SURUSS in perspective

BACKGROUND: Until the publication of the Serum Urine and Ultrasound Screening Study (SURUSS) report, it was difficult to compare the different antenatal screening tests for Down's Syndrome because of variations in study designs. We here present the main results from SURUSS, updated to take account of recent information on nuchal translucency in Down's Syndrome pregnancies, and discuss their implications. METHODS: SURUSS was a prospective study of 47,053 singleton pregnancies (including 101 pregnancies with Down's Syndrome) conducted in 25 maternity units. Nuchal translucency measurements were taken. Serum and urine samples collected between 9 and 13 weeks, and again between 14 and 20 weeks of pregnancy were stored. Samples from each affected pregnancy and five matched controls were tested for currently used or suggested biochemical Down's Syndrome screening markers. Pregnancies were followed up to determine the presence or absence of Down's Syndrome. For an 85% Down's Syndrome detection rate, the false-positive rate for the Integrated test (nuchal translucency and pregnancy associated plasma protein-A [PAPP-A] at 11 completed weeks of pregnancy, and alpha-fetoprotein, unconjugated oestriol [uE(3)], free beta or total human chorionic gondaotrophin (hCG) and inhibin-A in the early second trimester) was 0.9%, the Serum integrated test (without nuchal translucency) 2.7%, the Combined test (nuchal translucency with free beta-hCG and PAPP-A at 11 weeks) 4.3%, the Quadruple test (alpha-fetoprotein, uE(3), free beta or total hCG and inhibin-A) 6.2%, and nuchal translucency at 11 weeks, 15.2%. All tests included maternal age. Using the Integrated test at an 85% detection rate, there would be six diagnostic procedure-related unaffected fetal losses following amniocentesis per 100,000 women screened compared with 35 using the Combined test or 45 with the Quadruple test. CONCLUSIONS: The Integrated test offers the most effective and safe method of screening for women who attend in the first trimester. The next best test is the Serum integrated test. The Quadruple test is the best test for women who first attend in the second trimester. There is no justification for retaining the Double (alpha-fetoprotein and hCG) or Triple (alpha-fetoprotein, uE(3), and hCG) tests, or nuchal translucency alone (with or without maternal age) in antenatal screening for Down's Syndrome.     

Thoracoscopy in perspective.

The indications for thoracoscopy are undiagnosed pleural disease effusions of tumors; when tissue specificity is important for future treatment and adequate tissue is needed for estrogen binding studies; undiagnosed pleuropulmonary disease; biopsy of pulmonary lesions undiagnosed by other means; mediastinal masses, particularly in children; hilar masses; preoperative screening preliminary to thoracotomy for resection in malignant disease, particularly those with effusions; in spontaneous pneumothorax, to define the abnormality and indicate the need for thoracotomy; for postresection space problems; trauma, and, of course, for intrapleural pneumonolysis.     

Objective perspective in colposcopy

Colposcopy is a widely used diagnostic procedure, primarily in the assessment of women with abnormal cervical cytology. It is used by appropriately trained individuals using techniques that allow a full assessment of the abnormality and plan for further investigation or treatment. Certain key features are specifically looked for, and a colposcopic impression formed. Using a systematic approach to the colposcopic assessment can improve the diagnostic accuracy. In this chapter, we review various factors and meta-analyses in relation to the diagnostic performance of colposcopy. Newer technologies are being developed that will assist the clinician in assessing the colposcopic changes. Quality assurance of the training and practise of colposcopy is important to maintain appropriate management for women with cytological abnormalities.     

Kroener tubal ligation in perspective

An extensive review of the literature and clinical study of 404 women undergoing surgical sterilization procedures at the David Grant USAF Medical Center, Travis AFB, in 1970 and 1971, were made in order to evaluate the current status of tubal ligations, with their particular advantages and complications. Ninety-five per cent of 256 patients responded to follow-up written questionaire 6 to 22 months after their operation. Tubal ligation failure rate was 0.9 per cent, and 3.2 per cent of patients who underwent tubal ligation required further pelvic operations. It was concluded that tubal ligations in general and colpotomy with Kroener fimbriectomy in particular remain among the most effective, economic, rapid, safe, simple, and best accepted surgical sterilization procedures available. This procedure is attended by fewer complications than any of the other methods evaluated with the possible exception of laparoscopy with tubal fulguration, which requires further evaluation.     

Cervical cancer epidemiology in historical perspective

In 1846, uterine cancer was the most frequently observed malignant tumor in western Europe. It accounted for nearly 1/3 of all reported deaths in Paris. The cervix was regarded as the primary source in most cases. Several etiological theories in vogue today were discussed then. The relative infrequency of cervical cancer among Jewish women was reported by numerous writers. The possible role of circumcision of husbands was not seriously considered until 1935. More recent such studies have been inconclusive. A definite reduction in the death rate from cervical cancer has been evident since 1950. The parallel rise in incidence is accounted for by the more numerous in situ cases detected through cytologic screening. Nonwhite women in America above age 60 as well as the elderly in England and Wales have not shown equally improved rates. The hypothesis that the genital strain of herpes simplex virus (HSV-2), a venereally transmitted virus, is associated with cervical cancer has been advanced and much new evidence has recently been reporte d. A positive association between cervical cancer and HSV-2 antibodies is evident. Progression of dysplasia and carcinoma in situ is of uncert ain occurrence. Prolonged periodic check-up studies are needed to deter mine this. If the facts warrant, follow-up by aggressive therapy is indicated. Observer variability has been a problem. 1 pathologists' interpretation of dysplasia may be another's carcinoma in situ. The more severe dysplasias have been more likely to progress. Periodic cytological screening has reduced the percentages of cases 1st diagnosed in the invasive stage to 1/2 on 1/3 of the former incidence. Increases in survival rates have followed. Patients with regional spread have experienced little gain. Women at highest risk have tended to elude examinations.     

Prostaglandins: perspective in obstetrics and gynecology

Prostaglandins (PGs) are metabolic regulators produced at the cellular level to exert a local action, usually of a modulating type. Their biological function is analogous to cycle adenosine 3",5' monophosphate (cAMP) (i.e., acting as messengers) rather than to a steroid function, although PGs interact with both cAMP and steroids. Clinicians need to know the endogenous biosynthesis of PGs, their metabolism, and their detection to use PGs therapeutically with competence. Apparently, endogenous biosynthesis of PGs is catalyzed by a microsomal enzyme system composed of many different enzyme types. The required precursors are essential fatty acids, arachidonic acid, and bis-homo-y-linolieic acid in the unesterified form. Molecular oxygen and other cofactors are also required. This biosynthesis was worked out in sheep seminal vesicles, but it is now recognized that virtually all tissue types in mammals synthesize PGs. The metabolic degradation and inactivation of PGEs and PGFs, both derived from the same intermediate, are extremely rapid (Samuelsson et al., 1971, 1972). The most important first step is oxidation of the 15-hydroxyl group to a carbonyl, which modifies the activities of PGs and allows further degradation and elimination via urine; this series of steps protects the body from these potent agents. Detection and analysis are best achieved by deuterium-labeled intermediates which are determined by mass spectrometry. It is important to remember that various tissues have widely varying responses to PGs; for example, PGs have luteolytic action in sheep but do not induce uterine contractions, whereas the opposite seems true in humans.