Maternal alpha-fetoprotein screening: two years' experience in a low-risk district.

Over a two-year period, 3479 pregnant women in the Kings'' Lynn Health District were screened for neural tube defects by estimation of maternal serum alpha-fetoprotein. Most pregnancies were scanned by sonar for fetal maturity. Eight women had fetuses with open neural tube defects; four with anencephaly were associated with very high alpha-fetoprotein values. Of the four with open neural tube defects without anencephaly, only one was detected by screening and confirmed after amniocentesis. One other had a raised serum alpha-fetoprotein but a normal amniotic fluid value. The other two affected fetuses were missed. This disappointing outcome was attributed to the poor predictive value of alpha-fetoprotein in detecting open neural tube defects (anencephaly apart) rather than to errors in its estimation or in assessment of fetal maturity by sonar scan. We question the validity of screening, particularly in areas of intermediate or low incidence.     

Reasons for requesting radiographs in an accident department.

A prospective study of 500 patients was performed to determine the reasons for requesting radiographs in an accident and emergency department. Most examinations were requested either to confirm a clinically suspected abnormality or because of difficulty in excluding a significant bone injury on clinical grounds alone. Several requests were also made to reassure the patient. Medicolegal reasons were relatively few, and those made purely because the doctor feared litigation probably accounted for only 5% of requests. Undue emphasis on the medicolegal aspects of accident and emergency radiography in the United Kingdom is unhelpful in that it directs attention away from the real reasons for x-ray referral. Although a reduction in the number of x-ray examinations is desirable on the grounds of expense and radiation exposure it is likely to be obtained only by improving experience and acumen in the clinical assessment of injuries.