Physiologic, biochemical and genetic aspects of malignant hyperthermia

The value of the TAG-72 (CA 72-4) serum marker in primary diagnosis was investigated in 110 patients with histologically diagnosed ovarian cancer. A reference group consisted of 103 patients with benign pelvic masses. Compared to the well-established CA-125, TAG-72 showed a low sensitivity of 42% in the detection of ovarian cancer. By contrast, when the cut-off level for TAG-72 was set at 6 U/ml, it showed a very high specificity of 99%. When the measurement of TAG-72 was combined to that of CA-125, improvements in both the specificity (as compared to a single CA-125 determination) and the sensitivity (as compared to a single TAG-72 assay) were observed. In such a combined assay, our results suggest that the best predictive value (positive and negative) was obtained if CA-125 is assigned a relatively high cut-off value (65 U/ml) in conjunction with a low cut-off level (3.2 U/ml or 4 U/ml) for TAG-72. In the present study, at threshold values of 65 U/ml respectively, a sensitivity of 86%, a specificity of 83% and a positive and negative predictive value of 85% were obtained. In mucinous carcinomas of the ovary, however, the additional TAG-72 determination did not lead to a better predictive power than did CA-125 measurement alone.     

Effect of Saccharomyces boulardii against experimental oral infection with Salmonella typhimurium and Shigella flexneri in conventional and gnotobiotic mice

OBJECTIVE: To compare serum CA 125 assays with computed tomography (CT) and transvaginal ultrasound (TVUS) for early detection of disease recurrence in patients with ovarian cancer. METHODS: Sixty-two patients with non-mucinous epithelial ovarian cancer who had positive CA 125 levels (> 35 U/ml) were studied. We performed a retrospective review to determine the usefulness of serum CA 125 measurements. Setting the cut-off limit at either 35 U/ml or 16 U/ml, the accuracy of CA 125 measurements was compared with that of CT scanning, TVUS and operative findings at second-look laparotomy (SLL) in the early detection of recurrent tumors. RESULTS: Compared with SLL, both the specificity and the positive predictive value of CA 125 measurements were 100% at 16 and 35 U/ml. The sensitivity and the negative predictive value were 30.8 and 71.9%, respectively, below 35 U/ml and 53.8 and 79.3%, respectively, below 16 U/ml. The false-negative rate of CT was 36.1%. When the cut-off limit was reduced from 35 to 16 U/ml, 57.1% of patients considered to be in remission were reclassified as having persistent disease. A complete response confirmed by CT did not represent remission: CA 125 levels were 7.5-fold higher at the time of re-evaluation by CT. TVUS also lagged behind CA 125 assays in detecting disease recurrence. The sensitivity of ultrasound appeared to be lower than that of CT because it failed to detect extrapelvic lesions. CONCLUSION: A screening threshold (cut-off level) of 16 U/ml for CA 125 should be used to detect recurrent serous ovarian adenocarcinoma. Although ultrasound is a convenient method of detecting intrapelvic lesions, and has cost benefit, CT is necessary to detect extrapelvic recurrence. Neither CT nor ultrasound are more accurate than serial CA 125 assays in detecting disease recurrence.     

Relationship of preoperative serum CA-125 to survival in epithelial ovarian carcinoma

BACKGROUND: Epithelial carcinoma of the ovary has the highest death rate of any gynecologic malignancy in the developed world. The antigen CA-125 has been used over the past decade as a tumor marker for epithelial ovarian cancer and other cancers of coelomic epithelium. The object of this study was to see if the degree of elevation of preoperative CA-125 was related to length of survival in patients with epithelial ovarian carcinoma. METHODS: Eighty-two consecutive patients diagnosed with epithelial ovarian carcinoma were evaluated for their initial preoperative CA-125 level, time to recurrence, length of survival and level of primary debulking as well as International Federation of Gynecologists and Obstetricians stage, grade and histology. Ovarian tumors of low malignant potential were not included in the study. All patients had their initial surgery performed by one surgeon. RESULTS: Decreased length of survival was related to the degree of elevation of CA-125 prior to initial exploratory laparotomy (P = .047). The mean initial CA-125 for patients surviving five years or more (15 patients) was 899 U/mL, with an SD of +/- 1,880 U/mL, while the CA-125 for patients surviving less than five years (67 patients) was 1,978 U/mL, with an SD of +/- 1,852 U/mL (P = .02). Increased stage of disease at initial laparotomy showed a relationship to increased CA-125 (P < .0001). CONCLUSION: In epithelial ovarian carcinoma, high preoperative serum levels of CA-125 predict decreased length of survival.     

Use of the computed tomographic whole body scanner to stage and follow patients with advanced ovarian carcinoma

Advanced ovarian carcinoma continues to be a difficult tumor to evaluate noninvasively. Recent developments in chemotherapy have enhanced response rates in this disease, thus improving the likelihood of tumor regression. Computed Tomography (CT) allows the noninvasive estimation of tumor extent in patients with ovarian carcinoma. Seventeen patients with epithelial ovarian carcinoma had 22 whole body CT scans performed either just prior to or following laparotomy. For determination of tumor involvement, when the CT was positive, a high pathologic correlation was found at liver, ascitic, peritoneal, mesenteric, and omental sites (sensitivity). When the cT was negative, high pathologic correlation was found at ascitic and mesenteric sites (specificity). Lower and negative correlation at other disease sites is attributed to difficulty of CT detection of small (1 cm) tumor nodules on visceral surfaces. Eighteen patients with advanced ovarian carcinoma were followed prospectively during treatment with repetitive CT scans. CT results were compared with physical examination, other radiologic studies, and clinical status. In 83% (15/18) of patients and 88% (59/67) of CT scans performed, CT was found to contribute useful management information. Clinical decisions were made on the basis of CT alone in 43% (29/67) of scans performed. These data suggest that CT scanning is very useful in the staging and follow-up of patients with ovarian carcinoma and can replace other radiologic procedures, but it is not completely accurate and needs to be correlated with physical examination and in cases without tumors visible with CT, with laparotomy.     

Effect of angiotensin-converting enzyme inhibition on bronchial responsiveness

BACKGROUND: Many studies have shown that CA 125 levels frequently rise prior to clinical evidence of progression of ovarian cancer. For clinical trials an accepted definition of progression according to CA 125 is required. We therefore determined what change in CA 125 level was the most accurate predictor of relapse in patients on follow up after therapy for ovarian cancer. PATIENTS AND METHODS: Serial CA 125 levels were studied from 255 patients entering the North Thames Ovary Trial of 5 versus 8 courses of chemotherapy. An initial analysis was made 2 months after closure of the trial, a more detailed analysis was made after 81 confirmed relapses among evaluable patients and a final analysis was made one year later with longer follow-up. RESULTS: On the basis of the results from the interim analyses and the cut-off level of 22-35 U/ml used by different laboratories, 30 U/ml was chosen as the upper limit of normal. In the final analysis a doubling of CA 125 from the upper limit of normal was defined as progression. Using this method sensitivity was 85.9%, specificity 91.3%, positive predictive value 94.8%, and negative predictive value was 77.8%. Insisting on a confirmatory elevated CA 125 level reduced the false positive rate to < 2% with a sensitivity of 83.9%. The median lead-time prior to clinical progression was 63 days. CONCLUSION: A confirmed rise of serum CA 125 level to more than twice the upper limit of normal during follow up after first line chemotherapy accurately predicts tumour relapse.     

Sutureless cartilage graft laryngotracheal reconstruction using fibrin sealant

BACKGROUND: To estimate the value of CA-125 for the diagnosis of endometriosis in women with dysmenorrhea, as well as its significance in monitoring therapy and follow-up. METHODS: One hundred and fifty-seven women undergoing laparoscopy for dysmenorrhea were prospectively studied for serum CA-125 concentration. For those with advanced endometriosis receiving danazol treatment after conservative surgery, CA-125 was also determined every month during medication and once every 12 months after treatment. RESULTS: The sensitivity and specificity of serum CA-125 for the diagnosis of endometriosis were 61.1% and 87.5% respectively. Elevated CA-125 (>35 U/ml) was noted in 65/75 cases (86.70%) with advanced endometriosis, but in only 15/56 patients (26.8%) with minimal and mild endometriosis. Although there were significantly higher CA-125 levels in unmarried women, and a negative correlation (r=-0.1970, p=0.0284) between CA-125 and parity, there was no statistical difference in incidence of endometriosis by the status of marriage or parity. Ten women with advanced endometriosis were found with persistent endometriosis by laparoscopy during danazol treatment, even though they tested with normal CA-125 levels (<35 U/ml) at that time. Fifteen patients had elevated CA-125 levels before and one year after therapy, and were confirmed with recurrence of endometriosis by laparoscopy. Nine women with elevated CA-125 levels before treatment, were found without recurrence of endometriosis and had normal CA-125 levels one year after therapy. CONCLUSION: For endometriosis, CA-125 is a valuable adjuvant in the follow-up of recurrence in patients with advanced endometriosis and initially elevated CA-125 levels. It is not an effective screening tool for patients with dysmenorrhea, or for monitoring therapy. There was no significant correlation between the development of endometriosis and reproductive factors.     

Subcortical vascular dementia: survey of treatment patterns and research considerations

OBJECTIVE: The purpose of this study was to evaluate retrospectively the efficacy of a proposed panel of three cardiac markers (myoglobin, creatine kinase-MB mass [CK-MB], and cardiac troponin I) in the diagnosis of acute myocardial infarction (AMI) in patients with atraumatic chest pain. DESIGN: A total of 110 patients admitted for the evaluation of atraumatic chest pain were examined. Forty-one of these patients were diagnosed with AMI. RESULTS: Five of the 41 patients with AMI had abnormally elevated myoglobin levels, whereas values of CK-MB and/or cardiac troponin I remained negative. Creatine kinase-MB mass alone had a sensitivity of 92.7%, a specificity of 89.9%, a positive predictive value of 84.4%, and a negative predictive value of 95.0% for the diagnosis of AMI. Cardiac troponin I alone had a sensitivity of 90.2%, a specificity of 95.7%, a positive predictive value of 92.5%, and a negative predictive value of 94.3% for the diagnosis of AMI. Cardiac troponin I is a more specific marker for the diagnosis of AMI than CK-MB, particularly in patients with chronic renal failure who are evaluated for chest pain. The combination of CK-MB and cardiac troponin I increased the sensitivity to 100% and the negative predictive value to 100% and had a specificity of 88.4% and a positive predictive value of 83.7%. The panel was diagnostic for all patients with AMI within 12 hours after admission. CONCLUSIONS: Our preliminary results indicate that this panel is highly effective for evaluation of AMI in patients with atraumatic chest pain. Elevated myoglobin levels were useful in detecting patients at high risk for AMI who initially were not detected with other markers. The combination of CK-MB and cardiac troponin I provided much higher sensitivity and had a much higher negative predictive value for the evaluation of AMI than cardiac troponin I or CK-MB alone. The 100% negative predictive value is particularly important because it indicates that patients with negative CK-MB and cardiac troponin I values 12 hours after admission have a negligible likelihood of AMI.     

The role of ultrasonography in the evaluation of endometrial receptivity following assisted reproductive treatments: a critical review

We set out to estimate the value of ultrasonographic parameters as prognostic indicators of implantation following in-vitro fertilization (IVF) and embryo transfer. Our survey included 414 natural cycles, 3558 cycles following ovarian stimulation for IVF and embryo transfer, and 411 cycles with hormone replacement therapy for oocyte donation, reviewing 27 reports identified in a computerized literature research. The ultrasonographic prognostic indicators for implantation evaluated included peri-ovulatory endometrial thickness and pattern and Doppler measurements of uterine artery blood flow. Topics include: definitions of the ultrasonographic parameters proposed to evaluate uterine receptivity; the clinical context in which they were used; the proposed optimal timing for sonographic evaluation; and, finally, their actual correlation with pregnancy rate following assisted reproductive technologies. For various sonographic parameters, negative predictive value, positive predictive value, sensitivity and specificity were calculated, based on published data. Sonographic parameters had a high negative predictive value and sensitivity, but a limited positive predictive value and low specificity. Several confounding factors may influence the interpretation of reports, and the statistical evaluation sometimes lacks calculation of the positive and negative predictive values of the parameters examined. Although ultrasonographic parameters of endometrial receptivity have a strong negative value in setting some minimum criteria, their value as prognostic indicators for implantation following embryo transfer has yet to be proved.     

5-Fluorouracil + cisplatin + mitomycin C is a relatively most effective combination against xenograft lines of human colorectal cancer

BACKGROUND: The purpose of this study was to evaluate the diagnostic value of transvaginal ultrasound measurement of endometrial thickness, cytology obtained by Gynoscann, and histology of the endometrium sampled by Uterine Explora Curette compared with histology of the uterine specimen as the gold standard. METHODS: Consecutive patients admitted for hysterectomy had transvaginal ultrasound, sampling by Gynoscann, and Uterine Explora Curette done just before surgery, after informed consent. RESULTS: A total of 181 women entered the study. Sixteen had endometrial cancer, seven had atypical hyperplasia and nine had complex hyperplasia. A total of 168 patients had a transvaginal ultrasound done. At a cutoff limit of 4mm (endometrial thickness of 4mm or less indicating normal endometrium), the sensitivity was 90.3%, the specificity 24.8%, the positive predictive value 21.4% and the negative predictive value 91.9%. One endometrial cancer, one atypical and one complex hyperplasia were missed. The Gynoscann method showed a sensitivity of 62.5%, a specificity of 94.0%, a positive predictive value of 69.0% and a negative predictive value of 92.1%. Two cancers, three atypical and six complex hyperplasia were missed. The Uterine Explora Curette showed a sensitivity of 90.6%, a specificity of 100.0%, a positive predictive value of 100.0% and a negative predictive value of 98.0%. One endometrial cancer and two complex hyperplasia were missed. CONCLUSION: Transvaginal ultrasound is a reliable method in excluding endometrial pathology. The Uterine Explora Curette was superior to Gynoscann in diagnosing neoplasia of the endometrium. It was found to have the same diagnostic accuracy as conventional dilatation and curettage.     

Prediction of head-up tilt test result by analysis of early heart rate variations

BACKGROUND: Head-up tilt testing is a useful test for investigating vasovagal syncope. The determination of early, accurate, predictive criteria for a negative result would permit a reduction in the duration of the tilt test. METHODS AND RESULTS: Patients with no drug use and no illnesses other than recurrent unexplained syncope were recruited. In an initial study (110 consecutive patients), we aimed to determine a predictive criterion based on heart rate variations during the first minutes of upright tilting that could distinguish between patients with positive and negative tilt tests (patients with an early continual decrease in heart rate or blood pressure were excluded). Then we tested the predictive value of the established criterion in a second independent sample of patients with unexplained syncope (109 consecutive patients). An early sustained increase in heart rate < or = 18 bpm during the first 6 minutes of upright tilting at a 60 degree angle allowed us to predict negative tilt tests with 100% specificity, 100% positive predictive value, and 88.6% sensitivity. This criterion was validated in the second, prospective arm of the study (96.4% specificity, 98.4% positive predictive value, and 87.3% sensitivity), even with subsequent use of isoproterenol in low doses. CONCLUSIONS: In patients with no drug use and no illnesses other than recurrent unexplained syncope, a simple clinical criterion identifies patients who will not develop syncope during a prolonged upright tilt.     

Differentiating sigmoid diverticulitis from carcinoma on CT scans: mesenteric inflammation suggests diverticulitis

OBJECTIVE: The purpose of this study was to analyze the usefulness of two specific CT signs of sigmoid mesenteric inflammation (fluid at the root of the mesentery and vascular engorgement) for identifying and differentiating sigmoid diverticulitis from carcinoma. MATERIALS AND METHODS: CT scans of 69 patients with surgically proved sigmoid diverticulitis were retrospectively reviewed and compared with CT findings in 29 patients with surgically proved sigmoid carcinoma. Two specific patterns of inflammation of the sigmoid mesentery were analyzed: fluid at the root of the sigmoid mesentery and engorgement of the sigmoid mesenteric vessels. RESULTS: The CT findings were present more often in patients with sigmoid diverticulitis than in those with carcinoma (p < .001). Fluid at the base of the mesentery had a sensitivity, specificity, and positive predictive value for diverticulitis of 36%, 90%, and 89% respectively. Vascular engorgement alone had a sensitivity, specificity, and positive predictive value of 29%, 100%, and 100%, respectively. CONCLUSION: Our results suggest that CT findings of fluid at the root of the mesentery and vascular engorgement are useful in distinguishing sigmoid diverticulitis from carcinoma of the sigmoid.     

The level of urokinase-type plasminogen activator receptor is increased in serum of ovarian cancer patients

Ascites and serum of patients with ovarian carcinoma contain a soluble form of urokinase-type plasminogen activator receptor (uPAR). We now report that pro-uPA-Sepharose-purified uPAR from ascites of patients with ovarian carcinoma is the full-length molecule missing the glycosyl-phosphatidylinositol anchor, as determined by its amino acid composition. We next examined the significance of determining serum soluble uPAR (suPAR) levels in ovarian cancer patients using a specific ELISA and compared the results with serum concentrations of CA-125, an established diagnostic marker. Serum from pre- and postoperative ovarian cancer patients was assayed for suPAR and CA-125. The majority of the patients with ovarian cancer had enhanced preoperative serum levels of suPAR compared with healthy controls, but suPAR concentrations decreased after operation. Although uPAR was associated with most ovarian carcinomas, it appeared to be a less specific indicator for ovarian cancer than CA-125. On the other hand, suPAR was more specific for other types of solid tumors. Moreover, we have observed some cases of ovarian cancer that showed increase of suPAR but not of CA-125. The prognostic significance of serum suPAR assay for survival of ovarian carcinoma patients was evaluated using Cox's proportional hazards analysis. Our preliminary data show that high preoperative levels of suPAR were associated with worse survival of the patients, whereas CA-125 had no prognostic implications. This is the first report evaluating the assay of serum suPAR levels in ovarian cancer and analyzing its value as a tumor or prognostic marker.     

Correlation of peritoneal aspiration cytology with acute appendicitis

Fifty-one patients in whom a clinical diagnosis of acute appendicitis had been made underwent peritoneal aspiration cytology (PAC). Thirty-six had a positive result, 11 had a negative result and aspiration failed in four cases. All patients had an appendicectomy and the histological findings were correlated with the PAC results. Thirty-five of the 36 patients with a positive PAC had histologically proven appendicitis. Seven of the 11 patients with a negative result had normal appendices. The sensitivity of PAC for acute appendicitis was 85% and the specificity was 70%. The positive predictive value was found to be 97% and the negative predictive value 60%. Peritoneal aspiration cytology is a useful aid in the diagnosis of acute appendicitis however, a negative result does not exclude this diagnosis.     

Evaluation of the diagnostic usefulness of CA125 immunoscintigraphy for ovarian carcinoma follow-up after treatment: contribution of this technique in Grenoble University Medical Center

Immunoscintigraphy using indium-111-labeled OC125 monoclonal antibody F(ab')2 fragments is a technic complementary of morphological imaging (i.e. ultrasonography and computed tomography). It allows early detection of recurrences of ovarian carcinomas. We performed immunoscintigraphy 30 times in 26 patients who previously underwent radical treatment for ovarian carcinoma, and were suspected to have a recurrence. Our purposes were appreciation of diagnostic accuracy of the method, and above all its impact on clinical decisions and evolution of the patients. There were, after reevaluation of the results, 18 true positives, 7 true negatives, 3 false negatives and 2 false positive cases (sensitivity 85.7%, specificity 77.8%). Bayesian analysis showed positive and negative predictive values of 86% and 87% when probability of recurrence a priori was 50%, and 80% and 58% when probability of recurrence a priori was 70%. The result of immunoscintigraphy contributed to clinical decisions in 24 cases out of 30, and led to a correct decision for the patient in 21 cases. Conversely, for the 6 cases in which the result has not been considered, to take this result into account would have been beneficial in 4 cases, but harmful in 2. Finally, survival tended to be longer when immunoscintigraphy was negative, which could be associated with a better prognosis. We conclude that OC125-immunoscintigraphy may be useful for ovarian carcinoma follow-up and may contribute to a better therapeutic strategy.     

CA-125 and carcinoembryonic antigen assay vs. cytodiagnostic experience in the classification of benign ovarian cysts

OBJECTIVE: To compare the relative strengths of two factors involved in making an accurate differentiation between functional and epithelial ovarian cysts, along with their combination: (1) the cytologist's level of experience in interpreting ovarian cytology, (2) the use of the tumor markers carcinoembryonic antigen (CEA) and CA-125 in cyst fluid, and (3) a combination of (1) and (2). STUDY DESIGN: Papanicolaou-stained sediments from fluid aspirated from 31 resected ovarian cysts (6 functional and 25 epithelial) were blindly and independently evaluated by five pathologists with varying experience in ovarian cytology. Cyst fluid supernatant was used for CEA, enzyme-linked immunosorbent assay, and CA-125 radioimmunoassay; CEA levels > 5 ng/mL or CA-125 > 5,000 U/mL were considered elevated. Cysts were categorized cytologically and histologically as functional or epithelial and by tumor markers as "neither elevated" or "either or both elevated" (EBE). RESULTS: The agreement of histologic diagnosis with each pathologist's cytologic diagnosis ranged from 53% to 84% (53%, 71%, 83%, 82%, 84%), corresponding to increasing level of experience. The percentage of agreement with EBE was 77%, whereas combined experienced pathologist's diagnosis and EBE was 87%. Kappa equaled .45 for experienced cytopathologist's diagnosis or EBE alone. Kappa equaled .53 when the pathologist or EBE diagnosed an epithelial cyst, indicating results unlikely to occur by chance. CONCLUSION: The distinction of functional from epithelial ovarian cysts is best achieved by combining measurement of the tumor markers CEA and CA-125 with a high level of cytopathology experience.     

Genotypic analysis of the 5''-untranslated region of a pestivirus strain isolated from human leucocytes

Ovarian hyperstimulation syndrome (OHSS) is a relatively common and potentially life-threatening complication of ovarian stimulation, the pathogenesis of which remains unclear. To clarify the predictive values of serum estradiol levels and oocyte number in severe OHSS, and to investigate the impact of high serum estradiol levels on pregnancy outcome, we retrospectively analyzed clinical data from 431 cycles of ovarian stimulation for assisted reproduction performed from 1993 through 1995. Receiver operating characteristic plots were used to estimate the predictive power of the measured variables. The overall frequency of severe OHSS was 5.5%. Using a serum estradiol level of 3,600 pg/mL as the minimum cut-off value, the sensitivity was 58%, with a specificity of 92%, a positive predictive value of 29%, and a negative predictive value of 97%. The predictive power was similar when a cut-off point of 20 oocytes retrieved was used. The two criteria together gave a sensitivity of 33%, a specificity of 92%, a positive predictive value of 40%, and a negative predictive value of 98%. One of seven oocyte donors developed severe OHSS. The pregnancy rate was higher in patients with severe OHSS than in patients who did not develop this syndrome (73.9% vs 32.5%) but the pregnancy outcomes were not significantly different. We conclude that elevated estradiol concentrations and oocyte number appear to be helpful in predicting severe OHSS, but neither parameter by itself is predictive. This syndrome is rare in the absence of luteal hCG support, either exogenous or pregnancy-derived; when it occurs, there are usually extremely high preovulatory estradiol concentrations and numerous oocytes retrieved. High serum estradiol levels are unlikely to have adverse effects on pregnancy outcome in patients with severe OHSS.     

Pulmonary embolism: the role of computed tomography and magnetic resonance imaging

The technological progress in Computed Tomography (CT) (spiral and electron beam) and Magnetic Resonance Imaging (MRI fast sequences) has stimulated their interest in the diagnosis of acute and chronic pulmonary embolism (PE). They are noninvasive procedures able to identify thrombi up to the level of segmental pulmonary branches. This result, albeit not ideal, is significant, in view of the lower clinical relevance of peripheral emboli as compared to more central locations, especially in the absence of peripheral venous thrombosis. Spiral CT allows satisfactory assessment of pulmonary branches with high sensitivity (65-100%), specificity (89-96%), positive predictive value (95%) and negative predictive value (80-100%) in the diagnosis of PE. MRI with spin-echo sequences has also a satisfactory sensitivity (75-90%), specificity (up to 100%), positive predictive value (86%) and negative predictive value (85%). Recently, MR angiography was shown to be able to depict smaller pulmonary branches (6th and 7th generation), even if its efficacy in the identification of emboli has not been demonstrated as yet. CT and MRI are bound to play an increasingly relevant role in the diagnosis of PE.     

Elevated plasma corticosterone concentrations influence the onset of rigor mortis and meat color in broilers

BACKGROUND/PURPOSE: The focused assessment for the sonographic evaluation of trauma patients (FAST) in adults is effective in detecting intraperitoneal and intrapericardial fluid and can be performed quickly by surgeons in the emergency department (ED). The authors sought to validate the accuracy of FAST performed by surgeons during ED resuscitation of pediatric trauma patients. METHODS: Patients were assigned to one of three groups based on standard clinical criteria: immediate surgery, abdominal computed tomography (CT), or observation alone. FAST was then performed in the ED by a surgery resident (postgraduate year 3 or higher) or an attending trauma surgeon. Four views were used to assess the possible presence of fluid in the pericardial, subphrenic, subhepatic, and pelvic spaces. Time needed to conduct FAST was noted. Presence of peritoneal or pericardial fluid by FAST was compared with that determined by CT or surgery. Sensitivity, specificity, and predictive values were calculated. For those who did not undergo CT or surgery, FAST findings were compared with the clinical course. RESULTS: Technically adequate studies could be performed on 192 of 196 eligible children. Their ages ranged from 3 months to 14 years (mean, 6.9 years); 119 were boys (62%), and 188 (98%) had sustained a blunt injury. FAST was performed in a mean time of 3.9 minutes (range, 1-17 minutes). All FAST examinations were reviewed by our senior surgeon-sonographer (GSR). Interrater agreement between the performing and reviewing surgeon-sonographer was 100%. Sixty (31%) patients underwent either abdominal CT (n = 56; mean Injury Severity Score (ISS), 9.6) or immediate operation (n = 4; mean ISS, 18.8). Of the 10 patients with verified presence of intraperitoneal fluid, eight had positive and two had false-negative FAST examination results. Of the 50 patients with verified absence of intraperitoneal fluid, none had a positive FAST (ie, no false-positives); sensitivity was 80%; specificity, 100%; predictive value positive, 100%; predictive value negative, 96%. None of the 132 patients followed up clinically without CT or surgery (mean ISS, 4.5) had fluid documented by FAST, and all did well. CONCLUSIONS: The focused assessment for the sonographic evaluation of pediatric blunt trauma patients performed by surgical residents and attendings in the ED rapidly and accurately predicted the presence or absence of intraperitoneal fluid. The FAST is a potentially valuable tool to rapidly prioritize the need for laparotomy in the child with multiple injuries and extraabdominal sources of bleeding.     

The role of transvaginal ultrasonography and outpatient diagnostic hysteroscopy in the evaluation of patients with menorrhagia

To verify the reliability of transvaginal ultrasonography in diagnosing intrauterine disease and in evaluating the operability of submucous myomas and to determine the feasibility, acceptability and validity of hysteroscopy for menorrhagia, we performed a prospective 5 year study on 793 women of mean age +/- SD of 41.5 +/- 7.8 years. All the patients referred for excessive menstrual bleeding with uterine volume <12 week pregnancy who underwent complete physical examination, transvaginal ultrasonography and outpatient hysteroscopy with endometrial biopsy were included in the study. Outpatient hysteroscopy was not completed due to intolerance or was unsatisfactory due to excessive bleeding in 23 cases (2.9%). Only 28 women (3.5%) declared they would have refused the procedure had they imagined the pain involved. One case of pelvic infection was observed. Compared with hysteroscopy, transvaginal ultrasonography had 96% sensitivity, 86% specificity, 91% positive predictive value and 94% negative predictive value in the diagnosis of intrauterine abnormality. The sensitivity, specificity, positive and negative predictive values of ultrasonography in identifying submucous myomas operable hysteroscopically (intramural extension <50%) were respectively 80, 69, 83 and 65% with a k index of agreement between ultrasonography and hysteroscopy of 0.48. Thus, considering the good specificity and high negative predictive value, transvaginal ultrasonography may be suggested as the initial investigation in menorrhagic patients, limiting hysteroscopy to cases with positive or doubtful sonographic findings.