Diagnostic Performance of a Sonographic Volume and Solid Vascular Tissue Score (VSVTS) for Preoperative Risk Assessment of Pediatric and Adolescent Adnexal Masses

Study ObjectiveTo evaluate the diagnostic performance of a Volume and Solid Vascular Tissue Score (VSVTS) for preoperative risk assessment of pediatric and adolescent adnexal masses.DesignA retrospective cohort study comprised of all female individuals who presented with an adnexal mass that was managed surgically between April 2011 and March 2016.SettingThe Hospital for Sick Children (Toronto, Ontario, Canada).ParticipantsFemale individuals 1–18 years of age who presented to a large tertiary pediatric hospital with an adnexal mass that was managed surgically.Main Outcome MeasuresMain outcome measures included diagnostic performance of the VSVTS for malignancy via sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), negative likelihood ratio (LR?), and receiver operating characteristic area-under-the-curve (AUC) analysis.ResultsA total of 179 masses in 169 subjects were included. The malignancy rate was 10.6%. The AUC for the VSTVS was 0.919. A VSTVS cut-off value of 4 achieved a sensitivity of 79% (95% CI 0.54-0.93), specificity of 88% (95% CI 0.82-0.93), PPV of 0.44 (95% CI 0.33-0.56), NPV of 0.97 (95% CI 0.94-0.99), LR+ of 6.77 (95% CI 4.18-10.97), and LR? of 0.24 (95% CI 0.10-0.57).ConclusionsA sonographic scoring system based on the volume and presence of solid vascular tissue improves PPV for preoperative risk stratification of adnexal masses in the pediatric and adolescent population compared to existing ultrasound-only approaches. Further prospective research is needed to determine how best to incorporate components of such scoring systems into clinical management algorithms.     

Comparison between creatine kinase brain isoenzyme (CKBB) activity and Sarnat score for prediction of adverse outcome following perinatal asphyxia

AIM: To assess whether plasma creatine kinase brain isoenzyme (CKBB) levels or Sarnat scores are more accurate for prediction of poor neurological outcome in babies with suspected birth asphyxia. METHODS: In a retrospective study of 97 babies CKBB levels were compared to the presence of severe hypoxic ischaemic encephalopathy (HIE) as a predictive test for these outcomes: developmental delay, cerebral palsy, visual problems, deafness or death from perinatal asphyxia. The tests were compared using positive predictive values (PPV) and likelihood ratios (LR) with confidence intervals (CI). RESULTS: 3 babies had died from perinatal asphyxia and 14 survivors were found to have neurological or developmental problems. CKBB was elevated in babies with severe HIE (p = 0.0004). A receiver operator characteristic (ROC) curve showed the optimal discriminating value for CKBB to be 21 IU/L but the CKBB was a poor predictive test. For prediction of adverse outcome: CKBB > 21 sensitivity 76%, specificity 40%, PPV 21% and LR 1.3 (95% CI 0.8-1.7). Severe HIE sensitivity 53%, specificity 95%, PPV 69% and LR 10.6 (95% CI 3.8-29.2). CONCLUSION: CKBB is elevated following birth asphyxia but is a poor predictor of adverse neurological outcome.     

Preoperative Risk Stratification of Adnexal Masses in the Pediatric and Adolescent Population: Evaluating the Decision Tree System

Study ObjectiveTo evaluate the diagnostic performance of the Decision Tree System (DTS) rules 2 and 3 for surgically managed adnexal masses in the North American population and to compare it with the risk stratification criteria used at The Hospital for Sick Children (≥8 cm and complex/solid).DesignA retrospective cohort study of patients who presented with adnexal masses and were surgically treated between April 2011 and March 2016.SettingThe Hospital for Sick Children (Toronto, Ontario, Canada).ParticipantsPatients 1-18 years of age with adnexal masses who underwent surgical treatment.Interventions and Main Outcome MeasuresMain outcome measures included diagnostic performance (preoperative sensitivity, specificity, positive predictive value [PPV], and negative predictive value [NPV] for malignancy) of the DTS rules 2 and 3 and ≥8 cm and complex/solid criteria.ResultsThe malignancy rate was 10.4%. The DTS rules 2 and 3 had a sensitivity of 84% (95% confidence interval [CI], 79-90), specificity of 77% (95% CI, 71-83), PPV of 30% (95% CI, 17-42), and NPV of 98% (95% CI, 94-100). The 8 cm or larger and complex/solid criteria had a sensitivity of 89% (95% CI, 85-94), specificity of 71% (95% CI, 64-77), PPV of 27% (95% CI, 16-38), and NPV of 98% (95% CI, 96-100).ConclusionOur study showed that DTS rules 2 and 3 had similar diagnostic performance as the 8 cm or larger and complex/solid criteria in the same population, with a very high NPV and a low PPV. Future prospective investigations should be conducted to further assess how DTS components can be incorporated into future algorithms for the management of adnexal masses in the pediatric population.     

Preliminary report on a new and noninvasive method for the assessment of fetal lung maturity

OBJECT: Several patterns of fetal breathing movements (FBMs), i.e. abdominal wall movements (AWm), thoracic wall movements (TWm) and nasal fluid flow velocity waveforms (NFFVW), were investigated by ultrasound (US) technology and related to fetal pulmonary maturity and immaturity, i.e. fetal lung maturity (FLM) tests, in order to validate the hypothesis that they may indicate whether the fetal lung is mature or immature, regardless of gender, weight and gestational age. MATERIAL AND METHODS: We prospectively enrolled 143 high-risk pregnancies in which a complete US study of FBMs and FLM tests was performed. Among them 43 women satisfied the inclusion criteria. US-FLM was defined as the presence of regular NFFVW detected by pulsed Doppler and spectral analysis, or irregular NF-FVW synchronous with TWm detected by M-mode. An US guided amniocentesis was performed in order to collect amniotic fluid (AF) and FLM was evaluated by L/S (lecithin/sphingomyelin) determination, presence of phosphatidylglycerol (PG) and lamellar bodies (LBs) count. At the end of the study the diagnostic accuracy of US-FLM was compared to that of FLM tests. RESULTS: Diagnostic accuracy for US evaluation of FLM was as follows: sensitivity: 89.6%; specificity: 85.7%; PPV: 92.8%; NPV: 80%. Diagnostic accuracy of FLM tests was as follows: sensitivity: 100%; specificity: 51.7%; PPV: 100%; NPV: 50%. L/S determination predicted lung maturity with a sensitivity of 100%; specificity of 93.1%; PPV of 100%; NPV of 87.5%. CONCLUSION: Presence of regular NFFVW or irregular NFFVW and TWm correlate accurately with conventional FLM tests. We suggest that this noninvasive procedure may be helpful for assessing FLM, particularly under certain circumstances, e.g., oligo-anhydramnios, laboratory logistic equipment difficulties or heavily stained AF samples, amniocentesis refusal, religious concerns.     

Transvaginal color Doppler ultrasonography and CA-125 in suspicious adnexal masses.

OBJECTIVE: To compare diagnostic performance of color Doppler ultrasound and CA-125 in suspicious adnexal masses on B-mode sonography. MATERIALS AND METHODS: Data on 94 patients (mean age: 47.4 years, range: 17-79 years. Fifty-two (55.3%) premenopausal and 42 (44.7%) postmenopausal women) managed in our institution because of a suspicious adnexal mass were reviewed. All patients were evaluated by transvaginal color Doppler ultrasonography (CD) and serum CA-125 level determination prior to surgery. Definitive histopathological diagnosis was obtained in each case. Sonographic morphology evaluation was suspicious in all cases. CD was considered as suspicious when flow was detected and the lowest RI found was < or = 0.45. CA-125 cut-off was > or = 35 UI/ml. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for each method and compared. ROC analysis was performed for RI and CA-125. Areas under curve (AUC) were calculated and compared. RESULTS: Fifty-six (59.6%) tumors were found to be malignant and 38 (40.4%) benign. Sensitivity, specificity, PPV and NPV for CD were 87.5% (95% CIs: 75.3-94.4), 84.2% (95% CIs: 68.7-94), 89.1% (95% CIs: 77.7-95.9) and 82.1% (95% CIs: 66.5-92.5), respectively. Sensitivity, specificity, PPV and NPV for CA-125 were 83.9% (95% CIs: 71.7-92.4), 68.4% (95% CIs: 51.3-82.5), 79.7% (95% CIs: 66.2-89) and 74.3% (95% CIs: 56.7-87.5), respectively. Sensitivity, PPV and NPV were not statistically different. CD had higher specificity (P = 0.01). AUC curve for Doppler (0.75) was significantly higher than for CA-125 (0.61) (P = 0.0002). CONCLUSIONS: Our results indicate that color Doppler ultrasound has a better diagnostic performance as compared with CA-125, being significantly more specific.     

Accuracy of endometrial biopsy with the Cornier pipelle for diagnosis of endometrial cancer and atypical hyperplasia

OBJECTIVE: To establish the accuracy of endometrial biopsy with the Cornier pipelle in the diagnosis of endometrial cancer and atypical endometrial hyperplasia in our milieu. MATERIAL AND METHOD: We reviewed 1,535 anatomopathologic reports on endometrial biopsies taken from outpatients using the Cornier pipelle between 1997 and 2000, in pre- and postmenopausal patients with abnormal vaginal bleeding. In 168 patients (10.9%), curettage and/or hysterectomy was subsequently carried out. In these cases, the anatomopathologic reports were compared to determine sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and likelihood ratio (LR). RESULTS: Sensitivity was 84.2%, specificity was 99.1%, accuracy was 96.9%, PPV was 94.1%, NPV was 93.7% and LR was 93.5. In 249 cases (16.09%) the material was insufficient for study. CONCLUSION: We determined that endometrial biopsy taken with the Cornier pipelle is, as we practice it, an accurate method for diagnosis of endometrial cancer and its precursor, atypical hyperplasia.     

Human papillomavirus (HPV) testing in the management of women with abnormal Pap smears. Experience of a colposcopy referral clinic

BACKGROUND AND OBJECTIVES: Several detailed algorithms for the appropriate use of human papillomavirus (HPV) testing in the management of women with abnormal Pap (Papanicolaou) smears have been launched, but their direct country-to-country adoption is difficult. This necessitates their testing in individual settings, which is ongoing in our colposcopy referral clinic. METHODS: A series of 224 consecutive women attending the clinic with the usual referral indications (ASC-US or higher in Pap) were examined by the conventional diagnostic tools (PAP smear, colposcopy, punch biopsy) and subjected to HPV testing and viral typing for both low-risk (L-R) and high-risk (H-R) types by nested PCR-based techniques. Predictors of the high-grade diagnostic categories were analysed using both univariate- and multivariate modelling, and the performance characteristics (sensitivity, specificity, NPV, PPV) of all tests in detecting high-grade CIN were calculated. RESULTS: In the PAP test, ASC-US smears were most common (37.9%), followed by low-grade squamous intraepithelial lesions (LSIL) (26.3%) and high-grade SIL (HSIL) (4.9%). Colposcopy was performed for 180 women, of whom 48.3% had a normal transformation zone (TZ), 40.6% had ATZ1 (abnormal TZ grade 1), and 5.6% had ATZ2. In biopsy (n = 71), 49.3% had CIN1, 5.6% CIN2, and 16.9% CIN3. The HPV test was positive in 64 (28.8%) women, more often in those aged < 35 years (p = 0.025). High-grade colposcopy (ATZ2) was significantly associated with HSIL in the Pap test (OR 20.5; 95% CI: 4.34-96.47), and with HPV test positivity (OR 6.37; 95% CI: 1.58-25.73). The most significant predictors of CIN3 were HSIL in the PAP, HPV test positivity, and high-grade colposcopy. HSIL and HPV test (for H-R types), but not colposcopy, retained their significance as independent predictors of CIN3 also in adjusted multivariate models: OR 88.27; 95% CI 4.17-1867.04, and OR 19.46; 95% CI 2.01-187.75, for the HSIL and H-R HPV test, respectively. Changing the cut-off level of the Pap test from ASC-US to HSIL increased the specificity of the test up to 96.4%, with the loss in sensitivity from 87.5% to 43.8%. Colposcopy (ATZ2) had 92% specificity, and NPV competing with that of the Pap test. The sensitivity of HPV test exceeds that of the Pap test at HSIL cut-off level, but the specificity of the PAP test is clearly superior. CONCLUSIONS: Accurate predictors of significant cervical pathology (CIN3) are well defined, but the problem is the different performance of the diagnostic tools in clinical practice. A proficient combination of the tests is likely to result in the most satisfactory clinical practice in the management of women with abnormal Pap tests (MAPS).     

The diagnostic accuracy of magnetic resonance imaging in detecting cervical involvement in endometrial cancer

OBJECTIVES: The objective of this study was to determine the diagnostic accuracy of magnetic resonance imaging (MRI) in detecting cervical involvement by endometrial cancer. METHODS: A retrospective accuracy study of 135 consecutive women who underwent preoperative MRI and surgery for endometrial cancer at a single gynaecological cancer centre between 1st February 2003 and 30th November 2004. RESULTS: For the detection of any cervical involvement by MRI, the sensitivity was 72%, specificity 93.2%, positive predictive value (PPV) 89.8%, negative predictive value (NPV) 80.2%, positive likelihood ratio (+LR) 10.7 and negative likelihood ratio (-LR) 0.3. When cervical stromal invasion was considered alone, the sensitivity was 84.4%, specificity 87.4%, PPV 67.5%, NPV 94.7%, +LR 6.7 and -LR 0.18. CONCLUSION: We believe that MRI is able to accurately predict cervical involvement in endometrial cancer and allows a decision to be made on the type of hysterectomy to be offered.     

Cardiofemoral index as an ultrasound marker of fetal anemia in isoimmunized pregnancy.

OBJECTIVE: To test a new noninvasive ultrasound method for diagnosing fetal anemia in red blood cell isoimmunized pregnancies. METHODS: A diagnostic accuracy study was carried out to determine the cutoff point of an ultrasound measurement, the cardiofemoral index (CFI), calculated using the biventricular outer dimension (BVOD) and femur length to diagnosis severe anemia. The CFI measurement was performed before each of the 336 cordocenteses on 131 fetuses. Diagnosis test analysis and receiver-operating characteristics (ROC) curves were used and the area under the curve (AUC) was calculated to compare the overall accuracy of the CFI for anemia diagnosis, between fetuses with or without previous intrauterine transfusions (IUT). RESULTS: At first cordocentesis (n=131) the AUC was 0.75 (95% CI, 0.66-0.84). For cases where fetuses had undergone 1 previous transfusion (n=88) the AUC was 0.76 (95% CI, 0.64-0.88) and at the time of the third cordocentesis for IUT (n=53) it was 0.73 (95% CI, 0.59-0.86). For a 0.59 CFI threshold to diagnosis fetuses with hemoglobin deficit above 5 g/dL, sensitivity values were 87.2%, 88.0%, and 94.1% respectively for fetuses without IUT, with 1 IUT, and with 2 IUTs. Likelihood ratios for positive (LR+) and negative (LR-) test results were 1.98, 2.05, 1.69 and 0.23, 0.21, 0.13 respectively. CONCLUSION: The cardiofemoral index may be an effective noninvasive marker of severe fetal anemia in high-risk fetuses, with accuracy similar for fetuses either with or without previous transfusions.     

Use of oral glucose tolerance test in early pregnancy to predict late-onset gestational diabetes mellitus in high-risk women

AIM: To evaluate if any single plasma glucose level from the four values of the normal 100-g oral glucose tolerance test (OGTT) in early pregnancy (< or =20 weeks of gestation) could predict gestational diabetes mellitus (GDM) diagnosed from a second OGTT in late pregnancy (28-32 weeks). METHODS: Glucose levels of pregnant women at high-risk for GDM, who had had a normal early OGTT, and who underwent the second test in late pregnancy, were studied. Each of the four plasma glucose values of the early OGTT was determined for sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). The receiver operating characteristic curves of these four OGTT values were then constructed to find the optimal value to predict late-onset GDM. RESULTS: Of 193 pregnant women who had had a normal early OGTT, 154 also had a normal OGTT in late pregnancy while 39 had an abnormal test and were diagnosed with GDM. Among the four glucose values of the early OGTT, the 1-h value yielded the best diagnostic performance to predict late-onset GDM. The sensitivity, specificity, PPV, NPV, and area under the curve achieved from its optimal cutoff level of > or =155 mg/dL (8.6 mmol/L) were 89.7%, 64.3%, 38.9%, 96.1%, and 0.77, respectively. CONCLUSIONS: A 1-h glucose value > or =155 mg/dL at the early OGTT yielded the best diagnostic performance. However, the low specificity and PPV rendered it suboptimal to predict late-onset GDM. Nevertheless, a considerable number of high-risk women could avoid the second OGTT in late pregnancy due to its high sensitivity and NPV.     

The value of transvaginal sonography in the preoperative assessment of myometrial invasion in high and low grade endometrial cancer and in comparison to frozen section in grade 1 disease

OBJECTIVE: To evaluate the diagnostic accuracy of preoperative transvaginal sonography (TVS) in the detection of deep myometrial invasion in endometrial cancer cases classified by the grade of disease, and in comparison to frozen section analysis in grade 1 cases. METHODS: In a prospective study, 91 patients with confirmed endometrial carcinoma underwent preoperative TVS for evaluation of myoinvasion. Sonographic results were categorized as superficial (less than or equal to 1/2 myometrial depth) and deep invasion (greater than 1/2 myometrial depth). TAH-BSO followed by retroperitoneal lymph node sampling were performed in all patients with grade 2-3 tumors. In patients with grade 1 disease, the surgical specimen was intraoperatively evaluated by frozen section, and lymph node sampling was carried out if deep invasion was determined. The preoperative sonographic findings and the frozen section results were compared to the final histopathology report of myoinvasion. RESULTS: In 77 of the 91 (84.6%) patients, the sonographic assessment of the depth of myoinvasion was in accord with the final histopathologic findings. TVS demonstrated a sensitivity of 87.8% and a specificity of 82.7% in detecting deep invasion in the entire study group (grade 1-3), with positive and negative predictive values (PPV, NPV) of 74.3% and 92.3%, respectively. TVS in grade 1 cases (n=47) showed a sensitivity of 77.7%, a specificity of 79%, PPV of 46.6% and NPV of 93.7%. TVS in cases with grade 2-3 tumors (n=44) showed a sensitivity of 90%, specificity of 91.6%, PPV of 90% and NPV of 91.6%. Thus, the accuracy of TVS in grade 2-3 cases was superior to that achieved in grade 1 cases (91% vs 78.7%; p=.002). The myometrial invasion was assessed by frozen section in 41 out of 47 patients with grade 1 disease and demonstrated a sensitivity of 85.7%, a specificity of 100%, PPV of 100% and NPV of 97.1%. The specificity (100%) and accuracy (97.5%) of the frozen section were found to be superior compared to that of the TVS (79% and 78.7%) in detecting deep invasion in grade 1 cases (p=.008, p=.005, respectively). No statistically significant difference was found between the sensitivity of either technique. CONCLUSIONS: TVS appeared to be a more accurate method for preoperative assessment of myoinvasion in grade 2-3 endometrial cancer patients compared to grade 1 patients. In grade 1 cases, this method achieved lower accuracy in detecting deep invasion compared to the frozen section analysis. Based on these data, the value of preoperative TVS results as the sole criterion in the decision to perform extensive surgical procedures in grade 1 endometrial cancer is questionable and warrants further evaluation.     

HPV testing and monitoring of women after treatment of CIN 3: review of the literature and meta-analysis

According to the current guidelines in most western countries, women treated for cervical intraepithelial neoplasia grade 3 (CIN 3) are followed for at least 2 years after treatment by cytology.High-risk human papillomavirus (hrHPV) infections are necessary for the development and maintenance of CIN 3. HrHPV testing could be used to improve monitoring of women treated for CIN 3. This has prompted numerous studies for the implementation of hrHPV testing in monitoring of women treated for CIN 3. Included in this review are 20 studies, published between 1996 and 2003, comparing hrHPV testing with either resection margins or cervical cytology to predict recurrent/residual disease, and 11 of them could be used in a meta-analysis.In the meta-analysis of the 11 studies, the negative predictive value (NPV) for recurrent/residual disease of hrHPV testing was 98% (95% CI 97-99%), that of resection margins 91% (95% CI 87-94%), and that of cervical cytology 93% (95% CI 90-95%). When hrHPV testing was performed in conjunction with cytology, the sensitivity was 96% (95% CI 89-99%), specificity was 81% (95% CI 77-84%), the associated positive predictive value (PPV) was 46% (95% CI 38-54%), and the NPV was 99% (95% CI 98-100%). Combined hrHPV and cytology testing yielded the best test characteristics.We propose to include hrHPV testing in conjunction with cytology for monitoring women treated for CIN 3. Some follow-up visits for women testing negative for both hrHPV and cytology can be skipped. In western countries, this could mean that for women double negative at 6 months, retesting at 12 months should be skipped while keeping the 24-month follow-up visit.     

Evaluation of the direct antiglobulin (Coombs') test for identifying newborns at risk for hemolysis as determined by end-tidal carbon monoxide concentration (ETCOc); and comparison of the Coombs' test with ETCOc for detecting significant jaundice.

OBJECTIVE: First, to determine the sensitivity, specificity, and positive predictive value (PPV) of the direct antiglobulin test (DAT) for significant hemolysis in the neonate, as referenced to end-tidal carbon monoxide, the criterion standard for estimating the rate of hemolysis; and second, to evaluate the predictive value of the two procedures for significant jaundice. DESIGN: Consecutive term newborns admitted to the nursery of an inner-city university hospital over a 15-week period. DAT screening by the Blood Bank was performed on all. End-tidal carbon monoxide levels were obtained at 12+/-6 and at 24+/-6 hours of age. Infants of nonsmoking mothers whose 12-hour exhaled carbon monoxide level was > or = 95th percentile were defined as having significant hemolysis. RESULTS: n=660; DAT was positive in 23 (3.5%). Using the 12-hour end-tidal carbon monoxide > or = 3.2 microl/l (> or = 95th percentile) as reference (n=499 nonsmokers), the sensitivity of the DAT was 38.5% (10 of 26) and specificity 98.5% (466 of 473) for the detection of significant hemolysis. The PPV of the DAT for significant hemolysis at 12 hours was 58.8% (10 of 17). For significant jaundice the PPV of end-tidal carbon monoxide was greater than that for DAT (65.4% vs 52.9%), although not statistically so (p=0.25). The negative predictive values were similar. CONCLUSION: DAT fails to identify over half of the cases of significant hemolysis that are diagnosed by end-tidal carbon monoxide. A neonate with a positive DAT has about a 59% chance of having significant hemolysis. End-tidal carbon monoxide may also provide a more sensitive index for predicting significant jaundice.     

Fetal fibronectin as a predictor of preterm delivery in patients with preterm contractions and cervical changes

OBJECTIVE: The purpose of the study was to assess the clinical value of fetal fibronectin assay in the group of women presenting with preterm contractions and cervical changes. STUDY DESIGN: We prospectively evaluated 82 patients between 23-34 weeks of gestation presenting with signs and symptoms of preterm labor, intact membranes and cervical dilatation < 3 cm. In all cases cervico-vaginal samples were collected and assayed for the presence of fetal fibronectin. The primary outcome was delivery < or = 28 days from examination. RESULTS: The rate of preterm delivery (< 37 weeks) was 25.6% (21/82) and 17.1% (14/82) of the patients delivered < or = 28 days from the examination. The mean Bishop score was significantly higher in patients delivered < 28 days (5.9 +/- 1.2 vs 4.7 +/- 1.4; p = 0.004). Positive result of fFN (> 0.05 mg/ml) was found in 71.4% of patients that were delivered < or = 28 days and in 7.4% delivered > 28 days (p < 0.001). For predicting delivery < or = 28 days the positive fFN testing had sensitivity of 71.4%, specificity of 92.7%, PPV of 66.7% and NPV of 94%. The cutoff value for Bishop's score > or = 5 had sensitivity of 85.7% and specificity of 48.5%. Performing fFN testing only in patients with Bishop score > or = 5 resulted in the sensitivity of 71.4%, specificity of 95.6%, PPV of 76.9% and NPV of 94.2%. CONCLUSIONS: Fetal fibronectin is a very good predictor of imminent preterm delivery. It needs further research whether performing of the fFN assay can be limited only to the patients with the estimated Bishop's score > or = 5.     

Effectiveness of sonohysterography in infertile patient work-up: a comparison with transvaginal ultrasonography and hysteroscopy

OBJECTIVE: The aim of this comparative study was to evaluate the accuracy of transvaginal ultrasonography (TVU), sonohysterography (SHG) with sterile saline solution compared to hysteroscopy in the diagnosis of intrauterine pathology in a population of infertile patients before an in vitro fertilization (IVF) program. PATIENTS/METHODS: 98 infertile patients with a mean age of 33.9 years (range 27-41) underwent TVU assessment and SHG with sterile saline solution immediately followed by hysteroscopy. RESULTS: The clinical findings obtained by TVU, SHG and hysteroscopy were compared. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of TVU and SHG compared to hysteroscopy were calculated. The TVU sensitivity and specificity compared with hysteroscopy were 91 and 83% respectively. Using TVU, a 9.2% false positive rate (9 cases) and a 5.1% false negative rate (5 cases) were detected compared to hysteroscopy. The TVU PPV and NPV were 85.4 and 90% respectively. SHG yielded better results: sensitivity and specificity when compared to hysteroscopy were 98 and 94% respectively. The SHG PPV and NPV were 95 and 98% respectively. Accuracy of SHG was significantly better than TVU considering all intrauterine pathologies and polyps. CONCLUSION: In experienced hands, SHG is an easy, safe, and well-tolerated alternative to diagnostic hysteroscopy in the initial evaluation of uterine cavity infertile patients.     

Validation of hysteroscopic view in cases of endometrial hyperplasia and cancer in patients with abnormal uterine bleeding

STUDY OBJECTIVE: To validate hysteroscopic view with histology in cases of endometrial hyperplasia and cancer in patients with abnormal uterine bleeding (AUB) DESIGN: Retrospective study (Canadian Task Force classification II-3). SETTING: University teaching hospitals in Rio de Janeiro and S?o Paulo, and private office in Rio de Janeiro. PATIENTS: Four thousand and fifty-four patients with AUB in whom hysteroscopic views were complete and the histologic result was conclusive. INTERVENTION: Four thousand and fifty-four office hysteroscopies with complete views and conclusive histologic results. The material for histologic examination was obtained through biopsy of the lesion in an outpatient unit or through the resection of the entire lesion in patients who underwent surgery. Histology was considered the "gold standard" and compared with the hysteroscopic view. MEASUREMENTS AND MAIN RESULTS: In the histology of the 4054 examinations, 613 (15.2%) were endometrial hyperplasia, and 105 (2.6%) were endometrial cancer. The most frequent hysteroscopic finding was endometrial polyps (31.2%). In endometrial hyperplasia, the sensitivity of the hysteroscopic view was 56.3% (95% CI 52.2%-60.2%), specificity was 89.1% (95% CI 88.0%-90.1%), positive predictive value (PPV) was 48.0% (95% CI 44.3%-51.7%), negative predictive value (NPV) was 92.0% (95% CI 90.1%-92.9%), and accuracy was 72.7% (95% CI 70.7%-74.7%). Accuracy was defined as the proportion of correct results among the hysteroscopic examinations. In endometrial cancer, the sensitivity of the hysteroscopic view was 80.0% (95% CI 71.1%-87.2%), specificity was 99.5% (95% CI 99.2%-99.7%), PPV was 81.5% (95% CI 72.7%-88.5%), NPV was 99.5% (95% CI 99.2%-99.7%), and accuracy was 89.8% (95% CI, 85.9%-93.6%). In the 814 patients (20.0%) in whom the hysteroscopic view was normal, there were no false negatives for endometrial cancer; however, there were 37 (4.5%) false negatives for endometrial hyperplasia. In the histologic cases of endometrial cancer, 101 (96.2%) hysteroscopic views were compatible with cancer or hyperplasia (80.0% and 16.2%, respectively). Ninety-seven out of 103 hysteroscopic views with cancer findings (94.2%) had histologic diagnosis of cancer or hyperplasia (81.5% and 12.6%, respectively). CONCLUSION: It seems that even in face of good validity of hysteroscopic view for endometrial hyperplasia and cancer, histologic study is mandatory in the presence of any lesion as the hysteroscopic view cannot completely replace the histologic study in patients with AUB.     

The validation of a computerized system for the interpretation of the antepartum fetal heart rate tracings (version 89/2.34).

We have developed a knowledge-based system for the interpretation of the antepartum fetal heart rate tracings. This study consists of four groups of patient: (1) 49 normal pregnancies with a normal perinatal outcome; (2) 13 normal pregnancies with abnormal perinatal outcome; (3) 33 high-risk pregnancies with abnormal perinatal outcome; and (4) 16 high-risk pregnancies with normal perinatal outcome. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of our expert system (version 89/2.34) were estimated to be 60.0, 85.7, 75.0 and 75.0%, respectively. When the normal pregnancies with abnormal outcome and the high-risk pregnancies with normal outcome were excluded from the population, sensitivity, specificity, PPV and NPV were calculated to be 57.7, 82.9, 68.2 and 75.6%, respectively (corrected values). The prevalance of abnormal outcome for this study was 41.7%.     

Comparison of conventional versus three-dimensional ultrasound in fetal renal pelvis measurement and their potential prediction of neonatal uropathies

Objective: To establish a threshold value for fetal renal pelvis dilatation measured by automatic volume calculation (SonoAVC) in the third trimester of pregnancy to predict neonatal uropathies, and to compare these results with conventional antero–posterior (AP) measurement, fetal kidney 3D volume and renal parenchymal thickness.

Methods: In a prospective cohort study, 125 fetuses with renal pelvis AP diameter of ≥5?mm both at 20 weeks of gestation and in the third trimester, underwent an additional 3D volume measurement of the fetal kidney in the third trimester. Receiver operating characteristic (ROC) curves for establishing threshold values for fetal renal pelvis volume, AP measurement, fetal kidney volume and renal parenchymal thickness to predict neonatal uropathies were analyzed. Also, sensitivity, specificity, area under the curve (AUC) and likelihood ratios were calculated.

Results: A cut-off point of 1.58?cm³ was identified in the third trimester of pregnancy (AUC 0.865 (95% CI 0.789–0.940), sensitivity 76.3%, specificity 87.4%, LR+?6.06, LR??0.27) for measurements with SonoAVC. A cut-off value of 11.5?mm was established in the third trimester of pregnancy (AUC 0.828 (95% CI 0.737–0.918), sensitivity 71.1%, specificity 85.1%, LR+?4.77, LR??0.34) for the conventional AP measurement. A cut-off point for fetal kidney volume was calculated at 13.29?cm³ (AUC 0.769 (95% CI 0.657–0.881), sensitivity 71%, specificity 66%, LR+?2.09, LR??0.44). For renal parenchymal thickness, a cut-off point of 8.4?mm was established (AUC 0.216 (95% CI 0.117–0.315), sensitivity 31.6%, specificity 32.6%, LR+?0.47, LR??2.10).

Conclusion: This study demonstrates that 3D fetal renal pelvis volume measurements and AP measurements both have a good and comparable diagnostic performance, fetal renal volume a fair accuracy and renal parenchymal thickness a poor accuracy in predicting postnatal renal outcome.     

Value of a single early third trimester fetal biometry for the prediction of birth weight deviations in a low risk population

OBJECTIVE: To analyze the value of a single ultrasound biometry examination at the onset of the third trimester of pregnancy for the detection of small-for-gestational-age (SGA) and large-for-gestational-age (LGA) at birth in a low risk population. The aim of this study was to develop a simple and useful method for the detection of growth deviations during pregnancy in primary care (midwife or general practitioner) practices. SETTING: A Dutch primary care midwifery practice. STUDY DESIGN: In an earlier study, we developed parity and sex specific fetal growth charts of abdominal circumference (AC) and head circumference (HC) on the basis of ultrasound data of a low-risk midwifery population in the Netherlands. In the present study, we calculated sensitivity, specificity and predictive values at different cut-off points of AC and HC for the prediction of growth deviations at birth. Patients booked for perinatal care between 1 January 1993 and 31 December 2003 (n=3449) were used for the identification of cut-off points (derivation cohort) and those admitted between 1 January 2004 and 31 December 2005 (n=725) were used to evaluate the performance of these cut-offs in an independent population (validation cohort). For the determination of SGA and macrosomia at birth, we used the recently published Dutch birth weight percentiles. RESULTS: Most promising cut-offs were AC or=75(th) percentile for the prediction of macrosomia (birth weight >or=90(th) percentile). Within the validation cohort these cut-offs performed slightly better than in the derivation cohort. For the prediction of SGA, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 53% (95% CI 49-58%), 81% (95% CI 80-83%), 26% (95% CI 23-29%), and 93% (95% CI 93-94%), respectively. The false positive rate was 74%. For the prediction of macrosomia, the values of these parameters were 64% (95% CI 59-69%), 80% (95% CI 78-81%), 23% (95% CI 20-26%), and 96% (95% CI 95-97%), respectively. Here, false positive rate was 77%. No cut-offs were found that predicted extreme birth weight deviations (or=97.7 percentile) sufficiently well. CONCLUSIONS: In a low risk population, we could predict future growth deviations with a higher sensitivity and in a significant earlier stage (at the onset of the third trimester of pregnancy) than with the use of conventional screening methods (i.e., palpation of the uterus only and fundus-symphysis measurement). Sonographic measurement of fetal abdominal circumference enables to detect more than half of cases of SGA at birth and more than two-thirds of cases of macrosomia with acceptable false-positive rates. We suggest that fetuses with biometry results below the 25(th) percentile or above the 75(th) percentile at the onset of the third trimester of pregnancy should be more intensively investigated in order to distinguish between pathology (e.g., IUGR or macrosomia) and physiology and to decide about the appropriate level of further perinatal care.     

Calcium-creatinine ratio and microalbuminuria in prediction of preeclampsia

Objectives

To evaluate the predictive values of urinary calcium creatinine ratio (CCR) and microalbuminuria for preeclampsia.

Methods

Urinary calcium creatinine ratio and microalbuminuria were determined in a spot urine sample in 200 asymptomatic pregnant women between 20–24 weeks of gestation, who attended the antenatal OPD at St John’s Medical College and Hospital. The results were analyzed by Chi square test and Fisher Exact test to find the significant association of findings of preeclampsia and CCR and microalbuminuria. Area under Receiver Operator Curve (ROC) was used to find the predictive values of CCR at less than or equal to 0.04 and microalbuminuria for preeclampsia.

Results

It was found that CCR had a sensitivity, specificity, Positive Predictive Value (PPV) and Negative Predictive Value (NPV) of 69.2%, 98.2%, 85.7% and 95.8% respectively with a statistical accuracy of 87% and p value of <0.001 (strongly significant). It was found to be a good test for prediction of preeclampsia. Microalbuminuria had sensitivity, specificity, PPV and NPV of 53.6%, 86%, 36% and 95% and was found to be only a fair test for prediction of preeclampsia.

Conclusion

CCR at 0.04 in spot urine sample being a good test for prediction of preeclampsia can be recommended as a screening test in all asymptomatic pregnant women, for preeclampsia. Microalbuminuria does not seem to be effective as a screening tool for preeclampsia at present.