correlated with insulin and insulin:glucose ratio (p < 0.01) in obese children. The study documented an adverse Apo profile in obese Kuwaiti children. Since Apo changes are correctable through management of obesity, their identification in childhood offers prospects for prevention of early onset atherogenesis in adulthood.

Nutritional status of Kuwaiti elementary school children aged 6-10 years: comparison with the NCHS/CDC reference population

The objective of this cross-sectional sampling survey was to assess the nutritional status of Kuwaiti elementary school children aged 6-10 years in comparison with the NCHS/CDC American reference population. The study comprised a multistage stratified random sample of 8957 children (4401 males and 4556 females) which amounts to about 12% of the target population. Weights and heights of children were measured. Obesity was defined as weight-for-height (W/H) 2.00 to 5.00 standard deviation (SD) scores of the reference population. Underweight and short stature were defined as weight-for-height (W/H) and height-for-age (H/A) -4.00 to -2.00 and -5.00 to -2.00 SD scores, respectively. The results of this study showed that obesity was found to be significantly (P < 0.01) higher in males (15.7%) than in females (13.8%). Underweight was found to be almost equally prevalent among both genders (3.7% in males and 3.8% in females). Short stature (H/A) -5.00 to -2.00 SD scores) was found to be 7.1% (9.5% in males and 4.6% in females). When compared with an earlier study, changes in W/H were significant across most of the centile categories. However, significant changes in H/A were noted with less frequency than W/H; mostly in the upper centiles for both genders. More significant changes, however, were noted among males than females. In conclusion, Kuwaiti children were found to be heavier and shorter than American children. Moreover, the children were found to be fatter and slightly taller but nonetheless more nutritionally sound than a decade earlier.

Factors associated with overweight and obesity among Kuwaiti kindergarten children aged 3-5 years

The purpose of the study was to investigate factors associated with overweight and obesity among Kuwaiti children aged 3-5 years. A cross-sectional sample of 3473 pupils (1748 boys and 1725 girls) was selected for the study from kindergartens using a multi-stage random sampling technique. Overweight and obesity were defined as weight-for-height (W/H) > or = 90th-< 95th and > or = 95th centiles of the NCHS/CDC reference population, respectively. Questionnaires were used to obtain information about birth order, parents' education and occupation, family income, number of servants, eating habits, grandparents and number of persons living at home, number of siblings, socioeconomic status (SES), which was based on parents' education and occupation, family income, area of residence and number of servants. Weight and height were measured and the pupils' dental status was assessed. Factors that were found to be significantly associated with overweight and obesity were gender, age, region (governorate), parents' education, birth order, dental status, eating regular meals and SES. Factors that were significantly associated with overweight and obesity males were age, governorate eating regular meals, number of persons living at home and SES. Among females these factors were governorate, dental status, number of servants and SES. The logistic regression analysis showed that the same factors shared by both genders significantly contributed to the development of overweight and obesity except father's education. This study concludes that ecological factors play an important role in the development of overweight and obesity, especially those related to affluence; Kuwait has been undergoing modernization and increasing affluence and changes to sedentary lifestyle and increased food consumption may have contributed to changes in overweight and obesity among the children.

Placenta accreta in Kuwait: does a discrepancy exist between fundal and praevia accreta?

OBJECTIVE

The purpose of this retrospective study was to compare maternal and neonatal outcome in relation to site of placenta accreta by stratifying the site of placenta accreta into upper and lower uterine segment implantation.

SUBJECTS AND METHODS

Sixteen cases of placenta accreta which were reported in the Maternity Hospital of Kuwait over 11 years from January 1981 to July 1993 - (1990 and 1991 excluded) were retrospectively analyzed using the hospital medical records.

RESULTS

The incidence of placenta accreta was 9.8 per 100,000 deliveries. The rate of accreta in patients with placenta praevia was 880 per 100,000 placenta praevia, compared to a rate of 5 accreta per 100,000 placenta implanting in the upper uterine segment. There were no differences between accreta found in the upper segment and lower segment for maternal and neonatal mortality, maternal complication, past obstetric history and possibility of conserving the uterus. Significant differences were found in the birth weight, gestational age at birth, antenatal symptoms, time of diagnosis and mode of delivery when accreta was stratified by site of implantation.

CONCLUSION

Placenta praevia is a definite risk factor for placenta accreta. Combined abnormal penetration of placenta as in accreta and abnormality in site as in praevia does have a significant clinical implications.

Trisomy 18 in Kuwait

BACKGROUND

Trisomy 18 (Edwards' syndrome, T18) is the second most common trisomy in man. We describe 118 children with regular T18 who were ascertained clinically and cytogenetically in the Kuwait Medical Genetics Centre during 1980-1997.

METHODS

Ascertainment of T18 cases was performed shortly after birth. Chromosomal studies were carried out in addition to other relevant investigations. To investigate the factors associated with T18, a case-control study was carried out with 131 normal healthy newborns. Studied factors included maternal and paternal age, birth order, abortion, associated malformation, and survival. Multiple logistic regression analysis was used to adjust for confounding between variables.

RESULTS

There was a preponderance of females among T18 cases (female:male ratio 2.1:1). The majority of T18 cases (53%) died before the second week of life. The most common associated anomalies were: congenital heart (38.1%) and gastrointestinal (25.4%). Multiplicity of malformations was also observed. Significant seasonal variation in T18 cases was detected with a peak in spring. Of the 118 T18 cases, 59 were delivered during 1994-1997 (average overall T18 birth prevalence rate 8.95 per 10 000 live births [95% CI: 6.66-11.23]). Concerning maternal age, 30.5% of the T18 cases' mothers were > or =35 years compared to 10.7% in the control group. The difference was statistically significant, P = 0.002. Logistic regression analysis showed that maternal age >30 years was a significant risk factor for T18, after adjusting for confounding with paternal age. Paternal age and abortion were not found to be significant risk factors.

CONCLUSION

Trisomy 18 birth prevalence rate is high in Kuwait with advanced maternal age as a significant risk factor.

Clustering of trisomy 18 in Kuwait: Genetic predisposition or environmental?

BACKGROUND

This study describes 59 newborns with regular trisomy 18 (EdwardsA centAA syndrome, T18) who were ascertained clinically and cytogenetically at the Kuwait Medical Genetic Centre from 1994 to 1997, out of 118 T18 cases identified from 1980 to 1997.

MATERIALS AND METHODS

T18 cases were ascertained clinically and cytogenetically shortly after birth. In addition to assessing the T18 birth prevalence rate and confidence limits during the years 1994-1997, we investigated the possible etiological factors by a case-control study with normal healthy newborns. Studied factors included gender, parental age, birth order, abortion, clinical variables (presentation, amniotic fluid and mode of delivery), and survival.

RESULTS

The average T18 birth prevalence rate during the period was 8.95 per 10,000 live births (95% confidence limits 6.66-11.23). The T18 cases were mostly females, with a male:female ratio of 1:2.1, and the majority (53%) died before the second week of life. Maternal age above 30 years was found to be a significant factor for T18.

CONCLUSION

This high T18 birth prevalence rate suggests clustering of T18 in the highly inbred population of Kuwait. Such clustering may indicate a possible environmental, and to a lesser extent, genetic predisposition to aneuploidy nondisjunction.

Knowledge, attitudes, beliefs, and practices about HIV/AIDS in Kuwait

This survey is aimed at assessing knowledge, attitudes, beliefs and practices in Kuwait regarding AIDS/HIV. Structured face-to-face interviews were conducted during the year 1995 on a sample of 2,219 subjects, aged 18 to 60, health professionals were excluded. The survey instrument included 26 questions on AIDS/HIV knowledge, 6 about attitudes and beliefs, and 6 about behavior and practice. The remaining 22 items dealt with sociodemographic characteristics, role of religion, source of information, and satisfaction about AIDS control programs. Two thirds of subjects had good knowledge about the main modes of HIV/AIDS transmission. Using a multiple regression model, the knowledge score was positively associated with level of education, age, years of hearing about AIDS, and socioeconomic status. The multiple logistic regression showed that subjects tend not to change their behavior related to AIDS if they were less than 40 years old, had low education, were females, single, had a lower socioeconomic status, had heard about AIDS for less than 3 years, and had a low level of knowledge about AIDS. More than half of the participants were satisfied with the government's action for AIDS prevention. The majority of subjects thought that religion was important in dealing with daily life problems. In conclusion, while most of the people in Kuwait were aware of the main modes of AIDS transmission, a gap existed about modes that did not transmit the disease. This was reflected in their attitudes and practice toward AIDS patients. The study calls for a greater role for medical professionals, mass media, and religion in AIDS prevention and control.

Factors associated with obesity in Kuwaiti children

The prevalence of adult obesity in Kuwait is among the highest in the Arab peninsula, and cardiovascular disease, for which obesity is a risk factor, is the leading cause of death. This study reports familial and environmental factors associated with childhood obesity; in addition to adverse effects of obesity on children's serum lipids, lipoproteins, apolipoproteins, insulin, and blood pressure profiles. The authors carried out a pair-matched case-control study including 460 obese (body mass index >90th percentile of the age/sex specific reference value of the National Center for Health Statistics), school children 6 to 13 years old matched by age and gender to 460 normal weight controls. We ascertained obese children in a cross-sectional survey of a representative sample of 2400 school children selected from 20 schools by multistage stratified random sampling. Biochemical variables and blood pressure were adversely affected in obese children. The conditional logistic regression analysis showed that family history of obesity, and diabetes mellitus, respiratory and bone diseases in child were significant associated factors with obesity after adjusting for social and behavioural factors. Physical activity and parental social class were not significant. We recommend early preventive measures with emphasis on families in which one or both parents are overweight.

Obesity among Kuwaiti pre-school children aged 0-5 years: prevalence and comparison with the NCHS/CDC reference population

The purpose of the study was to assess the level of obesity among Kuwaiti pre-school children aged 0-5 years, and compare their nutritional status with the NCHS/CDC reference population. A Cross-sectional multi-stage stratified random sample of 7419 Kuwaiti children (3749 boys and 3670 girls), representing over 5% of the population at studied age was used for the study. Children below 42 months were randomly selected from five maternal and child health clinics, one from each of the five local authority areas of Kuwait. Children 42 months and above were selected from 24 kindergartens, proportionally from the 5 local authority areas. Weights and heights of children were measured. Obesity was defined as weight-for-height (W/H) 2.00 to 5.00 standard deviation (SD) scores of the NCHS/CDC reference population. Underweight and short stature were defined as W/H and height-for-age (H/A) -4.00 to -2.00 SD scores, respectively. Obesity among Kuwaiti pre-school children was found to be 8.2% (7.5% in males and 9.0% in females). Underweight was found to be almost similarly distributed among both genders (4.2% in males and 4.1% in females). Short stature was found to be 5.8% (6.1% in males and 5.6% in females). Kuwaiti pre-school children aged 0-5 years were, for the most part, found to be slightly heavier and shorter than American children of the reference population. The children were also found to be heavier and taller than a decade ago. The nutritional status of the children improved during the last ten years.

Validation of the Arabic version of the Health Assessment Questionnaire (HAQ) in patients with rheumatoid arthritis

Several instruments for measuring functional status in rheumatic diseases have been developed and validated. However, none is as yet available in Arabic.

OBJECTIVE

To translate the Health Assessment Questionnaire (HAQ) from English to Arabic and to test the metrological properties, reliability, and validity of the Arabic version.

METHODS

The study included 41 consecutive patients seen at the outpatient rheumatology clinic of a large teaching hospital in Kuwait for rheumatoid arthritis meeting 1987 American College of Rheumatology criteria. The HAQ was translated from English to Arabic by three translators who were aware of the intended use of the questionnaire. The translated questionnaire was administered to each patient during two clinic visits seven to ten days apart. Test-retest reliability was assessed based on the intraclass correlation coefficient. Internal consistency of individual items with the overall score was assessed using Cronbach's alpha coefficient. Construct validity was evaluated by determining Spearman's correlation between the Arabic HAQ score and disease activity variables.

RESULTS

There were 34 women and seven men, with a median age of 38 years and a median disease duration of 5.3 years. Test-retest reliability was 0.81, internal consistency was 0.93, and construct validity ranged from 0.5 (erythrocyte sedimentation rate) to 0.75 (pain).

CONCLUSION

The HAQ-A retains the characteristics of the original American version, and is a reliable and valid instrument for measuring functional disability in Arabic-speaking patients with rheumatoid arthritis.

Obstetric and gynecologic implication of brucellosis in Kuwait

OBJECTIVE

To study the possible correlation between maternal Brucella infection and reproductive failure as expressed by abortion, intrauterine fetal death, and preterm delivery.

STUDY DESIGN

Maternal enzyme-linked immunosorbent assay serologic and microagglutination testing and conception product culture for Brucella were done in 227 women with preterm delivery, 51 with intrauterine fetal death, 29 with spontaneous abortion, and 39 with term delivery of a normal baby.

RESULTS

Ingestion of raw milk was positive in 18% of the control cases, 28% of preterm delivery cases, 30% of intrauterine fetal death cases, and 21% of spontaneous abortion cases. Acute or chronic Brucella infection was found in 8% of preterm, 10% of intrauterine fetal death, and 7% of abortion cases. None of the control cases had evidence of Brucella infection. None of the four groups showed positive culture of the placenta for Brucella. The titres of Brucella-specific immunoglobulin G and M were significantly higher in the preterm, abortion, and intrauterine fetal death groups than in the control group.

CONCLUSION

A possible correlation may exist between Brucella infection and preterm and intrauterine fetal death, which does not seem to be related to transplacental infection but possibly may relate to the acute illness.

Association of fasting insulin with serum lipids and blood pressure in Kuwaiti children

To examine the association of hyperinsulinemia with the atherogenic risk profile in children, we studied the relationships of the fasting plasma insulin level with indices of obesity (body mass index [BMI] and sum of triceps and subscapular skinfold thickness [SFT]), body fat distribution (waist to hip ratio [WHR]), serum lipid, lipoprotein, and apolipoprotein levels, and blood pressure in a case-control study of 460 Kuwaiti prepubertal obese children aged 6 to 13 years matched by age and sex to 460 prepubertal non-obese controls. Obese children were ascertained in a representative cross-sectional study of 2,400 school children. Fasting insulin levels were positively correlated (P < .001) with serum triglyceride (TG) and very-low-density lipoprotein (VLDL) cholesterol levels and negatively correlated with high-density lipoprotein (HDL) cholesterol levels. No significant associations were observed between insulin and total cholesterol (TC), cholesterol, low-density lipoprotein (LDL) or apolipoprotein A-I (apo A-I). Stronger associations of insulin levels with lipoprotein fractions were observed in obese versus non-obese controls. Obese children had a higher concentration of apo B and a lower apo A-I:B ratio (P < .001). Insulin and the insulin to glucose ratio increased with age in obese children, whereas there were slight changes in non-obese children. TG and HDL cholesterol levels and systolic blood pressure (SBP) were significantly different across insulin quartiles in boys and girls. We conclude that the fasting plasma insulin level may be used as a marker for the development of obesity-associated metabolic disorders and elevated blood pressure in children.

Incidence and severity of ketoacidosis in childhood-onset diabetes in Kuwait. Kuwait Diabetes Study Group

In 1992, the diabetes registry was started in Kuwait, as part of DiaMond, a WHO multinational collaborative project on the incidence of childhood-onset diabetes. Children (243) aged below 15 years, were identified between 1 January 1992 and 31 December 1995. Children (203) were Kuwaiti and 40 were non-Kuwaiti children but resident of Kuwait. For the years 1992, 1993, the annual incidence of childhood onset diabetes for Kuwaiti children was 15.4 per 100,000 (95% confidence interval 12.9-19), and the degree of ascertainment was 92%. Polyuria, polydypsia, weight loss and nocturia were the most frequently reported symptoms; four children were in coma and one in shock at presentation. Nearly half of the children (49%) presented ketoacidosis (venous pH < 7.3 and/or plasma bicarbonate level < 18 mmol/l). and in 53 children (23.5%) it was severe (venous pH < 7.1 and/or plasma bicarbonate level < 10 mmol/l). In 62 children (25.5%) it was mild to moderate (venous pH 7.1-7.3 and/or plasma bicarbonate level 10.1-18 mmol/l). The incidence of severe ketoacidosis was similar in all age groups and sexes. All children recovered completely without major complications and no deaths were recorded. We conclude that diabetic ketoacidosis is a common presentation at the onset of diabetes in childhood in Kuwait and attests to the lack of awareness of general practitioners and parents to the symptoms and signs of diabetes in childhood.

Factors associated with asthma in school children

To investigate the factors associated with asthma in school children, a case-control study of 203 asthmatic and 203 non-asthmatic children (103 males and 100 females in each group) aged 6 to 18 years, was organized during the period September 1992 to May 1993 in Al Ain city, United Arab Emirates. Cases comprised known asthmatic children who were regularly receiving medication for asthma and were confirmed as asthmatics by a physician. Cases and controls were matched by age and sex. A questionnaire was used to obtain information about respiratory illnesses (pneumonia, bronchitis, bronchiolitis, sinusitis and croup); atopy (allergic rhinitis and atopic dermatitis) and familial allergic diseases (parental asthma and atopy). Information about socioeconomic status and limitations to children as a result of asthma were also obtained. Logistic regression analysis showed that bronchitis, atopy (allergic rhinitis and atopic dermatitis), croup, parental asthma and parental atopic dermatitis were significant risk factors for childhood asthma after adjusting for other confounding covariates. The model also showed that parental asthma (p < 0.0001) is much more influential than parental atopic dermatitis (p = 0.01) as a risk factor for asthma. Although pneumonia and sinusitis were significant risk factors when analyzed univariately, they were not significant after adjusting for other covariates. Bronchiolitis, smoking and socioeconomic status were beyond the reach of statistical significance as risk factors to asthma in our sample.

Post-war changes in the outcome of pregnancy in Maternity Hospital, Kuwait

To analyse the pre- and post-Gulf War changes in the outcome of pregnancy and to explore the possible causes that could have affected these changes, a retrospective analysis of medical records of patients delivering in Maternity Hospital Kuwait (MHK) was carried out for the period 1987-89 (pre-Gulf-War) and 1992 (post-Gulf War). The records of 1991 were used when adequate information was available. The normal z test was used to assess the significance between two proportions. There is a significant rise in abortion, low birth weight babies, triplet pregnancies, and major congenital anomalies in the post-war period. The still-birth rate, early neonatal mortality rate and perinatal mortality rate significantly increased in the immediate post-war period in 1991, but decreased to levels below the pre-war period in 1992. It should be investigated whether these changes are secondary to the changes in the population structure; the effects of war in terms of deterioration of health care services; environmental pollution caused by oil well fires, oil spills; or the psychological trauma, anxiety and stress caused by the Iraqi invasion of Kuwait.

Noise-induced hearing loss, nationality, and blood pressure

Noise exposure has been associated with increased catecholamine production and blood pressure elevation in laboratory studies and in human volunteers. Epidemiologic studies have given conflicting results. In order to determine whether noise-induced hearing loss predicts a rise in blood pressure, we reviewed occupational medicine records in an occupational health center serving three companies where noise exposure is commonly found. Height, weight, blood pressure, and screening audiometry are obtained as part of routine occupational health screening, and the results of the screening visit are abstracted from written clinical records. The results of pure tone screening audiometry are reported in nonstandardized fashion (Normal, WNL, NAD, for example, for normal). We reviewed records from 1990 and 1991 inclusive. One investigator, blind to blood pressure status, assigned each record to "no hearing loss," "not codable," or "hearing loss assumed to be due to noise" on the basis of the written audiometry report. Hearing loss due to causes other than noise was considered not codable. No attempt was made to quantify severity of hearing loss. Two hundred and sixteen charts were excluded as "not codable," 1,535 were classified as having no hearing loss, and 610 had some degree of hearing loss, most probably due to noise exposure. To adjust for confounding covariates, multiple regression analysis was used and indicated that hearing status improves the regression model for predicting diastolic blood pressure (p = 0.04), following age, nationality, body mass index (BMI), and month of testing, although the effect is small. Stratification by age and BMI revealed increased diastolic pressure in the group with hearing loss under age 45, regardless of obesity.(ABSTRACT TRUNCATED AT 250 WORDS)

The outcome of placenta accreta in Kuwait (1981-1993)

OBJECTIVES

To study the demographic characteristics of patients with placenta accreta and to identify the clinical features, maternal and neonatal complications of this condition.

METHODS

Sixteen cases of placenta accreta were identified in the Maternity Hospital of Kuwait during the period January 1981 to July 1993. Medical records were reviewed regarding past obstetric history, type of placenta, clinical presentation, maternal and fetal outcome.

RESULTS

The rate of placenta accreta was found to be 98 per 1,000,000 deliveries. Emergency hysterectomy was needed in 87.5% of cases. There was one maternal death (6.25%) and three perinatal deaths (18.75%). Hemorrhage was the major presenting symptom either externally and antenatally in previa accreta or postpartum in accreta of the upper segment or internally in the same cases. The major postoperative complications were coagulopathy, urinary injury, pelvic hematoma and abscess, in addition to cardiac arrest. These complications, when considered separately, were not affected by a previous history of uterine scarring.

CONCLUSIONS

Placenta accreta is a major cause of obstetric hemorrhage and has an adverse effect on maternal and neonatal outcome. It ought to be considered a possibility in patients with previous uterine scarring, placenta previa or retained placenta. It will remain a growing problem in the developing countries due to the rising incidence of previous multiple cesarean sections. Unfortunately the latter do not deter women in this part of the world from insisting upon having big families and refusing tubal ligation.

High incidence of childhood-onset IDDM in Kuwait. Kuwait Study Group of Diabetes in Childhood

OBJECTIVE

To determine the incidence of insulin-dependent diabetes mellitus (IDDM) in children aged 0-14 years in Kuwait, as part of the World Health Organization Multinational Collaborative Study (DIAMOND), and to determine if the incidence rates have increased.

RESEARCH DESIGN AND METHODS

All cases of IDDM diagnosed before the child's 15th birthday between 1 January 1992 and 31 December 1993 were recorded. Prospective notification of all children with newly diagnosed diabetes who were admitted to hospitals and periodic review of hospital medical records provided the primary source; notification by physicians working in diabetic clinics, in which registry of all new cases is mandatory, provided the secondary source of ascertainment.

RESULTS

The degree of ascertainment was 92.2%. The annual incidence of IDDM for children aged 0-14 years over the 2-year period was 15.4/100,000 (95% confidence interval, 12.4-19), with a male:female ratio of 1.2:1. The age-specific annual incidence rates for the age-groups 0-4, 5-9, and 10-14 years were 12.8, 15.1, and 18.3/100,000, respectively, with a male:female ratio of 1.45:1 in the 0- to 4-year-old age-group and an equal sex ratio in the 5- to 9- and 10- to 14-year-old age-groups. No significant difference was detected between incidence rates of IDDM in boys and girls in the three age-groups. There was no significant linear trend toward an increase in IDDM incidence rates as age advanced. Compared with a previous study by Taha et al. (Taha T, Moussa M, Rashed A, Fenech F: Diabetes mellitus in Kuwait: incidence in the first 29 years of life. Diabetologia 25:306-308, 1983), there was a nearly fourfold increase of IDDM in the age-group 0-14 years, mainly in those children < 5 years old, suggesting a rapid increase in a short period of time.

CONCLUSIONS

Kuwait has the highest incidence of IDDM in children in the region, and an apparently increasing incidence has been demonstrated over the last decade.

Contribution of body fat and fat pattern to blood pressure level in school children

OBJECTIVE

The study aims are investigating the effect of body fat and fat localization on blood pressure.

DESIGN

Case-control study.

SETTING

The study was carried out in the school health primary care.

SUBJECTS

The case-control study included 220 obese and 220 non-obese children aged 7-18 years from Al Ain city, United Arab Emirates between September 1992 to May 1993 inclusive. Each group consisted of 120 males and 100 females. Two schools were randomly selected from each of the three educational stages: primary, junior and secondary. The inclusion criterion for cases comprised children with body mass index (BMI; Quetelet index), > 90th percentile of age and sex-specific reference data of the French population. Non-obese healthy controls were randomly selected from the same classes from where obese children were identified in order to ascertain that cases and controls were matched by age and sex.

MEASUREMENTS

Anthropometric measures (weight, height, waist and hip circumferences), systolic and diastolic blood pressure were measured. To minimize inter-observer error, blood pressure was measured by one physician. We also collected information about other confounding social variables (family history of obesity and mother's education) and behavioural variables (preferred diet and physical activity).

RESULTS

There was significant difference of systolic and diastolic blood pressure means between obese and non-obese children (P < 0.001) in both males and females. Applying the multiple linear regression analysis to fix the confounding effect of age, sex, social and behavioural factors, the fatness index, BMI, was significantly related to systolic (P < 0.0004) and diastolic (P < 0.0001); while waist-to-hip circumference ratio (WHR) was not significant (P = 0.803 in systolic and P = 0.648 in diastolic blood pressure respectively).

CONCLUSIONS

Systolic and diastolic blood pressure showed a positive relationship with the fatness index BMI, but not with WHR, in both boys and girls. This is an evidence that WHR may not be a reliable indicator of body fat distribution in children.

Factors associated with obesity in school children

To investigate factors associated with the development of obesity in school children, the authors undertook a case-control study of 220 obese and 220 non-obese children aged 6 to 18 years from Al Ain, United Arab Emirates between September 1992 to May 1993 inclusive. The inclusion criterion for cases comprised children with body mass (Quetelet index) > 90th percentile of age-sex reference data of the French population. Questionnaires were used to obtain information about socioeconomic status (SES), family history of obesity, related diseases and behavioral factors (smoking, physical activity and preferred diet). Anthropometric measures (weight, height, waist and hip circumferences), systolic and diastolic blood pressure were measured. The waist/hip circumference ratio was used as an index for body fat distribution. The logistic regression analysis showed that family history of obesity, diet, physical activity and mother education were significant factors for development of obesity after adjusting for other confounding covariates. Neither smoking nor SES showed apparent relation to obesity. Both systolic and diastolic blood pressure showed stronger correlation with the fatness index, BMI, than with the fat distribution index, waist/hip ratio.

The standard physical growth chart for Saudi Arabian preschool children

This study presents growth charts of preschool based on cross-sectional data of the population in Riyadh, Saudi Arabia. Charts on weights and heights per age were designed separately for boys and girls. Boys consistently weighed more than girls for this age group at every age. Also, the boys were taller than the girls after the age of one year. Since the growth deficits in children from Saudi Arabia compared with internationally recommended reference populations may be attributed to genetic and environmental factors, the charts presented will suffice as a standard in monitoring the growth of Saudi children in particular and those in the Gulf region in general.

Bioassay from two parabolas

The paper deals with potency ratio estimation of parallel curve analytic dilution assays in case log dose-response relationship could be reasonably described by a parabola. It comprises: (1) testing the adequacy and validity of the quadratic model by the analysis of variance; and (2) estimation of the relative potency of an unknown in relation to a standard preparation, its standard deviation and fiducial limits for its true value. The method is applicable whenever successive doses of an unknown are a constant multiple of a standard in randomized blocks or completely randomized design. The method can be generalized to polynomial models of higher order.

Nonparametric estimation of potency ratio for dilution assays

The paper considers the estimation of the potency of an unknown test preparation in relation to a standard in a dilution assay. The method utilizes the Mantel-Haenszel one degree of freedom chi-square approach to test consistency of the observed potency ratio with a range of alternative potency ratios. The method is nonparametric as it does not require any distributional assumptions. However, it requires the doses employed to be equally spaced logarithmically. The dose-response curve is also required to be monotone over the dose range used.

Analysis of underlying and multiple-cause mortality data

"A variety of life table models were used for the analysis of the (1984-86) Kuwaiti cause-specific mortality data. These models comprised total mortality, multiple-decrement, cause-elimination, cause-delay and disease dependency. The models were illustrated by application to a set of four chronic diseases: hypertensive, ischaemic heart, cerebrovascular and diabetes mellitus. The life table methods quantify the relative weights of different diseases as hazards to mortality after adjustment for other causes. They can also evaluate the extent of dependency between underlying cause of death and other causes mentioned on [the] death certificate using an extended underlying-cause model." (SUMMARY IN FRE AND ITA)

Planning the size of clinical trials with allowance for patient noncompliance

Various approaches are considered for adjustment of clinical trial size for patient noncompliance. Such approaches either model the effect of noncompliance through comparison of two survival distributions or two simple proportions. Models that allow for variation of noncompliance and event rates between time intervals are also considered. The approach that models the noncompliance adjustment on the basis of survival functions is conservative and hence requires larger sample size. The model to be selected for noncompliance adjustment depends upon available estimates of noncompliance and event rate patterns.

Reliability of death certificate diagnoses

Consistency between death certificates and clinical records from 5 general hospitals in Kuwait was studied for 470 deaths with the following underlying or associated causes: hypertensive (HYP), ischaemic heart diseases (IHD), cerebrovascular diseases (CVD) and diabetes mellitus (DM). Direct causes were not considered since they are of little interest analytically. Only deaths with definite or most probable ascertainment were included. One cardiologist, who was provided with the WHO criteria and relevant documents on death certification, independently reviewed the records. To test the reviewer's bias and the reliability of his judgement, an adjudication process was effected by having one senior cardiologist re-review a random subsample of 140 records. The two reviewers showed good agreement. Specific diagnoses criteria for deciding the underlying cause of death in multiple morbid conditions by the reviewer were followed. Due to possible reviewer bias, we aimed at measuring the difference between initial certifiers and the reviewer rather than measuring the diagnostic accuracy of initial certifiers in reference to the reviewer. The agreement index kappa showed poor agreement between original and revised certificates. The original certificates under-estimated CVD as an underlying cause of death by 69.2%, DM by 60%, IHD by 33.5% and HYP by 31.8% in our sample. Associated causes were also consistently under-estimated by initial certifiers as compared with the reviewer. This bias calls for basing mortality statistics in Kuwait on hospital death committees' reports rather than on initial certifier death certificates, use of multiple-causes of death instead of one underlying cause and adequate training of the medical profession on the value and process of death certification.

Term infant asphyxia in Kuwait

In the developing nation of Kuwait, we undertook a case-control study of 43 consecutively born, asphyxiated, term infants. The asphyxia incidence of 9.4/1000 was only slightly higher than that in more developed countries. Severe morbidity occurred in 1.1/1000, and mortality in 1.1/1000. We found significant associations between asphyxia and primiparity, maternal hypertension, consanguinity, increased length of labour, and instrumental deliveries. Maternal age, socio-economic class, maternal illnesses other than diabetes, and breech delivery did not seem to play a role. The fact that the chosen method of delivery failed for a number of the asphyxiated patients, necessitating emergency Caesarian section, suggests that obstetric factors may need closer analysis.

Exact, conditional, and predictive power in planning clinical trials

It is shown how the predictive power, which takes account of prior clinical opinion about treatment differences, can be extended to group sequential designs based on a range rather than point of equivalence. It is found that such design when averaged over the whole prior distribution seems to be most conservative in terms of probability of firm conclusion followed by the nonzero null hypothesis design. Planning a trial based on calculations of the "exact" power or zero null hypothesis design may result in a practically unacceptable probability of firm conclusion.

Vitamin-D-deficiency rickets in Kuwait: the prevalence of a preventable disease

Two hundred and fifty children with clinical, biochemical and radiological evidence of vitamin-D-deficiency rickets were studied over a period of 5 years. Their ages ranged from 1 month to 2 years. Breastfed infants formed 63% of total cases. Intramuscular therapy with vitamin D in a dose of 600,000 IU, deep intramuscular, proved to be safe and effective. In contrast, oral vitamin D did not provide such satisfactory results, presumably owing to poor patient/parental compliance. This report reveals that vitamin-D-deficieny rickets is common in Kuwait in spite of abundant sunlight all through the year because children are wrapped up and kept indoors. Insufficient intake of vitamin D is another important factor in the pathogenesis of vitamin-D-deficiency rickets in Kuwait.

Efficacy of zona-free hamster egg sperm penetration assay as a predictor of in vitro fertilization

The efficacy of the zona-free hamster egg sperm penetration assay (SPA) as a predictor of in vitro fertilization (IVF) is studied. Indications for IVF were tubal factors in 35 couples and male factors in 24 couples. The diagnostic characteristics of SPA in reference to IVF for the whole group (n = 59) were reasonably reliable. Sensitivity was 74%, specificity was 84%, and diagnostic accuracy was 81%. However in patients with male factors, SPA was less reliable in terms of sensitivity (70%), specificity (57%), and diagnostic accuracy (63%), than in patients with tubal factors where the indicators were 80%, 97%, and 94%, respectively. Semen from patients with male infertility shared notable variations in terms of sperm density and motility which may account for the low SPA predictivity. SPA seems to be a useful screening test for prediction of IVF outcome. However other semen variables should be considered before interpretation, especially in male infertility where the diagnostic accuracy is low.

The profile of parasucide repeaters in Kuwait

A one-year cohort of 92 parasuicides was followed up at 6 monthly intervals for a period of 2 years since their index parasuicide to study the outcome and evaluate the level of social readjustment. One male patient died of suicide (1.1%) and 18 (19.6%) individuals repeated parasuicide using self-poisoning. The rate of repeated parasuicidal behaviour in this investigation was considerably higher than that reported in comparable studies from developing countries but similar to that from a number of western European cities. The data indicated that the probability of further episodes of parasuicidal behaviour increased in the few months after the index episode. Although the repeaters and non-repeaters were essentially similar in most of their sociodemographic characteristics, the former were a distinctive group in many respects. The factors found to be significantly associated with subsequent parasuicide included self-poisoning by prescribed drugs at the index parasuicide, previous parasuicidal behaviour prior to the index, occupational status of a housewife, past history of depression and/or dependence and precipitating life events in the family environment. Contrary to our hypothesized theory, none of the types of attitudes received by the patients from their family members at the index parasuicide related to outcome. The global level of social readjustment of non-repeaters was about three times higher than that of repeaters of parasuicide. The implications of these findings for future policy making were discussed with respect to prevention of parasuicide.

Plasma dopamine beta-hydroxylase: rapid diagnostic test for recurrent hereditary polyserositis

The diagnosis of recurrent hereditary polyserositis (RHP; also known as familial Mediterranean fever) remains one of exclusion since there has been no specific diagnostic laboratory test. A previous study suggested that the disorder is related to abnormal catecholamine metabolism. Plasma dopamine beta-hydroxylase (DBH) activity was assayed spectrophotometrically in 91 RHP patients and 162 controls. The activity was significantly higher in untreated symptom-free patients and in patients with acute attacks, than in controls (mean [SEM] 155.8 [14.1] vs 43.3 [1.9] mumol/min/1 p less than 0.0001). Colchicine treatment reduced DBH activity to control levels. The test showed a high diagnostic accuracy and specificity for RHP, whether the patient was symptom-free or having an acute attack. Moreover, it is easy to carry out.

Planning the size of survival time clinical trials with allowance for stratification

Approximate allocation designs for comparing two survival distributions are considered and compared with the exact solution. The influence of incorporating covariates by stratification, accrual and follow-up duration on trial size and power is investigated. The Bernstein and Lagakos design is suited for exponential survival due to its generality and allowance for stratification while the Freedman design is convenient for distribution-free survival in view of its simplicity. With other specifications fixed, the saving in sample size becomes minimal as the accrual period or post-accrual follow-up time units expand above three. Required sample size also increases dramatically when the number of strata exceeds three.

Postpartum glycated hemoglobin A1c and glucose tolerance test in mothers of large babies

An attempt to study macrosomia and carbohydrate metabolism was made by determination of glycated hemoglobin A1c and by the oral glucose tolerance test (OGTT) in early puerperium. We studied 76 women who gave birth to large babies greater than or equal to 4.5 kg, 74 women whose babies were 3-4 kg as controls, and 36 type II diabetics. The median of HbA1c concentration in the diabetics (8.06%) was significantly higher than in the controls (6.49%), and the large babies' mothers (6.48%), P less than 0.001. No significant difference was found between HbA1c or glucose intolerance in mothers of large babies and mothers with average size babies. HbA1c showed an association with glucose levels in the diabetics and controls, P less than 0.001, but not in the large baby group. Mothers of large babies were as old and obese as the diabetics. We speculate that the relationship of postpartum GTT, HbA1c and gestational diabetes is unwarranted.

Sperm chromatin heterogeneity as an infertility factor

Semen samples from husbands with a history of unexplained infertility (n = 33), of women with habitual abortion (n = 36), or normal fertile donors (n = 20) were subjected to conventional semen analysis (SA), Acridine orange test (AOT), and zona-free hamster egg penetration test (HEPT). The three tests operate independently. The most discriminatory test was AOT (p = 0.0001) followed by HEPT (p = 0.019). The frequency of sperm chromatin heterogeneity as detected by AOT red fluorescence was highest in habitual abortion (39.4%), followed by unexplained infertility (16.4%), and, last, donors (9.4%). However the percentage of penetration was highest in habitual abortion (50.7%), followed by donors (43.1%), and least in unexplained infertility (33.9%). Conventional semen parameters (sperm density, motility, abnormality, and vitality) were the least to discriminate between the three groups. The presence of abnormal sperm chromatin may lead to infertility as a result of early pregnancy loss.