[Elaboration and validation of an index for preeclampsia diagnosis]

OBJECTIVE

To build a consistent and valid preeclampsia diagnosis index (IDP) for its Spanish acronyms.

PATIENTS AND METHOD

The study was done in a Gyneco-Obstetrics Hospital and a Family Medicine Unit from March 2000 to February 2001. Fifty items were chosen from the literature, with a design to validate diagnostic tests, which were assessed by family doctors and gyneco-obstetricians in regard to their appearance and content validity. Concurrent criterion validity. Golden standard: Two gyneco-obstetricians diagnosed pre-eclampsia (hypertension and proteinuria). Simultaneously a family doctor (in an independent and blinded way) questioned, examined and recorded laboratory data of 219 preeclamptic patients and 251 non preeclamptic patients.

RESULTS

Preeclampsia diagnosis index is an additive index with 21 clinical and paraclinical parameters weighted according to their individual diagnostic capacity. It has two parts: The first one with 82% (95%CI 80-84) sensitivity; 93% (95%CI 91-95) specificity; the second one with 86% (95%CI 83-89) sensitivity; 75% (95%CI 65-85) specificity.

CONCLUSIONS

Preeclampsia diagnosis index is easily applied and has immediate results, which makes easier the physician's decisions.

Management of adnexal mass

OBJECTIVES

To assess diagnostic strategies for distinguishing benign from malignant adnexal masses.

DATA SOURCES

MEDLINE(R) and reference lists of recent reviews; discharge data from the Nationwide Inpatient Sample.

REVIEW METHODS

The major diagnostic methods evaluated were bimanual pelvic examination, ultrasound (morphology and Doppler velocimetry), MRI, CT, FDG-PET, CA-125, and scoring systems that incorporated multiple clinical, laboratory, and radiologic findings. Meta-analysis using a random-effects model was used to estimate pooled sensitivity and specificity for discriminating benign from malignant. We reviewed evidence for followup strategies for masses considered benign, and for adverse outcomes of diagnostic surgery. We also reviewed published models of the natural history of ovarian cancer and compared the impact of assumptions about natural history on outcomes.

RESULTS

The majority of studies did not describe whether patients presented with asymptomatic masses detected through screening or with symptoms. Prevalence of malignant masses in a U.S. postmenopausal screening population was approximately 0.1 percent, while benign masses were found in 0.8 to 1.8 percent of women. Pooled (a) sensitivity and (b) specificity were: bimanual exam (a) 0.45, (b) 0.90; ultrasound morphology scores (a) 0.86 to 0.91, (b) 0.68 to 0.83; Doppler resistive index (a) 0.72, (b) 0.90; pulsatility index (a) 0.80, (b) 0.73; maximum systolic velocity (a) 0.74, (b) 0.81; presence of vessels (a) 0.88, (b) 0.78; combined morphology and Doppler (a) 0.86, (b) 0.91; MRI (a) 0.91, (b) 0.88; CT (a) 0.90, (b) 0.75; FDG-PET (a) 0.67, (b) 0.79; and CA-125 (a) 0.78, (b) 0.78. Both sensitivity and specificity of CA-125 were better in postmenopausal than in premenopausal women. In modeled outcomes, combinations of imaging and CA-125 were both more sensitive and more specific than either alone. Performance of scoring systems in validation studies was consistently worse than in development studies; the highest demonstrated specificity observed was 0.91, with a concurrent sensitivity of 0.74. Evidence on followup strategies was sparse, although one large study provided good evidence for safely following unilocular cysts less than 10 cm in diameter. Overall complication rates in studies of surgically managed adnexal masses were low, but important clinical information was not reported.

CONCLUSIONS

All diagnostic modalities showed trade-offs between sensitivity and specificity, but the available literature does not provide sufficient detail on relevant characteristics of study populations to allow confident estimation of the results of alternative diagnostic strategies. Although modeling studies may prove useful in evaluating diagnostic algorithms, further work is needed to explore the implications of uncertainty about the natural history of ovarian cancer.

Light-induced fluorescence of the human cervix decreases after prostaglandin application for induction of labor at term

OBJECTIVE

To define the changes in cervical light-induced fluorescence (LIF), an index of cross-linked collagen, after the use of locally applied prostaglandin preparations for labor induction at term and the correlation between LIF and Bishop-Score.

STUDY DESIGN

The characteristic LIF of cervical collagen was measured from the surface of the cervix using a specially designed instrument (collascope) in 41 gravidas undergoing labor induction at term by prostaglandins. LIF and Bishop-Score were obtained directly before and 4h after the administration of prostaglandin. Paired Student's t-test, Wilcoxon Signed Rank test, Linear Regression, Spearman correlation and Fisher Exact test were used as appropriate.

RESULTS

Cervical LIF decreased significantly after prostaglandin application (0.982+/-0.04 [before] to 0.885+/-0.037 [after], p=0.025). The decrease in LIF correlated with the initial LIF before PG-application (r=0.61). The Bishop-Score increased in all 41 patients. No correlation was found between LIF versus Bishop-Score.

CONCLUSIONS

Cervical application of prostaglandins decreases the amount of cross-linked collagen as measured by LIF. This effect was observed only in patients with a prior high cross-linked collagen.

Frequency and diagnosis of bacterial vaginosis

OBJECTIVE

To determine the frequency of bacterial vaginosis (BV) in women with vaginal discharge, and to compare different diagnostic tests for its diagnosis.

DESIGN

Cross-sectional study.

PLACE AND DURATION OF STUDY

The Aga Khan University Hospital from June 1998 to May 2000.

PATIENTS AND METHODS

All women attending the Obstetrics and Gynecology clinics at The Aga Khan University Hospital, with the complaints of vaginal discharge, were examined with the help of a speculum. The vaginal pH was measured, samples for bacterial cultures were obtained. A slide was prepared for the gram's stain and Whiff-test was also performed. BV was diagnosed, when the vaginal discharge fulfilled at least three of the composite clinical criteria (Amsel's criteria), a standard method for the diagnosis of bacterial vaginosis: homogenous (pasty) discharge, pH more than 4.5, positive Whiff-test and the presence of clue cells.

RESULTS

The frequency of BV was observed to be 16.1% . The culture for Gardnerella vaginalis was compared with the composite clinical criteria. The sensitivity, specificity, positive and negative predictive values of the culture, calculated for the diagnosis of BV were 93.8%, 70%, 37.7% and 98% respectively.

CONCLUSION

The use of laboratory tests in conjunction with clinical findings is necessary for diagnosis of BV. The composite clinical criteria for the diagnosis of BV are rapid, reliable and inexpensive method.

Diagnosis of labor: a prospective study

Accurate diagnosis of the onset of labor remains a problem in obstetrics. Criteria commonly used to diagnose labor have never been scientifically evaluated. This prospective study involved 423 pregnant women who presented themselves with uterine contractions to 2 Italian hospitals (248 nulliparous patients total and 175 multiparous total) and who were either admitted or advised to return home. The obstetrician on duty collected data using a standardized form that listed common criteria for labor diagnosis. Multivariate analysis showed that a reduction of the interval between consecutive uterine contractions, odds ratio [OR] = 1.42; 95% confidence interval [95%CI] 1.06-1.90); abdominal pain of increasing intensity (OR = 1.42; 95% CI 1.01-2.02); cervical effacement (OR = 1.4; 95%CI 1.12-1.77); and cervical dilation (OR = 1.91; 95% CI 1.53-2.38) were significant markers of the onset of labor. On the other hand, backache had a negative diagnostic value (OR = 0.78; 95% CI 0.61-0.99). The value of criteria such as regular uterine contractions, loss of mucous plug, changes in intestinal habits, vomiting, pain that is relieved by walking, and changes in breathing pattern did not reach statistical significance.

Early non-invasive diagnosis of cervical cancer: Beyond Pap smears and human papilloma virus (HPV) testing

Cervical cancer is a major gynecologic malignancy around the world. However, current diagnostic methods such as Pap smear and human papilloma virus (HPV) testing are insufficient for an early diagnosis of cervical cancer, follow-up on therapy efficacy or to identify the women who might progress to cervical cancer (only about 1-5% of the HPV-positive women will develop cervical cancer). Patients with atypical squamous cells of undetermined significance (ASC-US) clearly need a better screening test. Developing a non-invasive method for early diagnosis of cervical cancer is essential. Our in vitro and translational research data support the hypothesis that: 1. Squamous cell cervical cancer is related to specific upregulation of tissue and serum Insulin-like Growth Factor-II levels (IGF-II; 100% sensitivity and 100% specificity). Serum IGF-I, but not IGF-II levels are elevated in other gynecological, breast, lung and prostate cancers. Serum IGF-II test helps in diagnosing cervical cancer as early as ASC-US or cervical intraepithelial neoplasia (CIN)-I and in monitoring therapy efficacy (p < 0.001 by Student's 't' test and Chi-square analysis). 2. Concomittant to increased serum IGF-II levels, IGF-Binding Protein 3 (IGF-BP3) levels are significantly decreased in persistent CIN and cervical cancer (p < 0.0001). As IGF-BP3 modulates IGF-II biological activity, significantly decreased serum IGF-BP3 levels (levels normalize after therapy; p < 0.001) may indicate a poor prognosis. Similar to serum IGF-II, serum IGF-BP3 levels help monitoring therapy efficacy in cervical cancer and advanced CIN. Measurement of serum IGF-II levels will help in early diagnosis of cervical cancer and monitoring of therapy outcome. Serum IGF-BP3 in conjunction with IGF-II levels may help in predicting prognosis as well as monitoring therapy efficacy.

Human papillomavirus (HPV) genotyping by HPV DNA chip in cervical cancer and precancerous lesions

OBJECTIVES

The human papillomavirus (HPV) is a well-known cause of cervical cancer. HPV tests are used as an adjunct test to decrease the false-negative rate of cytological screening. However, attempts are being made to replace the cytological screening with HPV tests. Therefore, this study was performed to examine the possibility of using HPV tests as screening test.

MATERIALS AND METHODS

The results of the tests that were performed at the same time including the ThinPrep cytology, the high-risk group hybrid capture II (HC-II) test, the HPV DNA chip (HD-C) test, and a punch biopsy were compared in 400 women who were referred to us due to abnormal cytology or cervicogram. The accuracy of each test was then evaluated, and the type of virus was investigated using a HD-C test.

RESULTS

The positive predictive values detected by the high-risk group HC-II test and HD-C test according to the histological diagnosis outcomes were 56.8 and 53.8%, respectively, for cervicitis; 91.5 and 91.5%, respectively, for cervical intraepithelial neoplasia I (CIN I); 88.1% and 81.0%, respectively, for CIN II; 88.6 and 84.2%, respectively, for CIN III, and 92.5 and 88.7%, respectively, for cancer (in 53 patients). The most prevalent types of HPV according to the HPV tests were types 16, 58, 18, and 52 in which type 16 was detected in the more advanced lesions. The sensitivity was 88.4% for the ThinPrep cytology, 89.9% for the HC-II for the high-risk group, and 86.2% for the HD-C test.

CONCLUSION

These results suggest the possibility of using the HC-II and HD-C tests as screening tests, which have a similar sensitivity as the ThinPrep cytology. Nonetheless, randomized controlled trials will be needed before the actual application of the HPV tests as screening tests. Despite the fact that the importance of HPV type 16 in cancer development was confirmed, the prevalence of types 58 and 52 were relatively high compared with those found in other studies, showing a need for further studies on this subject. These HPV types need to be considered in vaccine development.

Prognostic factors in microinvasive cervical squamous cell cancer: long-term results

We examined tumor-related pathologic factors and cone-related characteristics to identify parameters related to recurrence in microinvasive squamous cell carcinoma of the cervix treated with conization. This is a retrospective study on 67 consecutive cases of microinvasive carcinoma of the cervix [depth of invasion (DI) < 3 mm] treated with conization. The mean follow-up was 121 months (range 72-276 months). Four (6%) invasive recurrences were observed. Presence of lymphvascular space involvement (LVSI) was significantly related with recurrences (P < 0.05). The mean distance between tumor margin and apex of the cone (apical clearance) was 10.6 mm (range 5-22 mm), and the mean distance between lateral border of the cone and tumor margin (lateral clearance) was 6.5 mm (range 1.7-15 mm). We adopted cut-off values of 10 and 8 mm for apical and lateral clearances, respectively. We found a statistically significant difference between apical clearance and recurrence rate (P < 0.02). The LVSI was, other than DI, an important prognostic factor. Apical clearance was significantly correlated with recurrence. The cone-related characteristics, other than tumor-related pathologic factors, could help the decision concerning the definitive therapy for microinvasive carcinoma of the cervix.

Obesity and Clomiphene Challenge Test as Predictors of Outcome of in vitro Fertilization and Intracytoplasmic Sperm Injection

One hundred and sixty-two consecutive patients undergoing in vitro fertilization (IVF) or IVF/intracytoplasmic sperm injection (ICSI) were studied to determine the effect of obesity on the outcome of this treatment and to evaluate the prognostic value of the Clomiphene Challenge Test (CCT) in controlled ovarian hyperstimulation. In this prospective clinical study, we assessed the mean number of stimulation days, the mean gonadotropin level/day, cancellation rate, the mean thickness of the endometrium, the mean number of oocytes retrieved, the fertilization rate, the clinical pregnancy rate/embryo transfer and the abortion rate. Obese women had a doubled risk of cancellation due to poor response, although this was not statistically significant. Furthermore, they showed up to 45% lower fertilization rates compared to women of normal weight. The CCT was a good predictor of IVF and IVF/ICSI outcome. Women with an abnormal CCT needed more days of stimulation and higher doses of gonadotropins to reach an adequate stimulation, but still overall results were less than in women with a normal CCT. We conclude that obesity negatively affects IVF and IVF/ICSI outcome, and that CCT is a useful prognosticator of response to ovarian stimulation. Obese patients show a tendency to experience more cancellation due to poor response and lower fertilization rates. Obese women should be counseled on their possible poor performance in IVF and IVF/ICSI programs.

Prospective validation of two models predicting pregnancy leading to live birth among untreated subfertile couples

BACKGROUND

Models predicting clinical outcome need external validation before they can be applied safely in daily practice. This study aimed to validate two models for the prediction of the chance of treatment-independent pregnancy leading to live birth among subfertile couples.

METHODS

The first model uses the woman's age, duration and type of subfertility, percentage of progressive sperm motility and referral status. The second model in addition uses the result of the post-coital test (PCT). For validation, these characteristics were collected prospectively in two University hospitals for 302 couples consulting for subfertility. The models' ability to distinguish between women who became pregnant and women who did not (discrimination) and the agreement between predicted and observed probabilities of treatment-independent pregnancy (calibration) were assessed.

RESULTS

The discrimination of both models was slightly lower in the validation sample than in the original sample which provided the model. Calibration was good: the observed and predicted probabilities of treatment-independent pregnancy leading to live birth did not differ for both models.

CONCLUSIONS

The chance of pregnancy leading to live birth was reliably estimated in the validation sample by both models. The use of PCT improved the discrimination of the models. These models can be useful in counselling subfertile couples.

'We're having trouble conceiving...'

BACKGROUND

The growing trend for Australian women to delay childbearing has a significant impact on their individual fertility and the consequent need for assisted reproductive technology.

OBJECTIVE

This article defines infertility and highlights typical male, female, and unexplained combined causes of infertility. Initial fertility investigations best undertaken in general practice are outlined, and suggestions on when to refer a couple to a fertility specialist is clarified.

DISCUSSION

Initial assessment of the subfertile couple is best managed by the general practitioner whose relationship can facilitate quick understanding of how long the couple has been trying to conceive, age, and medical history. The woman can then undergo simple global blood and hormone tests while a semen analysis is appropriate for the man. On review, any abnormal tests can indicate referral to a fertility specialist for review and management.

Management of the infertile couple

BACKGROUND

With the further development of reproductive technology over the past 2 decades, options for subfertile couples have greatly increased.

OBJECTIVE

This article discusses the assessment of common male and female causes of infertility and describes a logical routine for the investigation and treatment of the subfertile couple using a flow chart approach.

DISCUSSION

We suggest an approach to assessment for general practitioners, and outline the likely course of more sophisticated testing and treatments that their patients may then experience.

Antral follicle count and FSH concentration after clomiphene citrate challenge test in the prediction of ovarian response during IVF treatment

BACKGROUND

We compared: (i) antral follicle count (AFC) in the early follicular phase, after the clomiphene citrate challenge test (CCCT) and before ovarian stimulation following pituitary down-regulation; and (ii) age of women, body mass index, basal and stimulated serum FSH concentrations and AFC in predicting the ovarian response of infertile women aged <40 years with basal FSH <10 IU/l on recruitment in their first IVF cycle.

METHODS

Two months prior to the treatment cycle, AFC and basal FSH concentration were determined on day 2-3 of a spontaneous period and on day 10 after CCCT. All women received a standard stimulation regimen. Ovarian response was represented by the number of oocytes, serum estradiol, the duration and dosage of gonadotrophins.

RESULTS

There was no significant difference between basal, stimulated and down-regulated AFC. AFC achieved the best predictive value in relation to the number of oocytes, followed by combined FSH concentration (sum of the two FSH concentrations) and age of women. Both basal AFC and combined FSH concentration were predictive factors of serum estradiol concentration, whereas stimulated FSH concentration was predictive of the total dosage of gonadotrophins.

CONCLUSION

Combined FSH concentration after CCCT provides additional information in predicting ovarian response.

Priming Effect of Misoprostol on Estrogen Pretreated Cervix in Postmenopausal Women

Misoprostol, which is a prostaglandin E1 analogue, is effectively used in cervical priming in women both for labor induction and for gynecological procedures. Although its efficacy is well documented in reproductive age women, during postmenopausal period this efficacy is limited probably due to estrogen deficit. Our objective is to evaluate if estrogen deficit in postmenopausal women is important for the effect of misoprostol on cervical ripening before diagnostic procedures. In this study, 45 patients were randomly allocated to estrogen or placebo group. The study group received local estrogen cream and other group received chlindamycine phosphate cream as placebo. The patients were given oral misoprostol 24 and 12 hours before the procedure for uterine cavity evaluation. Cervix was dilated by using Heagar dilator up to 6 mm. Data were analyzed by Student t-test, Mann-Whitney's U-test, chi-square test and paired samples t-test where appropriate. Basal cervical widths for the estrogen and placebo groups were 4.4 +/- 0.7 and 3.7 +/- 0.7 mm, respectively (p < 0.01). Mean time required for dilatation of cervix was 44.4 +/- 16.2 seconds for the estrogen group and 61.4 +/- 18.3 seconds for the placebo group (p < 0.01). As a conclusion, misoprostol treatment alone is not effective to get cervical priming in postmenopausal women, and as shown in our study, pretreatment with local estrogen overcome the failure. To get a beneficial effect of misoprostol on cervical ripening, estrogenic activity is necessary and when pretreated with local estrogen, misoprostol ameliorates cervical priming in postmenopausal women.

Comparison of two techniques for transcervical cell sampling performed in the same study population

OBJECTIVES

The aim of this study was to evaluate and compare the presence of fetal cells in transcervical cell (TCC) samples collected in the first trimester of pregnancy by two different procedures [mucus collection and intrauterine lavage (IUL)], performed consecutively in the same subjects scheduled for elective termination of pregnancy (TOP).

METHODS

A total of 126 mucus/IUL sample pairs were retrieved from pregnant women immediately before TOP at a gestational age ranging from 7 to 12 weeks; at termination, samples of placental tissue were collected in all cases. All mucus samples were analysed by a polymerase chain reaction (PCR) assay and, in a subset of experiments involving 56 specimens, also by fluorescence in situ hybridization (FISH) procedure. IULs were divided in two aliquots, one for PCR analysis and one for the preparation of FISH slides. All placental tissue samples obtained at termination were analysed by FISH for fetal sexing. The PCR assay for fetal sex determination was performed by using, in a multiplex reaction, primers for SRY (Y chromosome sex-determining region, 738 bp) and HUMARA (human androgen receptor on the X chromosome, 280 bp) genes. The FISH analysis was carried out using direct-labelled commercial probes for X chromosome alpha-satellite (DXZ1, Xp11.1-q11.1, spectrum green) and Y chromosome alpha-satellite (DYZ3, Yp11.1-q11.1, spectrum orange) regions.

RESULTS

In samples from known male pregnancies (n = 67), full concordance between IUL and mucus results could be found in 11 cases (16.4%); in 41 cases, Y chromosome material was detected by FISH (n = 2), by PCR (n = 5) or both (n = 34) in IUL samples, but not in the corresponding mucus samples. Y chromosome material was not documented in 10 mucus/IUL sample pairs. In 5 cases, the FISH (n = 2), the PCR (n = 1) or both (n = 2) failed to detect Y chromosome material in IULs, which was detected, however, by PCR in the corresponding mucus samples. Overall, correct sex prediction was achieved in 55/67 IULs (82%) and in 16/67 (23.9%) mucus samples from male pregnancies. In samples from known female pregnancies (n = 56), full concordance between results of IUL/mucus pairs and those on placental samples could be found in 53 cases (94.6%); in 3 cases, Y chromosome material was documented by PCR in mucus samples, but not in the corresponding IULs. Correct sex prediction was therefore achieved in 56/56 IULs (100%) and in 53/56 (94.6%) mucus samples from female pregnancies.

CONCLUSION

This study provides evidence that, among TCC sampling techniques, IUL, but not mucus collection, can yield fetal cells in a constant and reliable fashion, which is a basic prerequisite for possible clinical usage. This suggestion had already emerged from some previous investigations but, owing to the study design, differences in study populations can no longer be used to explain the very different and sometimes-conflicting results reported in earlier studies.

Effect of CME on primary care and OB/GYN treatment of breast masses

INTRODUCTION

CME program planners are being asked to move beyond assessments of knowledge to assessing the impact of CME on practice and patient outcomes.

METHODS

We conducted a pre-post analysis of administrative data from 107 physicians, nurse practitioners (NPs), or physician's assistants (PAs) who attended one or two continuing medical education (CME) programs (an in-person, mainly didactic session on breast complaints in women, or an individual mentorship with general surgeons) between August 2002 and March 2003. We examined associations between the number of trainings and attempted breast mass aspirations or general surgery referrals for breast masses; individual training and breast mass aspiration attempts or general surgery referrals; and provider type and attempted breast mass aspirations. Generalized linear mixed models were used to model dichotomous outcomes.

RESULTS

Clinicians who participated in individual trainings performed more breast mass aspirations after training (odds ratio (OR) 3.07, [95% confidence interval 1.10-8.54]). Participants who completed two trainings performed more breast mass aspirations after training (OR 2.33, [1.19-4.57]), while those who completed just one did not (OR 1.34, [0.39, 4.58]) but the effect started after the first training and did not strengthen after the second training. NPs and PAs attempted more aspirations after training (OR 6.1, [1.54, 24.1]), whereas physicians did not (OR 0.89 [0.36, 2.22]). Training was not associated with a change in referrals to general surgery. Referral appropriateness, pre-training readiness to change, and previous training in breast mass aspiration were not assessed.

DISCUSSION

Attempts to aspirate breast masses may increase after CME training. Individual training may be more effective than group training in increasing the likelihood of attempted aspirations.

Role of human papillomavirus testing in reducing the number of surgical treatments for precancerous cervical lesions

PURPOSE OF INVESTIGATION

To determine whether the addition of the Hybrid Capture II (HC II) test (Digene Corp., Gaithersburg, MD, USA) to cytological, colposcopical and histological results could reduce the number of surgical treatment procedures for precancerous cervical lesions.

METHODS

Surgical treatment of precancerous cervical lesions was performed in 181 women. Priorly, the women were tested for high-risk human papillomavirus (HPV). Sensitivity, specificity, positive and negative predictive value were calculated to assess the performance characteristics of HC II in the detection of cervical intraepithelial neoplasia grade 2 or worse (CIN 2+) and grade 3 or worse (CIN 3+).

RESULTS

Eighty (44.2%) women had a histological result < CIN 2; 117 (64.6%) women had < CIN 3. Fifty-three (29.3%) women with < CIN 2 tested HPV negative; 69 (38.1%) women with < CIN 3 tested HPV negative (p < 0.05). The sensitivity of HC II for detecting CIN 2+ and CIN 3+ was 76.2% and 87.5%, respectively.

CONCLUSION

A high proportion of women were overtreated probably due to cytological and histological overestimations. HPV testing would reduce the number of unnecessary surgical treatments and should be used as an additional screening tool.

Accuracy of Nugent's score and each Amsel's criteria in the diagnosis of bacterial vaginosis

OBJECTIVE

To determine the diagnostic accuracy of Nugent's score and each Amsel's criterion in the diagnosis of bacteria vaginosis (BV), considering Amsel's criteria as the gold standard.

DESIGN

Cross-sectional, descriptive study (diagnostic test) Setting: Family planning clinic, Siriraj Hospital, Mahidol University.

SUBJECTS

A total of 217 women who attended the Family Planning Clinic at Siriraj Hospital between August and December 2003.

METHOD

Pelvic examination was performed on each participant. Samples of vaginal discharge was tested for BV infection using both Amsel's criteria and Nugent's score. Interpretation was made blinded without knowledge of each test result. Using Amsel's criteria as a gold standard, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of Nugent's score and each of Amsel's criteria were estimated.

RESULTS

Considering Amsel's criteria as the gold standard, Nugent's score showed a sensitivity of 65.6% (95%CI 46.8%, 80.8%), specificity of 97.3% (95%CI 93.5%, 99.0%), positive predictive value (PPV) of 80.8% (95%CI 60.0%, 92.7%), negative predictive value (NPV) of 94.2% (95%CI 89.7%, 96.9%) and accuracy of 92.6% (95%CI 88.1%, 95.6%). Both vaginal pH and whiff test demonstrated 100% sensitivity. However, vaginal pH showed lower specificity than the whiff test (58.9% and 97.3% respectively).

CONCLUSION

Nugent's score might not be suitable to use as a screening test for diagnosis of BV due to its low sensitivity. The whiff test is the best clinical criteria of Amsel's criterion in the diagnosis of BV due to its high sensitivity and specitivity.

Selecting an appropriate hCG test for managing gestational trophoblastic disease and cancer

Human chorionic gonadotropin (hCG) is a glycoprotein composed of 2 dissimilar subunits, alpha and beta, joined non-covalently. This hormone is not only heterogeneous in peptide structure but also in combination of subunits and in the structure of carbohydrate side chains. Common hCG-related molecules in serum samples include regular hCG, hyperglycosylated hCG (ITA), nicked hCG, nicked ITA, hCG missing the beta-subunit C-terminal extension, free alpha-subunit, free beta-subunit, free beta-subunit missing the C-terminal extension, hyperglycosylatedfree beta-subunit and nickedfree beta-subunit. The same molecules plus beta-core fragment are present in urine samples. While ITA and regular hCG predominate in pregnancy samples, any one of these multiple hCG-related molecules may be the principal source of immunoreactivity in gestational trophoblastic disease, gestational trophoblastic neoplasm, choriocarcinoma and placental site tumor cases as well as in testicular cancer and germ cell tumor. As such it is critical to appropriately detect all these isoforms in the management of these diseases. Only 2 tests, the DPC Immulite (DPC, Inc., Los Angeles, California) and U.K. RIA (radioimmunoassay) (used at Charing Cross Hospital, London) appropriately detect all these hCG-related molecules. False positive hCG results are a major problem in the management of gestational trophoblastic disease and cancer. A particular problem is observed with the Abbott AxSym test. This test is flawed in design. It should be avoided in the management of gestational trophoblastic disease and cancer. As shown in a blind study, a proportion of false positive samples in the Abbott AxSym test (Abbott Laboratories, Inc., Chicago, Illinois) can also be false positive with the U.K. RIA; none are false positive with the DPC Immulite test. Results clearly show that the DPC Immulite/Immulite 2000 is the only appropriate assay for monitoring patients with gestational trophoblastic disease or cancer.

New modalities in detection of recurrent ovarian cancer

PURPOSE OF REVIEW

The vast majority of women diagnosed with ovarian cancer and subsequently treated with debulking surgery and adjuvant chemotherapy will ultimately relapse. As is the case with primary diagnosis, detection of recurrent ovarian cancer is limited due to lack of sensitivity and specificity. Specific guidelines for surveillance of this disease are controversial, partly because evidence to support such guidelines is scant and partly because the management of identified recurrences continues to be of minimal success. Subsequently, whether early detection actually can make a difference is not necessarily made clear in the literature. However, there are advances in radiological and molecular biology technology that may offer new possibilities in cancer surveillance. This review will outline the latest evidence to address their use in ovarian cancer.

RECENT FINDINGS

Most of the recent literature involving detection of recurrent ovarian cancer addresses the use of positron emission tomography. There are also some data addressing the use of magnetic resonance imaging and computed tomography in this arena. Data pertaining to other modalities such as biological markers are limited. Ca-125 is the accepted assay used for ovarian cancer surveillance, but other options are introduced that may hold promise for the future.

SUMMARY

A review of the recent literature concerning ovarian cancer surveillance techniques offers few new definitive avenues. While radiological technology and discoveries in detection assays are noteworthy, their potential impact on surveillance appears to be minimal at this time. Low sensitivity and specificity, along with expense, continue to be limiting factors.

Outcomes of teaching medical students core skills for women's health: the pelvic examination educational program

OBJECTIVE

The purpose of this study was to evaluate the outcomes of introducing an educational program that teaches medical students how to approach taking relevant and sensitive gynecologic histories and to perform pelvic examinations with the use of role-play with well women from the general community.

STUDY DESIGN

Medical students and the women recorded their perceptions of the program over a 2-year period. The outcomes of the program were evaluated by a comparison of medical student perceptions of confidence, competence, and anxiety; the mean number of pelvic examinations that were performed during their course both before and after the introduction of the program and results of students' continuous and summative assessment are given.

RESULTS

In the year before the introduction of the program, students performed a mean of 2.6 pelvic examinations (95% CI, 2.1, 3.0) compared with 4.1 pelvic examination (95% CI, 3.8, 4.4) in the first year of implementation and 4.0 (95% CI, 3.7, 4.3) in the second year of implementation (P <.05). Students reported improved competence and reduced anxiety to perform a pelvic examination without supervision (P <.05). All students passed their continuous assessment. Between 92% and 100% of students and women agreed that the program had clear learning objectives, was well organized, and was a useful and appropriate method of teaching that helped prepare them for the clinical setting.

CONCLUSION

This pelvic examination educational program has been evaluated positively by students and participant women and has resulted in a significant improvement in the amount of pelvic examination experience that medical undergraduates obtain.

The role of investigations for term stillbirths

The aim of the study was to document the role of laboratory investigations for unexpected stillbirths at term. It was a retrospective casenote review of 75 unexpected stillbirths at term from 1995 to 1999, at the National Maternity Hospital, Dublin, Republic of Ireland. Investigations performed included blood tests, chromosomal analysis, autopsy and placental histology. Perinatal autopsy was the most informative investigation with positive findings in 49% of cases. There were positive placental findings in 37% of cases. Six of the 26 cases showed abnormal karyotyping. Of the blood tests performed, the Kleihauer-Betke test was most informative, revealing a feto-maternal haemorrhage in 8% of cases and anticardiolipin antibodies were positive in 4% of cases. FBC, TORCH and glycosylated Hb were negative in all 75 patients. Despite thorough investigations 32 of cases (43%) remained unexplained.

Sonohysterography: a valuable tool in evaluating the female pelvis

A number of medical conditions, including abnormal uterine bleeding, endometrial cancer, monitoring tamoxifen therapy, infertility, and recurrent abortion, warrant investigation of the female genital tract. Diagnostic studies including hysterosalpingogram, ultrasound, and sonohysterography have proved useful in the investigation of these gynecologic conditions. This article discusses each of these tests with particular emphasis on sonohysterography and their current and potential contributions in both diagnostic and therapeutic applications. The utility of each as well as their comparative value to each other and existing gold standards is reviewed.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to outline the current screening methods for uterine cavity and pelvic abnormalities, to list the advantages of sonohysterography, and to describe the clinical situations where sonohysterography can be used.