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Down's RepriseFrom: James Smeltzer (James.Smeltzer@wellstar.org)Tue Apr 24 16:50:30 2001
Hi, I know you all know how shy I am on the subject. I will post any response for public viewing. Those of you still crazy enough to think you can usually find Down Syndrome by prenatal sonography just keep on truckin'! Jim S To Rebecca Smith-Bindmann: Hi, As it appears that JAMA will not print my letter, here is an opportunity. Please feel free to respond personally or to ultrasound@obgyn.net. I am still unsure of the probability of four DS births in our practice over the period in question, all of which were diagnosed or suspected by second trimester scan. I will figure it out for myself. So far in my review, isolated serum markers have diagnosed no chromosomal anomalies. We have one identified only by age and multiple soft markers with a missed outflow VSD (my second large one), a normal 13 week nuchal lucency, a normal serum marker screen. We only do anything but the AFP (PAPP-A, Free Beta HCG or ESTRIOL and Total HCG) on about the 30 percent of our practice with third party coverage or AMA. We are considering offering AFP OR second trimester scan to our other cash pay indigent patients, as the AFP is not predictive of NTD missed by sonogram or other adverse outcome in the absence of sonographic abnormalities. I am running down these results data, which takes a while. The questions are: 1. Do your data or do they not show categorically that results from different centers are not comparable? 2. Do they or do they not show that some centers are better? 3. Why do you not even bother to point this out? 4. How can these results be combined in a model that has the underlying assumption of independent trials to measure the same thing? Is that not what blows the variance of the estimates all to hell? 5. Why do you evaluate minor stigmata for their predictive power in isolation, when only atrioventricular septal defect, nuchal thickening and duodenal obstruction have that power, postnatally? 6. Why do you even consider the 95 percent of studies with "pretend" data from centers doing amnios on everyone, and therefore not using the information, when the relevant question is can you determine, prior to doing it, whether a patient needs an amnio or not? BTW, only about one in five of my AMA patients has an amniocentesis recommended, and so far all of the abnormals are in this group. About one in six is abnormal of the amnios I do. I refuse no-one an amniocentesis. I do believe in using all the information available to counsel a patient. Where are your data that this increases the amnio rate? Jim Smeltzer.
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