- Email: [email protected]
OBSTETRICS FOR MEDICAL STUDENTS
889
Committee.1 In the London borough of Tower Hamlets, which is served by the London Chest Hospital, reside about one-fifth of the
Bangladeshi population of Britain. A review of medical outpatient bookings revealed that 21 % of patients were of Asian origin, and 73% of these had been born in Bangladesh or born in the UK of Bangladeshi parents. Many of these patients speak very little English and many of the women who came to the UK since the early 1970s can neither write in their mother tongue nor speak English. Lacking the confidence to come to hospital on their own, they are accompanied by their husbands or other adult male relatives or by their children, who act as chaperones and interpreters but who have to take time off work or school. In January, 1984, a class in English as a second language was started as a pilot scheme one afternoon per week in the outpatients department, and a creche was arranged for those with pre-school children. The aim was to give women a basic understanding of English so that they could describe their own symptoms to the doctor and understand medical advice and to ensure greater safety when prescribed potentially dangerous drugs. The two English language teachers (one of whom speaks Bengali) and the creche worker were funded by the Tower Hamlets Institute of Adult Education, which has supervised and monitored the students’ progress. A minibus was hired from Tower Hamlets Community Transport and a woman driver was employed to transport the women and their children to and from the class. The classes are free and the expenses are met by charities. Some women have attained sufficient confidence and ability to transfer to an English language class in the community. This project could be a model for other hospitals in similar situations. The classes have also promoted goodwill between two large and equally important services (education and health) and between the hospital and the local Asian
community. London Chest Hospital, London E2 9JX
FREDA FESTENSTEIN
1. House of Commons 96-1 (1986-87). First Report: Bangladeshis in Britain. Vol 1. HM Stationery Office, 1986.
OBSTETRICS FOR MEDICAL STUDENTS
SIR,-Reviewing E. M. Symonds’ Essential Obstetrics and Gynaecology, Dr Frappell (March 19, p 622) feels that eight weeks of undergraduate obstetrics and gynaecology is too little. It may be too much. What does the medical student need to know? Not about the details of antenatal problems, the complications of labour, or hormonal treatment of the menopause-but certainly about the principles of childbirth, of antenatal care, and of fertility control. The system of attaching all students to a pregnant woman and allowing them to follow her through delivery, childbirth, and early motherhood (as practised in Newcastle upon Tyne) seems to me a much more useful way than lectures of teaching the subject to students who, if they are ever to look after pregnant women themselves, will have to study the subject as a postgraduate. Community Health Service, Newcastle General Hospital, Newcastle upon Tyne NE4 6BE TONY WATERSTON
SCREENING FOR OVARIAN CANCER BY CA-125 MEASUREMENT
SIR,-Dr Cruickshank (March 5, p 540) raises some important points about potential approaches to screening for ovarian cancer. However, he attributes to us (Feb 6, p 268) the statement that "the sensitivity of
serum CA-125 measurement in early stage ovarian is unknown". This is inaccurate; we said that the "specificity and sensitivity of CA-125 measurement for preclinical, early stage, ovarian cancer are unknown". The difference is crucial in the context of screening for preclinical disease. This did, however, provide Cruickshank with the opportunity to refer to his series of 15 patients with clinically diagnosed FIGO stage I and II ovarian cancer.’ CA-125 levels have been reported in at least 142 similar cases?-’2 These data suggest that serum CA-125 is increased pre-operatively in ovarian cancer patients in 51 % of 65 stage I cases, 91% of 46 stage II cases, and 68% of 157 stage I and IIcases combined. The sensitivity of serum CA-125 for preclinical, early
cancer
stage, ovarian cancer remains unknown and is one of the questions addressed by the second phase of our study (over 5000 volunteers recruited so far). Testing with a variety of tumour markers will likely achieve a higher sensitivity for ovarian cancer than CA-125 measurement alone. A multicentre study to examine this possibility is being organised, and Cruickshank’s participation would be welcomed. The inevitable increase in the false positive rate which will result from this approach may not be an insuperable problem if ultrasound is used as a secondary test in women with a positive result. Cruickshank criticises our method of follow-up by postal questionnaire and doubts its accuracy in excluding false negatives. The aim of our study was to examine the specificity (not the sensitivity) of the screen. As the specificity of a test is influenced more by the false positive rate than the false negative rate, the question of follow-up is less important than he implies. For instance, even if there were 10 false negatives among the 1010 volunteers screened (which is unlikely in view of the low incidence of ovarian cancer) the specificity of CA-125 would have remained 97-0% (979/1009, 969/999) and that of CA-125 combined with ultrasound 99.8% (1007/1009, 997/999). Cruickshank also states that there was "no mention of the proportion returning their questionnaire". This too is inaccurate. We said that there was "complete compliance with recall for ultrasound and follow-up". We are satisfied that only 1 of the 1010 volunteers had a diagnosis of ovarian cancer at 1-year follow-up. London Hospital, London E1 1BB
IAN
JACOBS
1. Cruickshank DJ, Fullerton WT, Klopper A. The clinical significance of pre-operative serum CA 125 in ovanan cancer. Br J Obstet Gynaecol 1987; 94: 692-95. 2. Bast RC Jr, Klug TL, St John ERN, et al. A radioimmunoassay using a monoclonal antibody to monitor the course of epithelial ovarian cancer N Engl J Med 1983; 309: 883-87. 3. Brioschi PA, Irion O, Bischof P, et al. Serum CA 125 in epithelial ovarian cancer: a 4.
longitudinal study. Br J Obstet Gynaecol 1987; 94: 196-201. Canney PA, Moore A, Wilkinson PM, et al. Ovarian cancer antigen CA125: a prospective clinical assessment of its role as a tumour marker Br J Cancer 1984; 50:
765-69. 5. Crombach G,
Zippel HH, Wurz H. Expenences with CA 125, a tumour marker for malignant epithelial ovarian tumours. Geburtshilfe Frauenheilkd 1985, 45: 205-12. 6. Kaesermann H, Caffier H, Hoffmann FJ, et al. Monoklonale Antikorper in Diagnostik 7.
8. 9.
10.
11.
12
und Verlaufskontrolle des Ovanalkarzinoms: CA 125 als Tumormarker. Klin Wochenshr 1986; 64: 781-83. Kivinen S, Kuoppala T, Leppilampi M, et al. Tumour-associated antigen CA 125 before and during the treatment of ovarian carcinoma. Obstet Gynecol 1986; 67: 468-72. Krebs HB, Goplerud DR, Kilpatrick J, et al Role of CA 125 as tumour marker in ovarian carcinoma. Obstet Gynecol 1986; 67: 473-77. Li-juan L, Xiu-feng H, Wen-shu L, et al. A monoclonal antibody radioimmunoassay for an antigenic determinant CA 125 in ovarian cancer patients. Chinese Med J 1986; 99: 721-26. Ricolleau G, Chatal J-F, Fumoleau P, et al. Radioimmunoassay of the CA 125 antigen in ovarian carcinomas: Advantages compared with CA19-9 and CEA. Tumour Biol 1984; 5: 151-59. Schilthuis MS, Aalders JG, Bouma J, et al Serum CA 125 levels in epithelial ovarian cancer Relation with findings at second-look operations and their role in the detection of tumour recurrence Br J Obstet Gynaecol 1987; 94: 202-07. Zanaboni F, Vergadoro F, Presti M, et al. Tumour antigen CA 125 as a marker of ovarian epithelial carcinoma Gynecol Oncol 1987; 28: 61-67.
ORONASAL
OBSTRUCTION, LUNG VOLUMES, AND ARTERIAL OXYGENATION
SIR,-Mr Swift and colleagues (Jan 16, p 73) report on the effects of oronasal obstruction on lung volumes and arterial oxygenation. Swift and colleagues claim that complete nasal obstruction will result, because of mouth breathing, in a decrease of total airflow resistance. Oral airflow resistance is lower than nasal airflow resistance only if a mouthpiece is worn.1 Cole et al studied normal subjects with the nose occluded by a noseclip: oral airflow resistance was 12-19 cm H20 x I-’ s (ie, within the normal range of nasal airflow resistance) and only decreased when a mouthpiece was used.Oral airflow resistance depends not only on the degree of oral aperture, but also on velolingual isthmus opening (the "soft palate mechanism").2 Thus, it is hazardous to conclude that the overall effect of complete nasal obstruction will be a decrease in airflow resistance. Similarly, Swift et al state that interdental wiring will result in an increase in resistance to breathing, because people
Committee.1 In the London borough of Tower Hamlets, which is served by the London Chest Hospital, reside about one-fifth of the
Bangladeshi population of Britain. A review of medical outpatient bookings revealed that 21 % of patients were of Asian origin, and 73% of these had been born in Bangladesh or born in the UK of Bangladeshi parents. Many of these patients speak very little English and many of the women who came to the UK since the early 1970s can neither write in their mother tongue nor speak English. Lacking the confidence to come to hospital on their own, they are accompanied by their husbands or other adult male relatives or by their children, who act as chaperones and interpreters but who have to take time off work or school. In January, 1984, a class in English as a second language was started as a pilot scheme one afternoon per week in the outpatients department, and a creche was arranged for those with pre-school children. The aim was to give women a basic understanding of English so that they could describe their own symptoms to the doctor and understand medical advice and to ensure greater safety when prescribed potentially dangerous drugs. The two English language teachers (one of whom speaks Bengali) and the creche worker were funded by the Tower Hamlets Institute of Adult Education, which has supervised and monitored the students’ progress. A minibus was hired from Tower Hamlets Community Transport and a woman driver was employed to transport the women and their children to and from the class. The classes are free and the expenses are met by charities. Some women have attained sufficient confidence and ability to transfer to an English language class in the community. This project could be a model for other hospitals in similar situations. The classes have also promoted goodwill between two large and equally important services (education and health) and between the hospital and the local Asian
community. London Chest Hospital, London E2 9JX
FREDA FESTENSTEIN
1. House of Commons 96-1 (1986-87). First Report: Bangladeshis in Britain. Vol 1. HM Stationery Office, 1986.
OBSTETRICS FOR MEDICAL STUDENTS
SIR,-Reviewing E. M. Symonds’ Essential Obstetrics and Gynaecology, Dr Frappell (March 19, p 622) feels that eight weeks of undergraduate obstetrics and gynaecology is too little. It may be too much. What does the medical student need to know? Not about the details of antenatal problems, the complications of labour, or hormonal treatment of the menopause-but certainly about the principles of childbirth, of antenatal care, and of fertility control. The system of attaching all students to a pregnant woman and allowing them to follow her through delivery, childbirth, and early motherhood (as practised in Newcastle upon Tyne) seems to me a much more useful way than lectures of teaching the subject to students who, if they are ever to look after pregnant women themselves, will have to study the subject as a postgraduate. Community Health Service, Newcastle General Hospital, Newcastle upon Tyne NE4 6BE TONY WATERSTON
SCREENING FOR OVARIAN CANCER BY CA-125 MEASUREMENT
SIR,-Dr Cruickshank (March 5, p 540) raises some important points about potential approaches to screening for ovarian cancer. However, he attributes to us (Feb 6, p 268) the statement that "the sensitivity of
serum CA-125 measurement in early stage ovarian is unknown". This is inaccurate; we said that the "specificity and sensitivity of CA-125 measurement for preclinical, early stage, ovarian cancer are unknown". The difference is crucial in the context of screening for preclinical disease. This did, however, provide Cruickshank with the opportunity to refer to his series of 15 patients with clinically diagnosed FIGO stage I and II ovarian cancer.’ CA-125 levels have been reported in at least 142 similar cases?-’2 These data suggest that serum CA-125 is increased pre-operatively in ovarian cancer patients in 51 % of 65 stage I cases, 91% of 46 stage II cases, and 68% of 157 stage I and IIcases combined. The sensitivity of serum CA-125 for preclinical, early
cancer
stage, ovarian cancer remains unknown and is one of the questions addressed by the second phase of our study (over 5000 volunteers recruited so far). Testing with a variety of tumour markers will likely achieve a higher sensitivity for ovarian cancer than CA-125 measurement alone. A multicentre study to examine this possibility is being organised, and Cruickshank’s participation would be welcomed. The inevitable increase in the false positive rate which will result from this approach may not be an insuperable problem if ultrasound is used as a secondary test in women with a positive result. Cruickshank criticises our method of follow-up by postal questionnaire and doubts its accuracy in excluding false negatives. The aim of our study was to examine the specificity (not the sensitivity) of the screen. As the specificity of a test is influenced more by the false positive rate than the false negative rate, the question of follow-up is less important than he implies. For instance, even if there were 10 false negatives among the 1010 volunteers screened (which is unlikely in view of the low incidence of ovarian cancer) the specificity of CA-125 would have remained 97-0% (979/1009, 969/999) and that of CA-125 combined with ultrasound 99.8% (1007/1009, 997/999). Cruickshank also states that there was "no mention of the proportion returning their questionnaire". This too is inaccurate. We said that there was "complete compliance with recall for ultrasound and follow-up". We are satisfied that only 1 of the 1010 volunteers had a diagnosis of ovarian cancer at 1-year follow-up. London Hospital, London E1 1BB
IAN
JACOBS
1. Cruickshank DJ, Fullerton WT, Klopper A. The clinical significance of pre-operative serum CA 125 in ovanan cancer. Br J Obstet Gynaecol 1987; 94: 692-95. 2. Bast RC Jr, Klug TL, St John ERN, et al. A radioimmunoassay using a monoclonal antibody to monitor the course of epithelial ovarian cancer N Engl J Med 1983; 309: 883-87. 3. Brioschi PA, Irion O, Bischof P, et al. Serum CA 125 in epithelial ovarian cancer: a 4.
longitudinal study. Br J Obstet Gynaecol 1987; 94: 196-201. Canney PA, Moore A, Wilkinson PM, et al. Ovarian cancer antigen CA125: a prospective clinical assessment of its role as a tumour marker Br J Cancer 1984; 50:
765-69. 5. Crombach G,
Zippel HH, Wurz H. Expenences with CA 125, a tumour marker for malignant epithelial ovarian tumours. Geburtshilfe Frauenheilkd 1985, 45: 205-12. 6. Kaesermann H, Caffier H, Hoffmann FJ, et al. Monoklonale Antikorper in Diagnostik 7.
8. 9.
10.
11.
12
und Verlaufskontrolle des Ovanalkarzinoms: CA 125 als Tumormarker. Klin Wochenshr 1986; 64: 781-83. Kivinen S, Kuoppala T, Leppilampi M, et al. Tumour-associated antigen CA 125 before and during the treatment of ovarian carcinoma. Obstet Gynecol 1986; 67: 468-72. Krebs HB, Goplerud DR, Kilpatrick J, et al Role of CA 125 as tumour marker in ovarian carcinoma. Obstet Gynecol 1986; 67: 473-77. Li-juan L, Xiu-feng H, Wen-shu L, et al. A monoclonal antibody radioimmunoassay for an antigenic determinant CA 125 in ovarian cancer patients. Chinese Med J 1986; 99: 721-26. Ricolleau G, Chatal J-F, Fumoleau P, et al. Radioimmunoassay of the CA 125 antigen in ovarian carcinomas: Advantages compared with CA19-9 and CEA. Tumour Biol 1984; 5: 151-59. Schilthuis MS, Aalders JG, Bouma J, et al Serum CA 125 levels in epithelial ovarian cancer Relation with findings at second-look operations and their role in the detection of tumour recurrence Br J Obstet Gynaecol 1987; 94: 202-07. Zanaboni F, Vergadoro F, Presti M, et al. Tumour antigen CA 125 as a marker of ovarian epithelial carcinoma Gynecol Oncol 1987; 28: 61-67.
ORONASAL
OBSTRUCTION, LUNG VOLUMES, AND ARTERIAL OXYGENATION
SIR,-Mr Swift and colleagues (Jan 16, p 73) report on the effects of oronasal obstruction on lung volumes and arterial oxygenation. Swift and colleagues claim that complete nasal obstruction will result, because of mouth breathing, in a decrease of total airflow resistance. Oral airflow resistance is lower than nasal airflow resistance only if a mouthpiece is worn.1 Cole et al studied normal subjects with the nose occluded by a noseclip: oral airflow resistance was 12-19 cm H20 x I-’ s (ie, within the normal range of nasal airflow resistance) and only decreased when a mouthpiece was used.Oral airflow resistance depends not only on the degree of oral aperture, but also on velolingual isthmus opening (the "soft palate mechanism").2 Thus, it is hazardous to conclude that the overall effect of complete nasal obstruction will be a decrease in airflow resistance. Similarly, Swift et al state that interdental wiring will result in an increase in resistance to breathing, because people