Witnessing history: a personal view of half a century in public health.

Former Chief Medical Officer Sir Kenneth Calman recently celebrated 50 years in medicine. It was a period which saw the evolution of the public health agenda from communicable diseases to diseases of lifestyle, the change from a hospital-orientated health service to one dominated by community-based services, and the increasing recognition of inequalities as a major determinant of health. This paper documents selected highlights from his career including the Aberdeen typhoid outbreak, AIDS, bovine spongiform encephalopathy, foot and mouth disease, radioactive fallout, the invention of computerised tomography and magnetic resonance imaging, and draws parallels between the development of the modern understanding of public health and the theoretical background to the science 100 years earlier.

Large calcifications in ovaries otherwise normal on ultrasound.

OBJECTIVE: To evaluate calcifications >or= 5 mm in length in ovaries that are otherwise normal on ultrasound, and to determine whether such large ovarian calcifications are an indicator of ovarian neoplasm. METHODS: This was a retrospective study reviewing pelvic ultrasound results at our unit between October 1994 and April 2002 to identify patients with ovarian calcifications that were >or= 5 mm in maximum length in otherwise normal ovaries, and who also had follow-up imaging studies. Patient medical histories were reviewed, calcification characteristics, including number, size, shape and laterality of calcifications, were recorded and follow-up imaging studies were reviewed to assess change in size of the calcification and to see if a neoplasm had developed. RESULTS: The study group consisted of 28 patients. The mean length of imaging follow-up was 35.2 +/- 30.7 months. The mean size of the calcifications was 7.4 +/- 2.3 (range, 5-13) mm. The calcification remained stable in all 28 patients and no ovarian neoplasms developed in any of the patients. Histological confirmation was available in one patient and this revealed dystrophic calcification in a corpus albicans. CONCLUSION: Calcifications ranging from 5 to 13 mm in length in otherwise normal ovaries remain stable on follow-up imaging and are not an indicator of current or future ovarian neoplasm. Published by John Wiley & Sons, Ltd.

Evaluation of the woman with postmenopausal bleeding: Society of Radiologists in Ultrasound-Sponsored Consensus Conference statement.

OBJECTIVES: A panel of 14 physicians practicing medicine in the United States with expertise in radiology, obstetrics and gynecology, gynecologic oncology, hysteroscopy, epidemiology, and pathology was convened by the Society of Radiologists in Ultrasound to discuss the role of sonography in women with postmenopausal bleeding. Broad objectives of this conference were (1) to advance understanding of the utility of different diagnostic techniques for evaluating the endometrium in women with postmenopausal bleeding; (2) to formulate useful and practical guidelines for evaluation of women with postmenopausal bleeding, specifically as it relates to the use of sonography; and (3) to offer suggestions for future research projects. SETTING: October 24 and 25, 2000, Washington, DC, preceding the annual Society of Radiologists in Ultrasound Advances in Sonography conference. PROCEDURE: Specific questions to the panel included the following: (1) What are the relative effectiveness and cost-effectiveness of using transvaginal sonography versus office (nondirected) endometrial biopsy as the initial examination for a woman with postmenopausal bleeding? (2) What are the sonographic standards for evaluating a woman with postmenopausal bleeding? (3) What are the abnormal sonographic findings in a woman with postmenopausal bleeding? (4) When should saline infusion sonohysterography or hysteroscopy be used in the evaluation of postmenopausal bleeding? (5) Should the diagnostic approach be modified for patients taking hormone replacement medications, tamoxifen, or other selective estrogen receptor modulators? CONCLUSIONS: Consensus recommendations were used to create an algorithm for evaluating women with postmenopausal bleeding. All panelists agreed that because postmenopausal bleeding is the most common presenting symptom of endometrial cancer, when postmenopausal bleeding occurs, clinical evaluation is indicated. The panelists also agreed that either transvaginal sonography or endometrial biopsy could be used safely and effectively as the first diagnostic step. Whether sonography or endometrial biopsy is used initially depends on the physician's assessment of patient risk, the nature of the physician's practice, the availability of high-quality sonography, and patient preference. Similar sensitivities for detecting endometrial carcinoma are reported for transvaginal sonography when an endometrial thickness of greater than 5 mm is considered abnormal and for endometrial biopsy when "sufficient" tissue is obtained. Currently, with respect to mortality, morbidity, and quality-of-life end points, there are insufficient data to comment as to which approach is more effective. The conference concluded by identifying several important unanswered questions and suggestions that could be addressed by future research projects.

Sonographic and Doppler characteristics of the corpus luteum: can they predict pregnancy outcome?

OBJECTIVE: To determine whether there is a relationship between gray scale or Doppler characteristics of the corpus luteum and first-trimester pregnancy outcome. METHODS: We conducted a prospective study of patients with spontaneous singleton pregnancies between 5 and 8 weeks' gestation. The corpus luteum size, sonographic appearance, resistive index, and peak systolic velocity were measured on transvaginal sonography. Maternal use of exogeneous progesterone was recorded. Only patients with known first-trimester outcome were included. RESULTS: There were 201 study patients. The corpus luteum could be visualized in 197 (98%) and had a mean +/- SD size of 1.9 +/- 0.6 cm, a mean resistive index of 0.50 +/- 0.08, and a peak systolic velocity of 20.5 +/- 11.2 cm/s. There were 151 first-trimester survivors (75.1 %) and 50 spontaneous losses (24.9%). In a comparison of the survivors and losses, there was no significant difference in mean corpus luteum size (1.9 versus 1.7 cm; P = .10, t test), mean resistive index (0.50 versus 0.50; P = .71, t test), peak systolic velocity (21 versus 19 cm/s; P = .29, t test), or sonographic appearance (P = .78, chi2 test). The lack of association between corpus luteum characteristics and outcome persisted when cases were stratified by progesterone use and the presence or absence of a heartbeat on the study sonogram. CONCLUSION: There is no apparent relationship between the characteristics of the corpus luteum and first-trimester pregnancy outcome.

Gynecologic ultrasound.

For most women, pelvic sonography using a transvaginal probe is the imaging modality of choice for evaluating the uterus and adnexae. It is reliable for detecting ovarian cysts and other adnexal masses, and it can often determine if a lesion can be observed on serial examinations or if it requires more urgent attention. Uterine ultrasound is reliable for evaluating both the normal and abnormal endometrium and myometrium. In cases that are technically limited, or in those that are difficult to interpret, a tailored MR imaging examination often can be helpful.

Comparison of tubal ring and corpus luteum echogenicities: a useful differentiating characteristic.

The purpose of this report is to compare the echogenicity of the tubal ring of an ectopic pregnancy and the corpus luteum with that of the ovary for improved detection of early ectopic pregnancy. In patients with ectopic pregnancy diagnosed at sonography on the basis of the presence of an adnexal tubal ring, echogenicity of the ring was compared with the echogenicity of the ovarian parenchyma. Twenty-six patients with tubal rings containing either a yolk sac or cardiac activity were included. Twenty-three (88%) of the 26 tubal rings had echogenicity equal to or greater than that of ovarian parenchyma. In 13 patients with ectopic pregnancy diagnosed on the basis of an empty tubal ring, 10 rings (77%) were more echogenic than the ovary. In 45 control patients with intrauterine pregnancy, the corpus luteum was more echogenic than the ovary in only 3 (7%). The tubal ring of an ectopic pregnancy is usually more echogenic than ovarian parenchyma, and the corpus luteum is usually equal to or less echogenic than the ovary. Echogenicity of an adnexal mass may help distinguish the tubal ring of an ectopic pregnancy from a corpus luteum.

Benign and malignant ovarian masses: selection of the most discriminating gray-scale and Doppler sonographic features.

PURPOSE: To determine the gray-scale and Doppler sonographic features that best enable discrimination between malignant and benign ovarian masses and develop a scoring system for accurate diagnosis with these features. MATERIALS AND METHODS: Gray-scale and Doppler sonographic features of 211 adnexal masses were correlated with the final diagnosis; the most discriminating features for malignancy were selected with stepwise logistic regression. RESULTS: Twenty-eight masses were malignant and 183 benign. All masses with a markedly hyperechoic solid component or no solid component were benign. For masses with a nonhyperechoic solid component, additional features that allowed statistically significant discrimination of benignity from malignancy were, in decreasing order of importance, (a) location of flow at conventional color Doppler imaging, (b) amount of free intraperitoneal fluid, and (c) presence and thickness of septations. A scoring formula that made use of values based on the logistic regression equation had an area under the receiver operating characteristic curve of 0.98 +/- 0.01. The cutoff score with the highest accuracy had a sensitivity of 93% and specificity of 93%. CONCLUSION: A solid component is the most statistically significant predictor of a malignant ovarian mass. A multiparameter scoring system that uses three gray-scale and one Doppler feature, developed by means of stepwise logistic regression, has high sensitivity and specificity for predicting malignancy.