563
without controlled randomised population-based studies should be strongly criticised. We have already expressed concern about the introduction of ovarian cancer screening,l as has the UK Co-ordinating Committee for Cancer ResearchThe study by Osmers et al addresses only one of the ten criteria of Wilson and Jungner3 for implementing a screening service-"there should be a suitable test". Even in this regard, there are insufficient data to provide a sensitivity and specificity for vaginosonogaphy in the early detection of endometrial carcinoma. The number of false negatives in the symptom-free group is unknown. In the self-selected symptomfree women, 16% (45/283) screened positive (endometrial thickness 4 mm). In more than two-thirds of these women no primary endometrial neoplasia was detected by diagnostic curettage, despite the acknowledged high frequency (3-5%) of endometrial cancer in the symptom-free group. To explain this high incidence Osmers et al postulated a significant proportion of non-progressive endometrial cancer in the population or spontaneous regression of endometrial cancer. This discussion emphasises how little we know of the natural history of this disease, understanding of which is a prime requirement for any screening test. It seems more likely that the high incidence of endometrial cancer in this group is related either to the selection bias of the symptom-free women or to the recognised difficulty in distinguishing between endometrial hyperplasia and carcinoma. With independent histology review, as many as 70% of endometrial cancers have been downgraded to hyperplasia.4 Osmers et al do not mention any correlation between histology at curettage and histology at hysterectomy with reference to myometrial invasion and stage. This is particularly relevant, because the paper implies that vaginosonography screening will lessen mortality from endometrial cancer by allowing early diagnosis. In current practice, however, 75 % of patients with endometrial cancer present with stage I disease, of whom more than 90% are disease-free after five years. It is difficult to believe therefore that with our current knowledge of the natural history of endometrial cancer any screening test can improve on these results. In addition, in view of the problems of acceptability encountered with cervical cytology screening, it seems unlikely that
vaginosonography in postmenopausal women will fare any better. However, vaginosonography does have potential clinical value in established endometrial cancer, with good concordance between ultrasound and histological assessment of myometrial invasions Consistent with Osmers and colleagues’ cut-off of 4 mm for pathological postmenopausal endometrium, the case of atypical endometrial hyperplasia in our own series had a double endometrial thickness on scan of 11mm. Department of Obstetrics and Gynaecology, University of Aberdeen, Aberdeen AB9 2ZD, UK
DEREK CRUICKSHANK HENRY KITCHENER
screening for early ovarian cancer. Br Med J 1989; 300: 194-95. 2. Sharp F. Screening for early ovarian cancer: report of a workshop to the UKCCCR subcommittee for coordination of research into gynaecological cancers. In: Sharp F, Masson WB, Leake RE, eds. Ovarian cancer biological and therapeutic challenges. Cambridge: Cambridge University Press, 1990: 461. 3. Wilson JMC, Jungner C. Principles and practice of screening for disease. (Public Health Paper no 34). Geneva: World Health Organisation, 1968.
MEAN
*Difference between pre- and
or
SIR,-Electrophysiological methods for the evaluation of efferent pathways have been increasingly included in neurological diagnostic routines.1,2 We measured the cognitive performance of
motor
groups of 10 normal volunteers before and after electrical cortical stimulation, magnetic cortical stimulation, and induction of somatosensory evoked potentials by peripheral stimulation of the tibial nerve. Neuropsychological assessment was done with a ’Cognitrone’ device.3,4This freely programmable test equipment
test,
t Maximum score=15
allows objective assessment of concentration, continuous attention, and fatiguability based on reaction time and number of errors. Additionally, we used the Benton test for visual memory, and the Wechsler memory scale. No differences in cognitive performance were observed before and after tibial nerve stimulation; however, after electrical and magnetic cortical stimulation there was a significant impairment of the speed of information processing and reaction, and performance of associate learning was significantly prolonged (table). Performance returned to normal within 24 h. Our results show that attention and reaction are temporarily reduced after electrical or magnetic cortical stimulation. Thus, we believe that it is essential to advise patients who undergo these tests of their temporary impairment of neuropsychological functions with consequent reduced fitness to drive.
Department of Neurology, University Hospital Innsbruck, A-6020 Innsbruck, Austria
L. SALTUARI M. MAROSI M. KOFLER E. KARAMAT B. SCHMIDHUBER J. KEMMLER M. JESCHOW
CW, Mills KR, Murray NMF. Measurement of central motor conduction in multiple sclerosis by magnetic brain stimulation. Lancet 1986; ii: 355-58. 2. Hess CW, Mills KR, Murray NMF. Percutaneous stimulation of the human brain: a comparison of electrical and magnetic stimuli. J Physiol (Lond) 1986; 378: 35 P. 3. Quatember R, Maly J. Neurologische untersuchungsmethoden altersspezifischer leistungsparameter. Wien Med Wochenschr 1980; 130: 688-92. 4. Sturm W, Dahmen W, Hartje W, Willmes K. Ergebnisse eines trainingsprogrammes zur verbesserung der visuellen auffassungsschnelligkeit und konzentrations fahigkeit bei hirngeschädigten. Arch Psychiatr Nervenkr 1983; 233: 9-22. 1. Hess
Induction chemotherapy in Jehovah’s Witnesses with leukaemia SiR,—Standard induction chemotherapy for acute nonlymphocytic leukaemia typically results in profound, and often prolonged, pancytopenia. Aggressive blood product support is usually neccesary. We report an attempt at induction for acute non-lymphocytic leukaemia in a Jehovah’s Witness who refused all blood products. A 35-year-old Korean woman was referred to us with a diagnosis of
Impaired driving fitness after electrical magnetic cortical stimulation
post-stimulation (Wilcoxon matched pairs
p
without controlled randomised population-based studies should be strongly criticised. We have already expressed concern about the introduction of ovarian cancer screening,l as has the UK Co-ordinating Committee for Cancer ResearchThe study by Osmers et al addresses only one of the ten criteria of Wilson and Jungner3 for implementing a screening service-"there should be a suitable test". Even in this regard, there are insufficient data to provide a sensitivity and specificity for vaginosonogaphy in the early detection of endometrial carcinoma. The number of false negatives in the symptom-free group is unknown. In the self-selected symptomfree women, 16% (45/283) screened positive (endometrial thickness 4 mm). In more than two-thirds of these women no primary endometrial neoplasia was detected by diagnostic curettage, despite the acknowledged high frequency (3-5%) of endometrial cancer in the symptom-free group. To explain this high incidence Osmers et al postulated a significant proportion of non-progressive endometrial cancer in the population or spontaneous regression of endometrial cancer. This discussion emphasises how little we know of the natural history of this disease, understanding of which is a prime requirement for any screening test. It seems more likely that the high incidence of endometrial cancer in this group is related either to the selection bias of the symptom-free women or to the recognised difficulty in distinguishing between endometrial hyperplasia and carcinoma. With independent histology review, as many as 70% of endometrial cancers have been downgraded to hyperplasia.4 Osmers et al do not mention any correlation between histology at curettage and histology at hysterectomy with reference to myometrial invasion and stage. This is particularly relevant, because the paper implies that vaginosonography screening will lessen mortality from endometrial cancer by allowing early diagnosis. In current practice, however, 75 % of patients with endometrial cancer present with stage I disease, of whom more than 90% are disease-free after five years. It is difficult to believe therefore that with our current knowledge of the natural history of endometrial cancer any screening test can improve on these results. In addition, in view of the problems of acceptability encountered with cervical cytology screening, it seems unlikely that
vaginosonography in postmenopausal women will fare any better. However, vaginosonography does have potential clinical value in established endometrial cancer, with good concordance between ultrasound and histological assessment of myometrial invasions Consistent with Osmers and colleagues’ cut-off of 4 mm for pathological postmenopausal endometrium, the case of atypical endometrial hyperplasia in our own series had a double endometrial thickness on scan of 11mm. Department of Obstetrics and Gynaecology, University of Aberdeen, Aberdeen AB9 2ZD, UK
DEREK CRUICKSHANK HENRY KITCHENER
screening for early ovarian cancer. Br Med J 1989; 300: 194-95. 2. Sharp F. Screening for early ovarian cancer: report of a workshop to the UKCCCR subcommittee for coordination of research into gynaecological cancers. In: Sharp F, Masson WB, Leake RE, eds. Ovarian cancer biological and therapeutic challenges. Cambridge: Cambridge University Press, 1990: 461. 3. Wilson JMC, Jungner C. Principles and practice of screening for disease. (Public Health Paper no 34). Geneva: World Health Organisation, 1968.
MEAN
*Difference between pre- and
or
SIR,-Electrophysiological methods for the evaluation of efferent pathways have been increasingly included in neurological diagnostic routines.1,2 We measured the cognitive performance of
motor
groups of 10 normal volunteers before and after electrical cortical stimulation, magnetic cortical stimulation, and induction of somatosensory evoked potentials by peripheral stimulation of the tibial nerve. Neuropsychological assessment was done with a ’Cognitrone’ device.3,4This freely programmable test equipment
test,
t Maximum score=15
allows objective assessment of concentration, continuous attention, and fatiguability based on reaction time and number of errors. Additionally, we used the Benton test for visual memory, and the Wechsler memory scale. No differences in cognitive performance were observed before and after tibial nerve stimulation; however, after electrical and magnetic cortical stimulation there was a significant impairment of the speed of information processing and reaction, and performance of associate learning was significantly prolonged (table). Performance returned to normal within 24 h. Our results show that attention and reaction are temporarily reduced after electrical or magnetic cortical stimulation. Thus, we believe that it is essential to advise patients who undergo these tests of their temporary impairment of neuropsychological functions with consequent reduced fitness to drive.
Department of Neurology, University Hospital Innsbruck, A-6020 Innsbruck, Austria
L. SALTUARI M. MAROSI M. KOFLER E. KARAMAT B. SCHMIDHUBER J. KEMMLER M. JESCHOW
CW, Mills KR, Murray NMF. Measurement of central motor conduction in multiple sclerosis by magnetic brain stimulation. Lancet 1986; ii: 355-58. 2. Hess CW, Mills KR, Murray NMF. Percutaneous stimulation of the human brain: a comparison of electrical and magnetic stimuli. J Physiol (Lond) 1986; 378: 35 P. 3. Quatember R, Maly J. Neurologische untersuchungsmethoden altersspezifischer leistungsparameter. Wien Med Wochenschr 1980; 130: 688-92. 4. Sturm W, Dahmen W, Hartje W, Willmes K. Ergebnisse eines trainingsprogrammes zur verbesserung der visuellen auffassungsschnelligkeit und konzentrations fahigkeit bei hirngeschädigten. Arch Psychiatr Nervenkr 1983; 233: 9-22. 1. Hess
Induction chemotherapy in Jehovah’s Witnesses with leukaemia SiR,—Standard induction chemotherapy for acute nonlymphocytic leukaemia typically results in profound, and often prolonged, pancytopenia. Aggressive blood product support is usually neccesary. We report an attempt at induction for acute non-lymphocytic leukaemia in a Jehovah’s Witness who refused all blood products. A 35-year-old Korean woman was referred to us with a diagnosis of
Impaired driving fitness after electrical magnetic cortical stimulation
post-stimulation (Wilcoxon matched pairs
p
