Re: !st Trimester Screening For Downs
From: Gary (jafar6@optonline.net)
Sun Feb 8 21:19:08 2004
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I applaud Dan for obtaining AIUM, I mean Fetal Medicine Foundation
certification in nuchal translucency screening. It is demanding,
requires significant effort and shows a commitment to quality.
My thoughts are as follows:
1. I am certified to obtain nuchal translucencies for prenatal
screening by an organization based in the United States and not by the
FMF. I have a pretty certificate to verify this and would be glad to
tell anyone privately (by e-mail) how they can get one too. One may ask
who allows this American group to certify. I believe God, Who has who
has not spoken out against this, some very qualified experts, and the
marketplace. I believe the Fetal Medicine Foundation has a similar
allowance to certify from those sources. I guess that's all you need,
as long as you don't try to be exclusive and imply greater legitimacy
than that. D'Alton and Malone's ** article quoted below does not
mention FMF certification as necessary or even mention it.
2. I am pleased with my current certifying organization and have
several concerns about the Fetal Medicine Foundation.
A. The FMF has promoted statistics that have not been confirmed in
large controlled studies. In the Article by Dalton and Malone,
mentioned below. The FMF quotes a sensitivity of 77% for trisomy 21
detection with a standard FP rate of 5%. This is based on modeling, and
not on clinical tests. The SURUSS study (mentioned in Malone's
article), the FASTER trial (just presented at the Society for
Maternal-Fetal Medicine meeting) and the EATABUN **(love that name),
study show a lower sensitivity and do not show significantly better
detection and false positive rates than the quad screen.
B. The FASTER and SURUSS trials showed that integrated first and
second trimester screening have better sensitivities and lower false
positive rates than first trimester screens alone. The genetics labs
working with the FMF do not (as of last week) provide integrated risk
assessment based on first and second trimester screening. With close to
a 90% detection rate, at about 2% false positive rate, this test
results in less invasive procedures, less fetal losses and better
detection. My "required" FMF course didn't mention it. It was run by a
genetics lab who didn't offer it, or believe in it.
When I tell patients that integrated screening is more accurate and
safer for the baby, although the results come back 2-3 weeks later,
many jump at it. Patients who have non-invasive screening are usually
looking to avoid invasive procedures, and these integrated screens give
them the best detection rate, and the best chance of avoiding an
invasive test.
C. The FMF has found nasal bone screening to be about as effective as
nuchal translucency screening. The FASTER trial could not confirm it.
D. I feel that the Genetics labs participating in the FMF education
process in the USA steer physicians to use their labs. They make it
seem that they are are the official arm of the official certifying
organization. Most don't offer integrated 1st and 2nd trimester
screening and they quote stats from the FMF models that have not been
confirmed.
3. I think Drs, Malone, Dr. Wapner**, Dr. D'Alton, Dr. Wald and all the
others who did such beautiful work in the large US and UK studies
should make recommendations for training and quality control. I am
guessing and hoping that they wont put all of us through the FMF
process.
4. It only gets better. The day is nearing when invasive studies for
Down syndrome will be a rarity. Several promising screens within our
reach include, iliac wing angle by 3-D ultrasound, and free fetal DNA
in the maternal circulation (which is increased in fetuses with trisomy
21). Maybe 3-D ultrasound will save nasal bone screening and make
nuchal translucencies easier to obtain. Meanwhile, our nuchal
certification diplomas and $2.00 still get us on the NYC Subways.
Btw, all my info about the FASTER trial comes from the abstract. I
couldn't attend the meeting. Could someone fill me in on what I missed
regarding this topic? I bet the same flame war was fought there.
Thank you in advance for that info.
--
Gary Kleinman, M.D.
Maternal-Fetal Medicine/Genetics
Bridgeport Hospital
Bridgeport, CT
*Malone, F, D'Alton, M and the Society for Maternal Fetal Medicine.
First-Trimester Sonographic Screening for Down Syndrome Obstetrics &
Gynecology 2003;102:1066-1079. For those certified by the FMF. Look
carefully at the box on page 1068. You will see that #'s 3 and 10 are a
bit different than the FMF's recommendations. Is July 4 closer than I
think?
**I believe it was Dr. Wapner who coined the acronym for the EATABUN
Study, for "Early Amniocentesis, Transabdominal, with Biochemical
Ultrasound Nuchal translucency. The study showed that first trimester
screening outperfromed second trimester screens, but did not mention
what proportion of the screens were quad screens. From my initial
Evelyn Wood type skimming of the methods section, it seems they
compared first trimester combined screening to a triple screen.
On Sunday, February 8, 2004, at 09:09 PM, Charlie Chambers wrote:
> ........If you know about this process, the Fetal Med Foundation, is
> trying to make sure that there is uniformity and quality assurance
> associated with this screening method. They also give continued
> feedback to already certified individuals in order to maintain
> quality. I've seen too many physicians who are using nuchal
> translucency without a basic understanding of the correct method. The
> criteria were nicely laid out in the Green journal about 2-3 months
> ago by Mary D'Alton et al, and echoed by F.M.F. ......
> Charlie Chambers
> Hood River, OR USA
> cchamber@alumni.rice.edu
--Boundary_(ID_CZu9JjEj8vBqoeS1DPQPrQ)
Content-type: text/enriched; charset=US-ASCII
Content-transfer-encoding: 7BIT
I applaud Dan for obtaining AIUM, I mean Fetal Medicine Foundation
certification in nuchal translucency screening. It is demanding,
requires significant effort and shows a commitment to quality.
My thoughts are as follows:
1. I am certified to obtain nuchal translucencies for prenatal
screening by an organization based in the United States and not by
the FMF. I have a pretty certificate to verify this and would be glad
to tell anyone privately (by e-mail) how they can get one too. One may
ask who allows this American group to certify. I believe God, Who has
who has not spoken out against this, some very qualified experts, and
the marketplace. I believe the Fetal Medicine Foundation has a similar
allowance to certify from those sources. I guess that's all you need,
as long as you don't try to be exclusive and imply greater legitimacy
than that. D'Alton and Malone's ** article quoted below does not
mention FMF certification as necessary or even mention it.
2. I am pleased with my current certifying organization and have
several concerns about the Fetal Medicine Foundation.
A. The FMF has promoted statistics that have not been confirmed in
large controlled studies. In the Article by Dalton and Malone,
mentioned below. The FMF quotes a sensitivity of 77% for trisomy 21
detection with a standard FP rate of 5%. This is based on modeling,
and not on clinical tests. The SURUSS study (mentioned in Malone's
article), the FASTER trial (just presented at the Society for
Maternal-Fetal Medicine meeting) and the EATABUN **(love that name),
study show a lower sensitivity and do not show significantly better
detection and false positive rates than the quad screen.
B. The FASTER and SURUSS trials showed that integrated first and
second trimester screening have better sensitivities and lower false
positive rates than first trimester screens alone. The genetics labs
working with the FMF do not (as of last week) provide integrated risk
assessment based on first and second trimester screening. With close
to a 90% detection rate, at about 2% false positive rate, this test
results in less invasive procedures, less fetal losses and better
detection. My "required" FMF course didn't mention it. It was run by a
genetics lab who didn't offer it, or believe in it.
When I tell patients that integrated screening is more accurate and
safer for the baby, although the results come back 2-3 weeks later,
many jump at it. Patients who have non-invasive screening are usually
looking to avoid invasive procedures, and these integrated screens
give them the best detection rate, and the best chance of avoiding an
invasive test.
C. The FMF has found nasal bone screening to be about as effective as
nuchal translucency screening. The FASTER trial could not confirm it.
D. I feel that the Genetics labs participating in the FMF education
process in the USA steer physicians to use their labs. They make it
seem that they are are the official arm of the official certifying
organization. Most don't offer integrated 1st and 2nd trimester
screening and they quote stats from the FMF models that have not been
confirmed.
3. I think Drs, Malone, Dr. Wapner**, Dr. D'Alton, Dr. Wald and all
the others who did such beautiful work in the large US and UK studies
should make recommendations for training and quality control. I am
guessing and hoping that they wont put all of us through the FMF
process.
4. It only gets better. The day is nearing when invasive studies for
Down syndrome will be a rarity. Several promising screens within our
reach include, iliac wing angle by 3-D ultrasound, and free fetal DNA
in the maternal circulation (which is increased in fetuses with
trisomy 21). Maybe 3-D ultrasound will save nasal bone screening and
make nuchal translucencies easier to obtain. Meanwhile, our nuchal
certification diplomas and $2.00 still get us on the NYC Subways.
Btw, all my info about the FASTER trial comes from the abstract. I
couldn't attend the meeting. Could someone fill me in on what I missed
regarding this topic? I bet the same flame war was fought there.
Thank you in advance for that info.
Gary Kleinman, M.D.
Maternal-Fetal Medicine/Genetics
Bridgeport Hospital
Bridgeport, CT
<bold><color><param>0000,5656,3F3F</param>*Malone, F, D'Alton, M and
the Society for Maternal Fetal Medicine.
</color><fontfamily><param>Lucida Grande</param>First-Trimester
Sonographic Screening for <color><param>CCCC,0000,0000</param>Down
</color>Syndrome
</fontfamily><italic><color><param>0000,5656,3F3F</param>Obstetrics &
Gynecology
</color></italic><fontfamily><param>Lucida Grande</param><color><param>0000,5656,3F3F</param>2003;102:1066-1079.
For those certified by the FMF. Look carefully at the box on page
1068. You will see that #'s 3 and 10 are a bit different than the
FMF's recommendations. Is July 4 closer than I think?
**I believe it was Dr. Wapner who coined the acronym for the EATABUN
Study, for "Early Amniocentesis, Transabdominal, with Biochemical
Ultrasound Nuchal translucency. The study showed that first trimester
screening outperfromed second trimester screens, but did not mention
what proportion of the screens were quad screens. From my initial
Evelyn Wood type skimming of the methods section, it seems they
compared first trimester combined screening to a triple screen. </color><bigger>
</bigger></fontfamily></bold>
On Sunday, February 8, 2004, at 09:09 PM, Charlie Chambers wrote:
<excerpt>........If you know about this process, the Fetal Med
Foundation, is trying to make sure that there is uniformity and
quality assurance associated with this screening method. They also
give continued feedback to already certified individuals in order to
maintain quality. I've seen too many physicians who are using nuchal
translucency without a basic understanding of the correct method. The
criteria were nicely laid out in the Green journal about 2-3 months
ago by Mary D'Alton et al, and echoed by F.M.F. ......<bigger>
</bigger></excerpt>
<excerpt><bigger>Charlie Chambers
Hood River, OR USA
cchamber@alumni.rice.edu
</bigger></excerpt>
--Boundary_(ID_CZu9JjEj8vBqoeS1DPQPrQ)--
