The use of ultrasound-based 'soft markers' for the prediction of pelvic pathology in women with chronic pelvic pain--can we reduce the need for laparoscopy?

OBJECTIVE: To assess the accuracy of new transvaginal ultrasound-scan-based markers and to compare them to conventional ultrasound methods used in the detection of common pelvic pathology in women with chronic pelvic pain (CPP). DESIGN: A prospective observational study. SETTING: Teaching hospital. POPULATION: A total of 120 consecutive women with CPP undergoing transvaginal ultrasonography before either diagnostic or operative laparoscopy. METHODS: Anatomical abnormalities, e.g. endometrioma or hydrosalpinx (hard markers), were documented. The woman was then assessed for the presence or absence of 'soft markers' (reduced ovarian mobility and site-specific pelvic tenderness). MAIN OUTCOME MEASURE: Presence or absence of pelvic pathology noted during laparoscopy. RESULTS: Seventy women had pelvic pathology, of whom 51 had endometriosis alone, 7 both endometriosis and pelvic adhesions, 6 pelvic adhesions, 1 hydrosalpinx with endometriosis and 5 hydrosalpinx and pelvic adhesions. The likelihood ratio for the hard markers was infinity (specificity was 100%), for the soft makers 1.9 (95% CI 1.2-3.1) and for a 'normal' ultrasound 0.18 (0.09-0.34). The pre-test probability of pelvic disease in our population of women with CPP was 58%, and this probability of disease was raised to 100% with the presence of hard markers and to 73% with the presence of soft markers. The pre-test probability of 58% fell to 20% when ultrasound finding was found to be normal. CONCLUSION: This new approach improves the detection and exclusion of significant pathology in women with CPP and may lead to a reduction in the number of unnecessary laparoscopies carried out on women with CPP.

Human chorionic gonadotrophin and progesterone levels in pregnancies of unknown location.

OBJECTIVE: To evaluate accuracy, user variability and impact of experience on the use of serum hCG and progesterone in women who have a pregnancy of unknown location (PUL's). MATERIALS AND METHODS: This was a retrospective study. Presenting 1932 consecutive women to an Early Pregnancy Unit had a transvaginal scan. The location of the pregnancy could not be found in 189 women (Pregnancy of unknown location, PUL), and so blood was taken to measure serum hCG and progesterone at presentation and subsequently after 48 h, according to the protocol. All women were monitored at regular intervals until the final outcome was known, which was a failing PUL, a viable or failing intra-uterine pregnancy, an ectopic pregnancy or a persisting PUL. The final study group comprised 185 PUL, as four cases of persisting PUL were treated and excluded from the analysis. Five investigators assessed the hormonal data independently. The investigator's experience as defined by the number of years working in obstetrics and gynecology ranged from 2 to 15 years. Each investigator knew the women were clinically stable and that the scan result was consistent with a PUL, i.e. there were no signs of intra- or extra-uterine pregnancy, and there was no hemoperitoneum on TVS. When assessing the PUL's, each investigator was given the hormonal results at time 0 and 48 h for serum hCG and progesterone and asked to classify the PUL's as failing PUL's, immediately viable intra-uterine PUL's and ectopic PUL's. No other clinical information about the women was made available. RESULTS: Complete data 185 women (89%): 102 failing PUL's, 63 immediately viable intra-uterine PUL's and 20 ectopic PUL's (total 185). The most experienced investigator obtained the best accuracy 163/185 (88.1%); not significantly different from those obtained by less experienced investigators (range 85.9-87.6%). Mean correct classification of failing PUL and immediately viable intra-uterine PUL's was 93% (range 89-95%); corresponding value for ectopic PUL's was 42% (range 25-60%). Agreement between observers for classification of failing PUL's and immediately viable intra-uterine PUL's was almost perfect (Cohen's kappa 0.86-0.90), whereas the value for ectopic PUL's group was fair to moderate (Cohen's kappa 0.39-0.67). All 5 investigators misdiagnosed same 35% of ectopic PUL's. CONCLUSIONS: Serum hCG and progesterone levels at defined times can be used to predict the immediate viability of a PUL, but cannot be used reliably to predict its location. Clinical experience does not significantly improve the ability to assess PUL outcome.

MR spectroscopy quantitation: a review of time-domain methods.

In this article an overview of time-domain quantitation methods is given. Advantages of processing the data in the measurement domain are discussed. The basic underlying principles of the methods are outlined and from them the situations under which these algorithms perform well are derived. Also an overview of methods to preprocess the data is given. In that respect, signal-to-noise and/or resolution enhancement, the removal of unwanted components and corrections for model imperfections are discussed.