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Byline: Ray Bahado-Singh, Utku Oz, Kirse Rinne, David Hunter, Laurence Cole, M.J. Mahoney, Alex Baumgarten Keywords: [beta]-Core fragment of human chorionic gonadotropin; Down syndrome; triple test Abstract: Objective: This study was undertaken to compare the Down syndrome screening efficiency of elevated maternal urine level of the [beta]-core fragment of human chorionic gonadotropin with that of the traditional serum triple test. Study Design: Urinary [beta]-core fragment and serum analyte levels were measured prospectively in women with singleton pregnancies who were undergoing second-trimester genetic amniocentesis. Urinary analyte levels were measured within a week of specimen collection. In some cases only [alpha]-fetoprotein was measured initially and human chorionic gonadotropin and unconjugated estriol levels were subsequently determined from the stored serum specimens. The Down syndrome screening efficiency of urinary concentration of [beta]-core fragment plus maternal age was compared with that of the traditional triple test. Receiver operating characteristic curves were generated for each algorithm and the areas under the curves were compared to determine which algorithm was superior. Results: There were a total of 926 study patients, of whom 21 (2.3%) carried fetuses with Down syndrome. The mean ([+ or -]SD) gestations at amniocentesis were 16.6 [+ or -] 1.5 weeks for the fetuses without Down syndrome and 17.7 [+ or -] 2.3 for the fetuses with Down syndrome. A total of 539 women (4 of whom carried fetuses with Down syndrome) had serum [alpha]-fetoprotein alone measured initially. Urinary concentration of [beta]-core fragment had a 61.9% detection rate with a 4.9% false-positive rate for Down syndrome, whereas the values for the triple screen were 57.1% and 11.2%, respectively. The areas under the receiver-operating characteristic curves were 0.8744 for elevated urinary [beta]-core fragment level and 0.7504 for the triple screen (P = .1116). When the false-positive rate was fixed at an ideal threshold value ([less than or equal to]5%) the urine test was superior (area under the curve, 0.0212 vs 0.0133, P < .05). Similarly, when we considered only cases in which the complete triple screen was performed prospectively (17 fetuses with Down syndrome and 431 fetuses without Down syndrome), the urine test was significantly better (area under the curve, 0.873 vs 0.624, P = .012). Conclusion: In this first reported direct comparison we consistently observed higher sensitivity values for screening with urinary levels of [beta]-core fragment than for serum triple screen, suggesting an equivalent or superior Down syndrome screening performance for the urinary analyte. It is important that freezing and prolonged urine storage before testing be avoided. The reduced cost (single- versus triple-analyte testing) and excellent screening performance support large-scale testing and evaluation of maternal urinary [beta]-core fragment measurement as an alternative to the traditional serum triple test. (Am J Obstet Gynecol 1999;181:929-33.) Author Affiliation: New Haven and Norwalk, Connecticut From the Department of Obstetrics and Gynecology, Yale University School of Medicine,.sup.a and the Department of Obstetrics and Gynecology, Norwalk Hospital..sup.b Article Note: (footnote) [star] Supported in part by a grant from The Norwalk Hospital, Norwalk, Connecticut., [star][star] Reprint requests: Ray Bahado-Singh, MD, Yale University School of Medicine, Department of Obstetrics and Gynecology, 333 Cedar St, New Haven, CT 06520-8063., a 0002-9378/99 $8.00 + 0 6/6/101979

Byline: Khalid S. Khan, Sabina F. Khan, Chika R. Nwosu, Neil Arnott, Patrick F.W. Chien Keywords: Diagnostic test; bias; likelihood ratio Abstract: Objective: Our goal was to determine the validity of authors' inferences about the value of the cervico-vaginal fetal fibronectin test in the prediction of preterm birth and the utility of uterine artery Doppler waveform analysis in the prediction of preeclampsia. Study Design: We evaluated all 35 diagnostic test studies (14 on fetal fibronectin and 21 on uterine artery Doppler) included in 2 meta-analyses. The information on authors' conclusions regarding the value of a positive or negative test result was independently abstracted from each article by 2 reviewers, and it was classified as definitely useful, moderately useful, slightly useful, or not at all useful. For the 'gold' standard, likelihood ratios of >10 and Author Affiliation: Birmingham and Dundee, United Kingdom From the Academic Department of Obstetrics and Gynaecology, University of Birmingham, Birmingham Women's Hospital,.sup.a and the Department of Obstetrics and Gynaecology, Ninewells Hospital and Medical School..sup.2 Article History: Received 2 October 1998; Revised 2 December 1998; Accepted 28 January 1999 Article Note: (footnote) [star] Reprint requests: Khalid S. Khan, MB, BS, MSc, Lecturer, Academic Department of Obstetrics and Gynaecology, Birmingham Women's Health Care NHS Trust, Birmingham, United Kingdom B15 2TH., [star][star] 0002-9378/99 $8.00 + 0 6/1/97472

Children whose autism was not detected by the Modified Checklist for Autism in Toddlers (M-CHAT) at 18 months old were more likely to have delays in social, communication, and fine [...]

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2016 MAR 12 (NewsRx) -- By a News Reporter-Staff News Editor at Obesity, Fitness & Wellness Week -- Investigators publish new report on Oncology. According to news reporting originating from [...]

2016 MAR 5 (NewsRx) -- By a News Reporter-Staff News Editor at Obesity, Fitness & Wellness Week -- Data detailed on Oncology have been presented. According to news originating from [...]

Byline: Gary J. Mires, Fiona L.R. Williams, Janice Leslie, Peter W. Howie Keywords: Notches; screening; uterine artery Abstract: Objective: The objective of the study was to evaluate the screening potential of routine uterine arterial Doppler ultrasonography as a predictor of adverse pregnancy outcome. Study Design: All women (n = 6579) with singleton pregnancies undergoing a fetal anomaly scan at 18 to 20 weeks' gestation between January 1, 1994, and December 31, 1995, at Ninewells Hospital and Medical School were screened for the presence of uterine arterial notching. Women who had evidence of bilateral notching were rescanned at 22 to 24 weeks' gestation. Outcome measures included proteinuric hypertension, premature separation of the placenta, and birth weight z score. Results: The sensitivity and positive predictive value of uterine arterial notching as a predictor of adverse pregnancy outcomes was low. For all types of notching and disease, outcome sensitivity was never higher than 44% and positive predictive value was never higher than 27%. In contrast, the relative risk of adverse pregnancy outcome in the presence of uterine arterial notching was uniformly high for all disease outcomes (range of relative risk 3.5-30.7). Significant obstetric morbidity was seen in 57% of women with bilateral notches at 18 to 20 weeks' gestation and 72% of women with persistent bilateral notches. Conclusions: As a screening test for adverse pregnancy outcomes, detection of uterine arterial notching is poor. Nevertheless, the presence of bilateral uterine arterial notching is associated with a significantly increased risk of adverse pregnancy outcome. In units performing routine anomaly screening, the addition of maternal uterine arterial Doppler ultrasonography may help to discriminate this small group of women at high risk. (Am J Obstet Gynecol 1998;179:1317-23.) Author Affiliation: Dundee, United Kingdom Article History: Received 20 January 1998; Revised 16 March 1998; Accepted 5 May 1998 Article Note: (footnote) [star] From the Departments of Obstetrics and Gynaecology,a Epidemiology and Public Health,b and Obstetric Ultrasound,c Ninewells Hospital and Medical School., [star][star] Reprint requests: Gary Mires, MD, Department of Obstetrics and Gynaecology, Ninewells Hospital and Medical School, Dundee, Tayside, United Kingdom DD1 9SY., a 0002-9378/98 $5.00 + 0 6/1/91464

Byline: Timothy R.B. Johnson, Lisa L. Paine, Donna M. Strobino, Frank R. Witter Keywords: Antepartum testing; nonstress test; racial difference Abstract: OBJECTIVE: The object of the study was to determine whether population differences exist with respect to outcomes of women with reactive and nonreactive nonstress test results. STUDY DESIGN: An epidemiologic evaluation was conducted on 2579 women who underwent nonstress tests in the Fetal Assessment Center of the Johns Hopkins Hospital within a week of delivery. Risk factors such as hypertension, diabetes, and postterm pregnancy were used in a logistic regression model to evaluate the ability of the nonstress test to predict outcomes including proxies of fetal distress and fetal and neonatal death. The sensitivities, specificities, and predictive values of the nonstress test for predicting these outcomes in cohorts of black and white women were also determined. RESULTS: The nonstress test was consistently more sensitive for black women than for white women in predicting several perinatal outcomes, but specificity and negative predictive value were consistently lower for black women. The positive predictive value for fetal and neonatal death was higher for white women than for black women. Although the nonreactive nonstress test result seemed to be predictive of certain perinatal events, the odds ratio for predicting perinatal mortality in any study population was no greater than when the nonstress test result was reassuring. CONCLUSIONS: Epidemiologic characteristics affecting test results, such as disease prevalence and population differences, may lead to clinically significant differences in outcome prediction when these tests' results are used. These differences should be considered in the implementation of antepartum fetal testing programs. (Am J Obstet Gynecol 1998;179:779-83.) Author Affiliation: Baltimore, Maryland Article History: Received 16 December 1997; Revised 4 February 1998; Accepted 11 March 1998 Article Note: (footnote) [star] From the Fetal Assessment Center, Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University and Hospital., [star][star] Reprint requests: Timothy R.B. Johnson, MD, Department of Obstetrics and Gynecology, University of Michigan Medical Center, 1500 E Medical Center Dr, L4000 Women's Hospital, Box 0276, Ann Arbor, MI 48109-0276., a 0002-9378/98 $5.00 + 0 6/1/90204

Byline: Michael J. Hussey, Edward S. Levy, Xavier Pombar, Peter Meyer, Howard T. Strassner Keywords: Amniotic fluid; chorioamnionitis; glucose; Gram stain Abstract: OBJECTIVE: The aim of the study was to compare the diagnostic utility of the Gram stain, the amniotic fluid glucose level, and the ratio of amniotic fluid glucose level to serum glucose level in detecting intra-amniotic infection. STUDY DESIGN: We conducted a prospective study of 127 patients with preterm labor and 26 patients with preterm premature rupture of the membranes (153 total). All patients underwent amniocentesis to diagnose intra-amniotic infection. The diagnostic criterion for intra-amniotic infection was a positive amniotic fluid culture result. RESULTS: The Gram stain is 80% sensitive and 91% specific when a positive is considered the presence of white blood cells or bacteria. Amniotic fluid glucose level and the ratio of amniotic fluid glucose level to serum glucose level are significantly lower when amniotic fluid culture results are positive, but as diagnostic tests they are inferior to the Gram stain. Logistic regression models that combine predictors yield superior accuracy with respect to individual tests. The most accurate combination was amniotic fluid glucose level and Gram stain with white blood cells or bacteria. Although the number of patients with preterm premature rupture of the membranes was small in this study (n = 26), analysis of our data suggests that the diagnostic performance levels of these tests were similar when used in patients with preterm labor and intact membranes and in patients with premature rupture of the membranes. CONCLUSIONS: The amniotic fluid glucose level and the ratio of amniotic fluid to serum glucose level have equivalent diagnostic utility and are inferior to the Gram stain. The combination of Gram stain with amniotic fluid glucose level is superior to any individual test. (Am J Obstet Gynecol 1998;179:650-6.) Author Affiliation: Chicago, Illinois Article History: Received 25 April 1996; Revised 14 May 1996; Accepted 13 February 1998 Article Note: (footnote) [star] From the Section of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Rush-Presbyterian-St Luke's Medical Center., [star][star] Reprint requests: Michael J. Hussey, MD, Department of Obstetrics and Gynecology Section of Maternal-Fetal Medicine, Rush-Presbyterian-St Luke's Medical Center, 1653 W Congress Pkwy, Chicago, IL 60612., a 0002-9378/98 $5.00 + 0 6/1/89547

Byline: J.Douglas Kirk, Samuel Turnipseed, William R Lewis, Ezra A Amsterdam Abstract: Study objectives: To determine the safety and utility of immediate exercise testing in the evaluation of low-risk patients presenting to the emergency department with chest pain and its applicability to a heterogeneous population of men and women. Methods: We conducted a prospective study of the safety and utility of immediate exercise testing in low-risk patients, as indicated by clinical and ECG criteria. The study group was large, heterogeneous, and included patients with a history of coronary artery disease. The patients were treated at a large, university medical center. Exercise testing (immediate exercise treadmill testing) was performed by internists, and cardiac serum enzyme levels were not measured before the exercise test. Results: A total of 212 patients (121 men, 91 women) underwent exercise testing with no adverse effects. Twenty-eight (13%) patients had positive results on exercise ECGs. Twenty-three of the latter had further evaluation that revealed evidence of coronary artery disease in 13 (57%). Fifty-nine percent (125/212) of patients had negative exercise test results and 28% (59/212) had nondiagnostic tests. All patients with negative test results and 93% with nondiagnostic test results were discharged directly from the ED. Thirty-day follow-up was achieved in 201 (95%) patients and revealed no mortality in any of the patients in the three groups. One patient with a positive exercise test result returned to the ED within 30 days with mild congestive heart failure. Conclusion: Our results in this patient population support the safety and utility of immediate exercise testing of low-risk patients who present to the ED. [Kirk JD, Turnipseed S, Lewis WR, Amsterdam EA: Evaluation of chest pain in low-risk patients presenting to the emergency department: The role of immediate exercise testing. Ann Emerg Med July 1998;32:1-7.] Article History: Received 16 September 1996; Revised 20 January 1998; Accepted 10 February 1998 Article Note: (footnote) [star] From the Divisions of Emergency Medicine and Cardiovascular Medicine, Department of Internal Medicine, University of California-Davis Medical Center, Sacramento, CA., [star][star] Reprint no. 47/1/90875 , a Reprints not available from the author. Address for correspondence: J Douglas Kirk, MD, Division of Emergency Medicine, University of California, Davis, Medical Center, PSSB, Suite 2100, 2315 Stockton Boulevard, Sacramento, CA 95817

Byline: Regine Ahner, Petra Kub-Csizi, Harald Heinzl, Diana Bikas, Michaela Rabl, Peter Wagenbichler, Peter Husslein Keywords: Fetal fibronectin; time of delivery; Bishop score; onset of labor Abstract: OBJECTIVE: Our aim was to determine from what time onward fetal fibronectin is consistently detectable in the cervicovaginal secretions before delivery and to what extent the actual time of delivery can be better determined by this procedure than by the sole use of the Bishop score. STUDY DESIGN: A fast-reacting fetal fibronectin test was performed on 206 women on their expected date of confinement. In addition, the cervical status was evaluated with use of a modified Bishop score. Follow-up evaluations were subsequently carried out in the course of the routine examinations. RESULTS: Women with a positive fetal fibronectin test result and a high Bishop score were delivered after a median of 1.7 days. Conversely, women with a negative fetal fibronectin test result and a low Bishop score were delivered after a median of 7.1 days. CONCLUSION: Determination of fetal fibronectin in combination with the Bishop score makes it possible to predict the actual time of delivery with a greater degree of accuracy.(Am J Obstet Gynecol 1997;177:1478-82.) Author Affiliation: Vienna, Austria Article History: Received 8 November 1996; Revised 10 June 1997; Accepted 23 June 1997 Article Note: (footnote) [star] From the Departments of Obstetrics and Gynecologya and Medical Computer Sciences,b University of Vienna, and Ignaz-Semmelweis Women's Hospital.c , [star][star] Reprint requests: Regine Ahner, MD, Abt. f. Geburtshilfe u. Gynaekologie, Univ. Frauenklinik, Wadahringer Gurtel 18-20, A-1090 Vienna, Austria., a 6/1/84239

Byline: Katharine D. Wenstrom, John Owen, D.C. Chu, Larry Boots Keywords: Maternal serum; Down syndrome screening Abstract: Objective: The purpose of this study was to determine, among six second-trimester maternal serum analytes, the best three-analyte combination for fetal Down syndrome detection. Study Design: With use of commercially available assay kits, medians for free [beta]-human chorionic gonadotropin, CA 125, and dimeric inhibin A were established in stored sera from 45 to 50 euploid pregnancies at each week of gestation from 14 to 22 weeks and from 33 Down syndrome pregnancies. Maternal serum [alpha]-fetoprotein, unconjugated estriol, and intact human chorionic gonadotropin levels measured in each sample before storage were retrieved. All 20 possible three-analyte combinations were evaluated in the multiple-marker screening test for Down syndrome. Results: The mean maternal age of the study population was 35.6 [+ or -] 5.3 years. The best three-analyte combination was maternal serum [alpha]-fetoprotein, free [beta]-human chorionic gonadotropin, and dimeric inhibin A: 97% of Down syndrome cases were detected at a false-positive rate of 16%. At a slightly higher false-positive rate (18%) maternal serum [alpha]-fetoprotein, estriol, and intact human chorionic gonadotropin detected only 79% of cases. Conclusions: Of six second-trimester maternal serum analytes, the best three-analyte combination for fetal Down syndrome detection was maternal serum [alpha]-fetoprotein, free [beta]-human chorionic gonadotropin, and dimeric inhibin A. This retrospective analysis should now be confirmed prospectively. Author Affiliation: Birmingham, Alabama Article Note: (footnote) [star] From the Center for Obstetric Research, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Alabama at Birmingham., [star][star] Reprint requests: Katharine D. Wenstrom, MD, University of Alabama at Birmingham, Department of Obstetrics and Gynecology, 618 S. 20th St., UAB Station, Birmingham, AL 35233-7333., a 0002-9378/97 $5.00 + 0 6/6/85022

Byline: Raymond H. Kaufman, Ervin Adam, Joseph Icenogle, William C. Reeves Keywords: Human papillomavirus (HPV); atypical squamous cells of undetermined significance; low-grade squamous intraepithelial lesion; cervical intraepithelial neoplasia Abstract: OBJECTIVE: Our purpose was to evaluate the cost-effectiveness of the use of a Food and Drug Administration-approved human papillomavirus test in triaging patients with Papanicolaou smears showing atypical squamous cells of undetermined significance or a low-grade squamous intraepithelial lesion for colposcopy compared with an algorithm that used cytologic follow-up. STUDY DESIGN: Four hundred sixty-two women referred to our Colposcopy Clinic with a Papanicolaou smear report of atypical squamous cells of undetermined significance or a low-grade squamous intraepithelial lesion underwent repeat Papanicolaou smear, cervical colposcopy, directed cervical biopsy, and endocervical curettage. In addition, human papillomavirus testing by the Food and Drug Administration-approved HPV Profile (Digene Diagnostics, Silver Spring, Md.) test was done. A comparision of sensitivity, specificity, and cost-effectiveness of an algorithm determining the need for colposcopy on the basis of repeat cytologic testing versus an algorithm that incorporated repeat cytologic testing and human papillomavirus screening was done. The cost-effectiveness of both of these triage algorithms was also compared. RESULTS: As expected, high-risk human papillomavirus deoxyribonucleic acid was detected with greater frequency in relation to increasing severity of cervical intraepithelial neoplasia. In 268 women, the follow-up smear obtained in our clinic was reported as negative. High-risk human papillomavirus types were found in 23.5% of these women. In the human papillomavirus-negative women, 5.9% had grade 2 or 3 cervical intraepithelial neoplasia confirmed on cervical biopsy. In comparison, 20.6% of those with a positive result of the human papillomavirus test had grade 2 or 3 cervical intraepithelial neoplasia on biopsy (p < 0.001). Despite this difference, the sensitivity of a positive result of a high-risk human papillomavirus test in predicting the presence of grade 2 or 3 cervical intraepithelial neoplasia was only 52%. Among the women for whom a follow-up clinic Papanicolaou smear was reported as showing atypical squamous cells of undetermined significance or a low-grade squamous intraepithelial lesion, there was no difference in the frequency of biopsy-proved grade 2 or 3 cervical intraepithelial neoplasia between those women with a positive human papillomavirus test result and those with a negative test result. Colposcopy would have been recommended for 194 women because of a repeat clinic smear revealing atypical squamous cells of undetermined significance, a low-grade squamous intraepithelial lesion, or a high-grade squamous intraepithelial lesion, and in 21.6% of these women grade 2 or 3 cervical intraepithelial neoplasia was shown on biopsy (sensitivity 63%, specificity 62%). Colposcopy would have been recommended for 180 women because high-risk human papillomavirus or a high-grade squamous intraepithelial lesion was detected at the clinic visit, and in 25% of this group grade 2 or 3 cervical intraepithelial neoplasia was evident on biopsy (sensitivity 67%, specificity 66%). Sensitivity and specificity were virtually identical for the two algorithms, but the cost of human papillomavirus testing was nearly double that of triage based on repeat cytologic testing alone ($692 vs $1246 per case). CONCLUSION: The Food and Drug Administration-approved HPV Profile test is not a cost-effective triage for patients referred with Papanicolaou smears reported as showing atypical squamous cells of undetermined significance or low-grade squamous lesions. (Am J Obstet Gynecol 1997;177:930-6.) Author Affiliation: Houston, Texas and Atlanta, Georgia Article History: Received 28 January 1997; Revised 7 May 1997; Accepted 21 May 1997 Article Note: (footnote) [star] From the Departments of Obstetrics and Gynecology and Microvirology, Baylor College of Medicine,a and the Centers for Disease Control and Prevention.b , [star][star] Reprint requests: Raymond H. Kaufman, MD, 6550 Fannin, No. 701, Houston, TX 77030., a 6/1/83419