Systematic reviews to evaluate diagnostic tests

Diagnostic testing and screening is a critical part of the clinical process because inappropriate diagnostic strategies put patients at risk and entail a serious waste of resources. It is being increasingly recognised that absence of clear summaries of individual research studies on the repeatability, accuracy and impact of tests, which are often scattered across many different journals, is a major impediment. Just as the need to develop means to systematically review research assessing the effectiveness of treatments has been pursued over the last decade, so more recently attention has focused on how research on diagnostic tests might also be systematically reviewed. These reviews present a huge methodological challenge. This paper describes the use of a systematic approach to collation, appraisal and synthesis of information contained in the primary literature about accuracy of diagnostic strategies.

A rapid and systematic review of the effectiveness and cost-effectiveness of the taxanes used in the treatment of advanced breast and ovarian cancer

SECOND-LINE TREATMENT, PACLITAXEL (MEDIAN PROGRESSION-FREE SURVIVAL): The median progression-free survival in the paclitaxel arm was 3.5 months. This was significantly longer than the mitomycin control arm (1.6 months, p = 0.026). BREAST CANCER - SECOND-LINE TREATMENT, PACLITAXEL (MEDIAN OVERALL SURVIVAL): The median length of overall survival in the paclitaxel arm was 12.7 months, compared with 8.4 months in the mitomycin arm. BREAST CANCER - SECOND-LINE TREATMENT, PACLITAXEL (QUALITY OF LIFE): Quality of life was not reported. BREAST CANCER - SECOND-LINE TREATMENT, PACLITAXEL (ECONOMIC EVALUATION): The only economic evaluation that compared paclitaxel with control (mitomycin) was submitted in confidence and has been removed from this report. Six economic evaluations involved comparisons of paclitaxel and docetaxel, which are given below. BREAST CANCER - SECOND-LINE TREATMENT, DOCETAXEL: Four randomised controlled Phase III trials were identified: 303 Study, 304 Study, Scand and Bonneterre. A total of 1092 patients were included. One of these was a preliminary report of a study before completion of accrual (Bonneterre). Patients in the 303 Study had previously received chemotherapy involving alkylating agents; those in the other three had received anthracyclines. There were six economic evaluations on docetaxel. BREAST CANCER - SECOND-LINE TREATMENT, DOCETAXEL (QUALITY OF TRIALS): The 303 and 304 Studies were analysed on an intention to treat basis; the Scand trial excluded a single patient. The length of follow-up ranged from 11 months (Scand) to 23 months (303 Study). At least two-thirds of the participants in these trials had died. The Scand study recommended cross-over to alternate treatment on objective signs of disease progression. Patients crossing over in this way were violating the randomisation; however, no details were given concerning whether or not such patients were censored. In the economic analyses, there were no direct comparisons for the estimation of benefits. BREAST CANCER - SECOND-LINE TREATMENT, DOCETAXEL (MEDIAN PROGRESSION-FREE SURVIVAL): The median progression-free survival in the docetaxel arm ranged from 4.75 months (304 Study) to 7 months (Bonneterre). Patients in the docetaxel arms of the 304 and Scand studies had significantly longer progression-free survivals than controls (4.75 months versus 2.75 months, p = 0.001; 6.3 months versus 3 months, p = 0.001). BREAST CANCER - SECOND-LINE TREATMENT, DOCETAXEL (MEDIAN OVERALL SURVIVAL): The median overall survival in the docetaxel arm ranged from 10.4 months (Scand) to 15 months (303 Study). Patients in the docetaxel arms of the 304 Study survived for significantly longer than the mitomycin plus vinblastine arm (11.4 months versus 8.7 months, p = 0.03). BREAST CANCER - SECOND-LINE TREATMENT, DOCETAXEL (QUALITY OF LIFE): Quality of life was evaluated in two of the trials: the 303 and 304 Studies. There were no significant differences between docetaxel and control in either of these trials in terms of global health status, although differences were apparent on some subscales. These did not appear to follow a consistent pattern across the trials. BREAST CANCER - SECOND-LINE TREATMENT, DOCETAXEL (ECONOMIC EVALUATIONS): All six of these involved comparisons of paclitaxel and docetaxel, where the range of cost-utility ratios for incremental quality-adjusted life-years (QALYs) gained was pound 1990-pound 2431. In addition, three analyses compared docetaxel and vinorelbine. The cost-utility ratio for incremental QALYs gained was pound 14,050 in the only one of these carried out in the UK. OVARIAN CANCER - FIRST-LINE TREATMENT, PACLITAXEL: Four randomised controlled Phase III trials were identified: EORTC, TITGANZ, E1193 and CA139-278. (ABSTRACT TRUNCATED)

Hysterectomy with bilateral salpingo-oophorectomy: a survey of gynecological practice

BACKGROUND

Oophorectomy at the time of hysterectomy can be carried out by open and minimally invasive methods. The objective of this survey was to determine the current operative practice concerning oophorectomy at hysterectomy for benign gynecological disease in the UK, and to establish practitioners' views regarding the desirability of a randomized controlled clinical trial to compare various operative techniques for this procedure.

SETTING

Gynecologists associated with the British Society of Gynecological Endoscopy.

METHODS

A self-administered structured questionnaire was posted to 323 UK gynecologists to enquire about their surgical practice in performing oophorectomy at hysterectomy and their willingness to participate in a randomized trial.

RESULTS

The postal questionnaire was returned by 147 (46% response rate). For performing oophorectomy at hysterectomy, 84 (57%) routinely used laparotomy only. However, 67 (46%) in total were competent in all surgical methods i.e. laparotomy, vaginal and laparoscopical. Of these, 38 (57%) were willing to enter patients into a proposed clinical trial comparing vaginal and laparoscopically assisted oophorectomy at hysterectomy.

CONCLUSION

The current surgical approach to performing oophorectomy at hysterectomy varies widely. This suggests that opinion regarding the relative roles of abdominal, vaginal and laparoscopic methods is divided. Hence, a rigorous randomized trial comparing the efficacy and safety of these methods is practicable and urgently needed.

Using unconditional and conditional standard deviation scores of fetal abdominal area measurements in the prediction of intrauterine growth restriction

OBJECTIVE

To compare the performance of unconditional and conditional standard deviation scores (Z scores) of fetal abdominal area (FAA) measurements in the antenatal identification of infants born with anthropometric features of intrauterine growth restriction.

METHODS

A prospective observational study, involving 274 low-risk women participating in a longitudinal study of serial ultrasound in pregnancy. Conditional Z scores were established for the last FAA prior to delivery with reference to measurements made both 28 and 56 days previously. Unconditional Z scores (size) were calculated from the last FAA measurement prior to delivery. Receiver-operator characteristics curves were employed to determine an optimal cut-off point for Z scores to predict intrauterine malnourishment. The main outcome measures were: likelihood ratios (LR) for conditional and unconditional Z scores of FAA in the prediction of infants with skinfold thickness < 10th percentile; ponderal index < 25th percentile or mid-arm circumference to occipitofrontal circumference ratio (MAC/OFC) of < -1 SD. An LR of > 10 generates significant changes in the pretest probability of growth restriction, whereas an LR of 5-10 generates only moderate changes.

RESULTS

Conditional Z scores with 28- and 56-day separations predicted growth restriction with LR 7.5 (95% confidence interval [CI], 3.7-14.7) and 4.8 (95% CI, 2.8-7.8) for ponderal index but did not usefully predict skinfold thickness or MAC/OFC. Unconditional Z scores did not usefully predict any of the parameters of growth restriction.

CONCLUSIONS

Quantifying third trimester fetal growth by means of FAA conditional Z scores is moderately useful in predicting infants with a low ponderal index and is superior to unconditional FAA Z scores in late pregnancy.

Controlled analysis of factors associated with insufficient sample on outpatient endometrial biopsy

We examined the relative significance of hysteroscopic and ultrasonographic evidence of endometrial atrophy in relation to insufficient sample on outpatient endometrial biopsy in women with abnormal uterine bleeding. Multivariate logistic regression modelling was used to evaluate the independent effects of age, menopausal status, hysteroscopic findings and sonographic endometrial thickness on outpatient endometrial sampling (sufficient or insufficient) used as the binary dependent variable. Insufficient sample on endometrial biopsy was associated with hysteroscopic finding of endometrial atrophy (OR 4.79, 95% CI 1.05-21.91, P = 0.04) and sonographic endometrial thickness below 5 mm (OR 0- 19. 95% CI 0.07-0.53, P = 0.001). There was no association with patient's age and menopausal status. In conclusion, when reassuring women with insufficient sample on outpatient endometrial biopsy, one can be confident about absence of pathology provided the hysteroscopic and sonographic endometrial assessment is consistent with endometrial atrophy.

Validity of ultrasound estimation of fetal weight

OBJECTIVE

To assess the validity of ultrasound estimation of fetal weight at term.

METHODS

We conducted a prospective observational study whereby all ultrasonic biometric measurements were done by a single observer. Fifty pregnant women at term had ultrasonic measurement of various fetal biometric parameters performed within a week of delivery. Fetal weight was estimated by the use of four reported methods (Aoki, Campbell, Shepard, and Hadlock formulas). We compared estimated weight with the birth weight after the estimated fetal weight was adjusted by adding 25 g for each day between the ultrasound measurements and delivery.

RESULTS

The adjusted estimated fetal weight obtained from all four formulas tended to be lower than measured birth weight. The smallest mean difference was obtained with the Shepard and Aoki formulas (51.4 g and 60.5 g, respectively), whereas the Campbell and Hadlock formulas produced larger mean differences (141.8 g and 190.7 g, respectively). The Aoki formula generated the smallest range between the limits of agreement (-324.2 to 445.2 g) whereas the Campbell formula produced the largest range (-286.5 to 570.1 g). The range between the limits of agreement generated with the Shepard and Hadlock formulas were intermediate between those produced by the Aoki and Campbell formulas. The intraclass correlation coefficients generated with the Aoki and Shepard formulas were identical (0.90). The intraclass correlation coefficients obtained with the Hadlock (0.84) and Campbell formulas (0.85) were lower.

CONCLUSION

The validity of ultrasonic estimation of fetal weight at term with all four formulas was high.

Modernizing the journal club

Traditionally journal clubs provide a forum to learn presentation skills. We propose a new approach to teaching and learning in journal clubs, focusing on literature acquisition and critical appraisal skills. This approach will enable trainees to use journal clubs for personal professional development as well as for application of new knowledge in clinical medicine to improve patients' outcomes.

Surgical correction of congenital uterine anomalies

Congenital uterine abnormalities have been associated with poor reproductive outcome. Anatomical corrections utilizing open or endoscopic surgery has been recommended to improve these outcomes. This article assesses the available evidence.

The risk of premalignant and malignant pathology in endometrial polyps

OBJECTIVE

To evaluate the risk of premalignant and malignant pathology among endometrial polyps.

DESIGN

Prospective cohort study.

SETTING

Minimal Access Surgical Training (MAST) center in a large teaching hospital.

METHODS

Among 248 patients seen in outpatient hysteroscopy clinic (1996-97), 62 had endometrial polyps. All patients had endometrial sampling for histological assessment. To determine the magnitude of malignant potential among polyps, we compared the pathological findings in polyps (cases) with non-polypoidal specimens (controls).

RESULTS

Out of 62 polyps, histologically 53 (85.5%) were benign, seven (11.3%) had hyperplasia, and two (3.2%) were associated with malignancy. Hyperplasia was more frequent in endometrial specimens with polyps than in those without (11.3% vs 4.3%, p=0.04), but the incidence of carcinoma in the two groups was the same (3.2% vs 3.2%, p= 1.0).

CONCLUSION

In abnormal uterine bleeding, hyperplasia was, but cancer was not, more common in women with endometrial polyps compared to those without polyps.

How useful is uterine artery Doppler flow velocimetry in the prediction of pre-eclampsia, intrauterine growth retardation and perinatal death? An overview

OBJECTIVE

To evaluate the clinical usefulness of Doppler analysis of the uterine artery velocity waveform in the prediction of pre-eclampsia and its associated complications of intrauterine growth retardation and perinatal death.

DESIGN

Quantitative systematic review of observational diagnostic studies using online searching of the MEDLINE database coupled with scanning of the bibliographies of primary and review articles including known unpublished studies.

MATERIAL

Twenty-seven studies involving 12,994 subjects stratified into population subgroups at low and high risk of developing pre-eclampsia and its complications.

OUTCOME MEASURES

The outcome measures studied were: 1. the development of pre-eclampsia; 2. intrauterine growth retardation; and 3. perinatal death. The main meta-analyses were the flow velocity waveform ratio +/- diastolic notch derived by transabdominal Doppler ultrasound as the measurement parameter. The analyses were conducted using likelihood ratio as a measure of diagnostic accuracy. A likelihood ratio of 1 indicates that the test has no predictive value for the outcome. Prediction for the outcome event is considered conclusive with likelihood ratios of > 10 or < 0 x 1 for a positive and negative test result, respectively. Moderate prediction can be achieved with likelihood ratios of 5-10 and 0 x 1-0 x 2 whereas likelihood ratios values of 1-5 and 0 x 2-1 would generate only minimal prediction.

RESULTS

In the low risk population a positive test result, predicted pre-eclampsia with a pooled likelihood ratio of 6 x 4 (95% CI 5 x 7-7 x 1), while a negative test result had a pooled likelihood ratio of 0 x 7 (95% CI 0 x 6-0 x 8). For intrauterine growth retardation the pooled likelihood ratio was 3 x 6 (95% CI 3 x 2-4 x 0) for a positive test result and 0 x 8 (95% CI 0 x 8-0 x 9) for a negative test result. Using perinatal death as outcome measure, the pooled likelihood ratio was 1 x 8 (95% CI 1 x 2-2 x 9) for a positive test result and 0 x 9 (95% CI 0 x 8-1 x 1) for a negative test result. In the high risk population a positive test result predicted pre-eclampsia with a pooled likelihood ratio of 2 x 8 (95% CI 2 x 3-3 x 4), while a negative test had a likelihood ratio of 0 x 8 (95% CI 0 x 7-0 x 9). For intrauterine growth retardation the pooled likelihood ratio was 2 x 7 (95% CI 2 x 1-3 x 4) for a positive test result and 0 x 7 (95% CI 0 x 6-0 x 9) for a negative result. For perinatal death the pooled likelihood ratio was 4 x 0 (95% CI 2 x 4-6 x 6) for a positive test result and 0 x 6 (95% CI 0 x 4-0 x 9) for a negative result.

CONCLUSION

Uterine artery Doppler flow velocity has limited diagnostic accuracy in predicting pre-eclampsia, intrauterine growth retardation and perinatal death.

Quality of medical information about menorrhagia on the worldwide web

OBJECTIVE

To evaluate the quality of medical information on the management of menorrhagia on the worldwide web.

DESIGN AND PROCEDURES

An on-line search of the Internet, locating relevant web sites by using key phrases 'heavy periods' and 'patient information' in seven search engines. Quality was defined as the extent to which the characteristics of a web page satisfied its stated and implied objectives. Assessment focused on credibility and content of each web page. Source, currency and editorial review process assessed credibility and hierarchy and accuracy of evidence assessed content of the web pages.

MAIN OUTCOME MEASURES

Rate of compliance with preset criteria for quality of health information on the Internet.

RESULTS

Nine relevant web pages were located, none of which complied with all of the criteria for quality. Seven of these pages displayed the source and five showed the currency of the information, while none described an editorial review process. Four web pages displayed a hierarchy of evidence and one web page depicted all the criteria for accuracy of its contents.

CONCLUSION

None of the web pages provided complete information to women on heavy periods according to the quality criteria. This makes it difficult for the user without medical knowledge to determine which web page is credible and useable and which should be ignored or rejected. There is a need to be vigilant about the quality of information on the Internet.

Benchmarks of fairness for health care reform: a policy tool for developing countries

Teams of collaborators from Colombia, Mexico, Pakistan, and Thailand have adapted a policy tool originally developed for evaluating health insurance reforms in the United States into "benchmarks of fairness" for assessing health system reform in developing countries. We describe briefly the history of the benchmark approach, the tool itself, and the uses to which it may be put. Fairness is a wide term that includes exposure to risk factors, access to all forms of care, and to financing. It also includes efficiency of management and resource allocation, accountability, and patient and provider autonomy. The benchmarks standardize the criteria for fairness. Reforms are then evaluated by scoring according to the degree to which they improve the situation, i.e. on a scale of -5 to 5, with zero representing the status quo. The object is to promote discussion about fairness across the disciplinary divisions that keep policy analysts and the public from understanding how trade-offs between different effects of reforms can affect the overall fairness of the reform. The benchmarks can be used at both national and provincial or district levels, and we describe plans for such uses in the collaborating sites. A striking feature of the adaptation process is that there was wide agreement on this ethical framework among the collaborating sites despite their large historical, political and cultural differences.

A controlled analysis of authorship trends over two decades

OBJECTIVE

The purpose was to assess authorship trends over time by taking account of publication type and controlling for number of investigating centers and funding status in a multivariable analysis.

STUDY DESIGN

A database of 403 randomized studies and 193 controlled observational studies was assembled by means of a combination of electronic and hand search of 4 generic obstetrics and gynecology journals for the years 1975, 1980, 1985, 1990, and 1995. A multivariable logistic regression model was built for evaluating the effect of time on authorship with multiauthored articles as the binary outcome variable (articles were classified as either those with <6 authors or those with >/=6). The analysis was performed separately for the 2 types of publications, and it was adjusted for the confounding effects of number of centers, funding status, and journal of publication. The beta coefficient (and its exponent) associated with the time term in the logistic model provided a measure of the trend in publication of multiauthored articles.

RESULTS

In randomized studies the odds of publishing a multiauthored article, given the number of centers, funding status, and journal, were increased on average by 6% with every 5-year increment in time (odds ratio, 1.06; 95% confidence interval, 1.02-1. 10; P =.007). Similarly, in controlled observational studies, there was a 10% increase in the odds of publishing multiauthored articles (odds ratio, 1.10; 95% confidence interval, 1.01-1.20; P =.03).

CONCLUSION

There is an inflationary trend in authorship that is not explained solely by the increased collaboration between centers and funding for research.

Misleading authors' inferences in obstetric diagnostic test literature

OBJECTIVE

Our goal was to determine the validity of authors' inferences about the value of the cervico-vaginal fetal fibronectin test in the prediction of preterm birth and the utility of uterine artery Doppler waveform analysis in the prediction of preeclampsia.

STUDY DESIGN

We evaluated all 35 diagnostic test studies (14 on fetal fibronectin and 21 on uterine artery Doppler) included in 2 meta-analyses. The information on authors' conclusions regarding the value of a positive or negative test result was independently abstracted from each article by 2 reviewers, and it was classified as definitely useful, moderately useful, slightly useful, or not at all useful. For the "gold" standard, likelihood ratios of >10 and <0. 1 were regarded as definitely useful, 5 to 10 and 0.1 to 0.2 were regarded as moderately useful, 2 to 5 and 0.2 to 0.5 were regarded as slightly useful, and 1 to 2 and 0.5 to 1 were regarded as not at all useful. The agreement between the authors and the reference standard was computed by simple percentage agreement and weighted kappa statistic.

RESULTS

Among articles assessing the diagnostic value of fetal fibronectin the simple agreement between the authors and the "gold" standard was 26% (7/26) with a kappa of 0.05 (P =.83), and authors overestimated the value of the test result in 66% (17/26) of instances. Similarly, among articles assessing uterine artery Doppler the simple agreement between the authors and the "gold" standard was 31% (13/42) with a kappa of 0.28 (P =.31), and authors overestimated the value of the test result in 48% (20/42) of instances.

CONCLUSION

Authors claimed more positive conclusions than could be supported by their data. When studies are reported in a misleading manner, the chance of misinterpretation on the part of the clinical reader is increased. The use of explicit criteria that are based on likelihood ratios may reduce the risk of erroneous inferences.

Single and serial estimates of amniotic fluid volume and umbilical artery resistance in the prediction of intrauterine growth restriction

OBJECTIVES

To determine whether single or serial estimates of both the amniotic fluid index (AFI) or pulsatility index (PI) of the umbilical artery Doppler waveform can usefully identify infants with anthropometric features of intrauterine growth restriction (IUGR).

METHODS

A total of 274 women underwent serial antenatal ultrasound examinations at predetermined intervals. Four biophysical parameters were considered: AFI and PI prior to delivery and change in AFI and PI over a 28-day period in the third trimester. All values were expressed as standard deviation scores. IUGR was diagnosed if the neonate demonstrated skinfold thickness < 10th centile, ponderal index < 25th centile or mid-arm circumference to occipitofrontal circumference (MAC:OFC) < -1 SD. Receiver operator characteristic curves were used to determine an optimal cut-off point, and test performance of the biophysical parameters were expressed as likelihood ratios (LR).

RESULTS

The test performances of all four ultrasound parameters for any of the three diagnostic criteria for IUGR was poor. The highest positive LR was only 2.5 (95% CI 1.5-4.1) for PI prior to delivery in the prediction of ponderal index < 25th centile.

CONCLUSION

Despite positive associations between single and serial estimates of AFI and PI with abnormal neonatal morphometry, the likelihood ratios remained low. The results of this study do not support the use of single or serial estimates of AFI or umbilical artery PI in the prediction of IUGR.

Logistic regression models in obstetrics and gynecology literature

OBJECTIVE

To evaluate the reporting of multivariable logistic regression analyses and assess variations in quality over time in the obstetrics and gynecology literature.

METHODS

Methodologic criteria for reporting logistic regression analyses were developed to identify problems affecting accuracy, precision, and interpretation of this approach to multivariable statistical analysis. These criteria were applied to 193 articles that reported multivariable logistic regression in the issues of four generic obstetrics and gynecology journals in 1985, 1990, and 1995. Rates of compliance with the methodologic criteria and their time trends were analyzed.

RESULTS

The proportion of articles using logistic regression analysis increased over time: 1.7% in 1985, 2.8% in 1990, and 6.5% in 1995 (P < .001 for trend). Violations and omissions of methodologic criteria for reporting logistic models were common. The research question, in terms of dependent and independent variables, was not clearly reported in 32.1%. The process of variable selection was inadequately described in 51.8% of the articles. Among articles with ranked independent variables, 85.1% did not report assessment of conformity to linear gradient. Tests for goodness of fit were not given in 93.2% of articles. The contribution of the independent variables could not be evaluated in 36.2% of the articles because of a lack of coding of the variables. Interactions between variables were not assessed in 86.4% of articles. Analysis of variations in the quality of logistic regression analyses over time showed no increase in reporting of the criteria concerning variable selection and goodness of fit. However, the proportion of articles reporting one quality criterion concerning interpretation of the substantive significance of independent variables showed a trend toward improvement: 42.3% in 1985, 73.6% in 1990, and 75.4% in 1995 (P = .004 for trend).

CONCLUSION

The reporting of multivariable logistic regression models in the obstetrics and gynecology literature is poor, and the time trends of improvement in quality of reporting are not particularly encouraging.

The diagnostic accuracy of ultrasound scan in predicting endometrial hyperplasia and cancer in postmenopausal bleeding

OBJECTIVE

To determine the accuracy of ultrasound scan in the diagnosis of endometrial hyperplasia and cancer in postmenopausal bleeding.

DESIGN

A prospective diagnostic accuracy study (1996-97).

SETTING

Minimal access surgical training centers in two large teaching hospitals.

METHODS

Ultrasound scan and outpatient endometrial sampling were performed on 96 patients with postmenopausal bleeding. Patients unable to have these outpatient procedures had a formal inpatient hysteroscopy and curettage. Test performance characteristics were computed for ultrasound scan comparing its estimate of endometrial thickness with histologic diagnosis that served as a 'gold' standard.

OUTCOME MEASURES

Accuracy of the ultrasonic endometrial thickness was estimated using sensitivity, specificity and predictive values for binary data. For multilevel data, the diagnostic accuracy was computed using likelihood ratios (LRs). An LR < decreased the probability that endometrial hyperplasia/cancer was present, whereas an LR > 1 increased the probability that such lesion was present.

RESULTS

Using endometrial thickness > or =4 mm, the sensitivity of ultrasound to detect the endometrial malignancy was 92.9%, the specificity was 500%, and the positive and negative predictive values were 24.1% and 97.6% respectively. Analysis using likelihood ratio (LR) revealed that LR was 0.14 for endometrial thickness > or =4.0 mm, 0.94 for endometrial thickness 4.1-9.0 mm, and 3.3 for endometrial thickness >9.0 mm.

CONCLUSION

In women with postmenopausal bleeding, malignancy can probably be safely excluded if sonographic endometrial thickness is < or = 4.0 mm. However, the probability of endometrial hyperplasia/cancer is not particularly altered by the knowledge that endometrial thickness on scan is >4.0 mm.

Is real-time ultrasonic bladder volume estimation reliable and valid? A systematic overview

To assess the reliability and validity of real-time ultrasonic estimation of bladder volume we conducted an overview of the published literature identified using MEDLINE search (1966-96) and scanning of the bibliographies of known primary and review articles. Short-listed papers were classified into reliability (observer agreement) and validity (comparison of ultrasound estimation with actual bladder volume) studies. Study selection and data extraction were performed independently in duplicate. There were 81 subjects enrolled in 3 reliability studies and 504 subjects in 16 validity studies. Where reported, the index of concordance for reliability ranged from 0.923 to 1.00, while for validity it ranged from 0.914 to 0.983. However, there were several inadequacies in the design, conduct and analysis of these studies, leaving some doubt about the trustworthiness of the high levels of reliability and validity reported in the literature.

Role of laparoscopy in the management of chronic pelvic pain

Laparoscopy has rapidly become an important diagnostic and therapeutic tool in gynaecological surgery. The entity of chronic pelvic pain is best investigated laparoscopically before any treatment is planned. Often diagnosis and treatment can be a one-stage procedure.