The first trimester 'combined test' for the detection of Down syndrome pregnancies in 4939 unselected pregnancies

The high detection rate (DR) for Down syndrome (DS) pregnancies which can be achieved by measuring fetal nuchal translucency (NT) early in pregnancy can be improved by combining it with placental hormones [pregnancy-associated plasma protein A (PAPP-A) and free beta-human chorionic gonadotrophin (fbeta-hCG)] and maternal age ('combined test'). In this study we wanted to assess the DR using the 'combined test' in an unselected population of self-referred pregnant women at a false-positive rate (FPR) of about 5%. NT, PAPP-A, fbeta-hCG and maternal age were measured in all women with singleton pregnancies who booked for delivery in our hospital from 1 December 1997 to 31 April 2000 and who were between 10 and 13 completed weeks of gestation [crown-rump length (CRL) 35-70 mm]. The specific DS risk was calculated using the computer program Alpha Version 5aa (Logical Medical Systems, London, UK). A total of 4939 women were tested. Out of 14 DS pregnancies that occurred during this period of time, 12 were detected with the test. A total of 246 women had a false-positive test result in a non-DS pregnancy (FPR 5.0%). This makes the 'combined test' by far the best test for the detection of DS pregnancies in a low-risk population. The constant increase in maternal age at the time of delivery can also lead to an improved DR if a simple age-dependant protocol for DS detection is used, but only at the price of a much higher number of amniocenteses and subsequent abortions. The DR for DS can be increased much more markedly using the 'combined test' with a FPR that still remains at the level as it was in the early 1970s.     

Prenatal diagnosis: what does four-dimensional ultrasound add?

INTRODUCTION: The key benefit of 4D ultrasound lies in providing real-time 3D images of embryonic or fetal movements, previously limited by technological advancement. AIM: To classify types of first trimester embryonic and fetal movements in normal pregnancies as seen by 4D sonography. RESULTS: Three types of movements can be visualized in the first trimester: gross body between seven and eight weeks, limb movements after ten weeks and complex limb movements after 11 weeks of gestation. DISCUSSION: An alteration from the given pattern of motoric development should be considered as an indication for further investigation. CONCLUSION: 4D ultrasound enables visualization of more details of the dynamics of small anatomical structures. Therefore, body and limb movements can be visualized a week earlier than with 2D.     

Role of hysteroscopy in detection and extraction of endometrial polyps: results of a prospective study

OBJECTIVE: The aim of this study was to determine whether hysteroscopy improves the detection and extraction of endometrial polyps in postmenopausal women. This method was compared with curettage complemented by Randall polyp forceps. STUDY DESIGN: In a prospective study hysteroscopy was performed before and after curettage in postmenopausal women. In addition to curettage, the Randall polyp forceps was used to extract endometrial polyps. Curettage and polyp extraction by Randall forceps were performed by a second surgical team that did not know the results of hysteroscopy. RESULTS: A total of 83 patients were included in the study because of either postmenopausal bleeding (n = 40) or ultrasonographic abnormal endometrium (n = 37), or both (n = 6). Thirty-two patients received either hormone replacement therapy or tamoxifen. Hysteroscopy revealed endometrial polyps in 51 patients. Polyps were diagnosed by curettage alone in 22 (43%) cases. In 18 of these 22 cases remnants of polyps were extracted by Randall forceps, and in another 23 cases polyps were only found by use of the Randall forceps. Thus in 45 (88%) of 51 patients the detection of endometrial polyps by curettage and Randall forceps was possible. A second hysteroscopy procedure revealed remnants of polyps or polyps in 31 cases. These patients with incomplete curettage predominantly had a preoperative endometrial thickness of > or =10mm. CONCLUSIONS: Curettage alone in postmenopausal patients is not sufficient for detection and extraction of endometrial polyps. Additional use of Randall forceps improves detection of polyps considerably. However, with both procedures complete extraction of polyps was not achieved in a considerable number of patients. Hysteroscopy-controlled extraction was superior, especially in those patients with an endometrial thickness of >10 mm.     

Impact of pathogen burden in patients with coronary artery disease in relation to systemic inflammation and variation in genes encoding cytokines

The number of infectious pathogens to which an individual has been exposed (pathogen burden) has been linked to the development and the prognosis of coronary artery disease (CAD). The interaction among infection, genetic host susceptibility, and CAD remains unclear. This study was aimed at evaluating the modulation of the association between CAD and pathogen burden, by serum levels of inflammatory markers and polymorphisms of the interleukin (IL)-6 and tumor necrosis factor (TNF)-alpha genes. Immmunoglobulin (Ig) G or IgA antibodies to 8 pathogens were determined in 991 patients with CAD and 333 control subjects. Serum levels of high-sensitivity C-reactive protein, fibrinogen, IL-6, and TNF-alpha were also measured. All subjects were genotyped for the IL-6/G-174C, the TNF/C-851T, and the TNF/G-308A polymorphisms. Analysis of single pathogens demonstrated a positive relation to the presence of CAD for some (Chlamydia pneumoniae, cytomegalovirus, Helicobacter pylori, and herpes virus simplex type 1), but not all pathogens. A strong association between increasing pathogen burden and CAD was confirmed, even after adjustment for risk factors. The prevalence of a high pathogen burden (>/=4 pathogens) was 50% in patients and 21% in controls (p <0.0001). A high pathogen burden was associated with decreased high-density lipoprotein cholesterol levels (p <0.001). The association between CAD and pathogen burden was modulated by the IL6/G-174C polymorphism, the odds ratio being higher in heterozygotes than in both types of homozygotes (p <0.05). This interaction appeared to be mediated by variations in serum IL-6 levels. No such interaction was detected with any of the 2 TNF-alpha polymorphisms.     

Estimating the relative risk in cohort studies and clinical trials of common outcomes

Logistic regression yields an adjusted odds ratio that approximates the adjusted relative risk when disease incidence is rare (<10%), while adjusting for potential confounders. For more common outcomes, the odds ratio always overstates the relative risk, sometimes dramatically. The purpose of this paper is to discuss the incorrect application of a proposed method to estimate an adjusted relative risk from an adjusted odds ratio, which has quickly gained popularity in medical and public health research, and to describe alternative statistical methods for estimating an adjusted relative risk when the outcome is common. Hypothetical data are used to illustrate statistical methods with readily accessible computer software.     

The role of inflammation and infection in acute coronary syndrome

INFLAMMATORY PROCESS: Within the vessel wall is considered to be crucial for initiation and progression of atherosclerosis. As response to endothelial injury a focal inflammatory response arises which can lead to plaque vulnerability and rupture and a consecutive acute coronary syndrome. Systemic markers of inflammation like C-reactive protein (CRP) or interleukin (IL) 6 are elevated in stable angina and acute coronary syndrome and are associated with future cardiovascular events even in initially healthy people. Alongside classical risk factors infectious agents like cytomegalovirus or Chlamydia pneumoniae are discussed to be involved in the local and systemic inflammatory response. Seroepidemiological studies revealed disparate results of the association between antibody titers against Chlamydia pneumoniae or cytomegalovirus and prevalence of coronary artery disease or future cardiovascular events. In animal models Chlamydia pneumoniae and cytomegalovirus increase accelerated neointimal response, however, molecular mechanisms are not entirely clear. CONCLUSION: Whereas local and systemic inflammatory processes play a crucial role in atherogenesis and prognosis the causal role of infection in atherogenesis remains controversial.     

Die Radiofrequenzablation des weichen Gaumens (Somnoplastik)

Twenty-nine patients (26 male and 3 female) with habitual or obstructive snoring and socially disturbing character were followed over a ten week period. All patients were treated with radiofrequency volumetric tissue reduction (RFVTR) of the soft palate. In 21 patients this operation was combined with other surgery of the upper airway, eight patients had soft palate reduction with RFVTR exclusively. With this method an electrode is positioned in the musculature of the soft palate submucosally. RFVTR may be performed under local anesthesia and has to be repeated if necessary. Ten weeks postoperatively 24 of 29 patients, respectively their social-partners, reported subjective reduction of snoring after the first treatment. Markable improvement of snoring was seen in 20 of 29 patients postoperatively and reduction of the respiratory-disturbance-index (RDI) for more than 10 was noticed in 7/29 patients polysomnographically. 5/8 patients who were treated with RFVTR exclusively, showed reduction of snoring and 3/8 patients had RDI-reduction for more than 10. We conclude, that RFVTR of the soft palate is successful in the treatment of snoring and may be helpful in the treatment of mild obstructive-sleep-apnea-syndrome (OSAS).