Zusammenfassung Der Stellenwert der Kontrastmittel-verstärkten Sonographie (CEUS) in der Mammadiagnostik wird nach wie vor kontrovers diskutiert – und findet beispielweise auch Erwähnung in der EFSUMB-Leitlinie. Zwei Jahrzehnte nach Einführung der CEUS in Deutschland ist die KM-verstärkte Untersuchung der Brustdrüse primär wissenschaftliches Betätigungsfeld, jedoch klinisch wenig etabliert.

Zusammenfassung Die Mammographie bildet unter Ergänzung des Ultraschalls (US) die Standardmodalität im Mammakarzinom-Screening. In einer EFSUMB-Leitlinie von 2019 fassten die Autoren den zusätzlichen Einsatz der US-Elastographie im Bereich der Brustdrüse als Möglichkeit zur Steigerung der diagnostischen Genauigkeit zusammen. Jedoch wurde der Stellenwert des Kontrastmittel-verstärkten US (CEUS) in der Mammadiagnostik in einer EFSUMB-Leitlinie von 2018 als aktiver Forschungsgegenstand beschrieben, der aktuell noch nicht für die klinische Praxis empfohlen werden kann.

BACKGROUND: Besides mammography, breast ultrasound is the most important imaging modality for women with suspected breast cancer. New software tools bear high potential for improved detectability and specification of malignant breast lesions. OBJECTIVE: To compare the halo depicted around malignant breast lesions by ultrasound using Acoustic Structure Quantification (ASQ) of raw image data with the echogenic rim seen in B-mode ultrasound. METHODS: This retrospective study included 37 women for whom conventional B-mode ultrasound of the breast and ASQ were available as well as histopathology findings for comparison. Software tools were used to measure the halo area or echogenic rim and tumor area and calculate halo-to-lesion ratios for the two ultrasound modes. Six inexperienced readers characterized the breast lesions based on this information. Specificity, sensitivity, positive predictive value (PPV), and negative predictive value (NPV) were determined. ANOVA, the Wilcoxon test, and ROC curve analysis were performed. RESULTS: There was a linear relationship between ASQ-based and B-mode-based halo-to-lesion ratios; however, a systematic error was also noted. ASQ-derived ratios tended to be higher for breast lesions with lymphangioinvasion (p = 0.051, n.s.) and higher N-stages (p > 0.925, n.s.), while there was no correlation with other markers. Because of the significantly greater conspicuity of peritumoral halos in the ASQ mode, inexperienced readers achieved greater sensitivity (78% vs. 74%) and specificity (75% vs. 71%) and higher NPVs (75% vs. 71%) and PPVs (78% vs. 74%) compared with B-mode images. Greater halo conspicuity affected the identification of malignant lesions with both modes; ASQ was found to be particularly well suited (F-Bimage (1,100) = 19.253, p <0.001; F-ASQ (1,100) = 52.338, p <0.001). The inexperienced readers were significantly more confident about their diagnosis using the ASQ maps (z = -3.023, p = 0.003). CONCLUSIONS: We conclude that the halo in ASQ and the echogenic rim in B-mode ultrasound are attributable to different morphologic correlates. ASQ improves diagnostic accuracy and confidence of inexperienced examiners because of improved halo visibility.

Abstract Objective: A current descriptive assessment of perinatal outcomes in pregnancies complicated by previable preterm premature rupture of membranes (pPPROM) at <24 weeks of gestation, after expectant treatment. Study design: Maternal and short-term neonatal data were collected for patients with pPPROM. Results: Seventy-three patients with 93 fetuses were hospitalized with pPPROM at 15–24 weeks’ gestation. Among these patients, 27.4% (n=20) chose pregnancy termination, 27.4% (n=20) miscarried and 45.2% (n=33) proceeded to live births. After a median latency period of 38 days, ranging from 1 to 126 days, 24 singletons and 20 multiples were live-born, of whom 79.5% (n=35) survived the perinatal period. The main neonatal sequelae were pulmonary hypoplasia (29.5%; n=13), connatal infection (56.8%; n=25), intraventricular hemorrhage (25%; n=11; resulting in five neonatal deaths) and Potter’s syndrome (15.9%; n=7). Nine newborns died, within an average of 2.8 days (range, 1–10 days). The overall neonatal survival rate was 51.5% – including miscarriages but not elective terminations. The intact survival rate was 45.5% of all live-born neonates. Conclusions: Even with limited treatment options, overall neonatal survival is increasing. However, neonatal mortality and morbidity rates remain high. The gestational age at membrane rupture does not predict neonatal outcome.

THEORY:Although medical students are exposed to a variety of emotions, the impact of emotions on learning has received little attention so far. Shame-provoking intimate examinations are among the most memorable events for students. Their emotions, however, are rarely addressed during training, potentially leading to withdrawal and avoidance and, consequently, performance deficits. However, emotions of negative valance such as shame may be particularly valuable for learning, as they might prompt mental rehearsal. We investigated the effect of shame on learning from the perspective of cognitive load theory.HYPOTHESES:We hypothesized that (a) training modality determines state shame, (b) state shame directly affects the quality of a clinical breast examination as one example of a shame-provoking exam, and (c) students who experience shame during training outperform those who just discuss the emotion during subsequent performance assessments.METHOD:Forty-nine advanced medical students participated in a randomized controlled, single-blinded study. After a basic, low-fidelity breast examination training, students were randomized to further practice either on a high-fidelity mannequin including a discussion of their emotions or by examining a standardized patient's real breasts. Last, all students conducted a breast examination in a simulated doctor's office. Dependent variables were measures of outcome and process quality and of situational shame.RESULTS:Students training with a standardized patient experienced more shame during training (p < .001, d = 2.19), spent more time with the patient (p = .005, d = 0.89), and documented more breast lumps (p = .026, d = 0.65) than those training on a mannequin. Shame interacted with training modality, F(1, 45) = 21.484, p < .001, η2 = 0.323, and differences in performance positively correlated to decline in state shame (r = .335, p = .022).CONCLUSIONS:Students experiencing state shame during training do reenact their training and process germane load-in other words, learn. Furthermore, altering simulation modality offers a possibility for educators to adjust the affective component of training to their objectives.

ABSTRACT Objective To evaluate prospectively the uterine scar after Cesarean section (CS) and the corresponding uterine region after vaginal delivery (VD) at 6 weeks postpartum using transabdominal (TAS) and transvaginal (TVS) sonography with magnetic resonance imaging (MRI) fusion to investigate whether fusion imaging allows standardized and reproducible identification of the scar location and measurement of uterine wall thickness compared with high‐resolution MRI alone. Methods Pelvic MRI was performed 6 weeks after delivery in 30 women (10 with planned CS (PCS), 10 with emergency CS (ECS) and 10 with VD). After transfer of MRI‐DICOM datasets to the ultrasound system, the scar region after CS and the corresponding uterine region after VD were examined by TAS (5 MHz) and TVS (10 MHz) using smart fusion with MRI to guide visualization of the region in the corresponding sectional planes for both modalities. Vascularization of the scar region was determined as a percentage area using power Doppler ultrasound. Anterior (AW) and posterior (PW) uterine wall thickness was measured using TAS and TVS with fusion imaging and using MRI alone. Results TVS with fusion imaging was applied successfully for uterine assessment at the end of the postpartum period in all women. TAS failed to identify the scar area in three women. Imaging techniques were similar in the evaluation of AW and PW thickness following VD. MRI and MRI/TVS fusion showed significant differences in AW thickness or scar area, in terms of the difference relative to PW thickness, in women with PCS and ECS (MRI: PCS, 4.3 mm; ECS, 4.2 mm; VD, 0.8 mm; P = 0.034; MRI/TVS fusion: PCS, 2.0 mm; ECS, 3.3 mm; VD, 0.0 mm; P = 0.01). The degree of vascularization in the scar region measured by power Doppler ultrasound was lower after PCS (13.1 ± 9.4%/area) and ECS (17.0 ± 8.2%/area) than after VD (34.6 ± 8.5%/area; P = 0.0017). Conclusion MRI/ultrasound fusion imaging can be performed in a reproducible manner for examination of the postpartum uterus. MRI/TVS fusion enables standardized identification of the CS scar location and vascularization is reduced in this area. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Objective of this randomized-controlled multicenter-trial was to determine whether the amniotic fluid index (AFI) or the single deepest vertical pocket (SDP) technique for estimating amniotic fluid volume is superior for predicting adverse perinatal outcome. Pregnant women at term were randomized in AFI or SDP group for assessing amniotic fluid at four unversitary hospitals. These two groups were not different with regards to primary outcome parameter (rate of postpartum admission to NICU), but concerning secondary outcome parameters: there were significantly more cases with the diagnosis oligohydramnios (9,8 vs. 2.2 %), more induction of labour for oligohydrmanios (12.7 vs. 3.6 %) and more abnormal CTG (32.3 vs. 26.2 %) in the AFI group. None of the methods were superior to predict adverse perinatal outcome. However, the probability to diagnose oligohydramnios and to induce labour for oligohydramnios was higher when AFI technique was used.

Objectives: Aim of this study was to detect microorganisms in fetal membranes and placental tissue in preterm chorioamnionitis by combining fluorescence in situ hybridization (FISH) with broad range PCR. The combination of the two molecular techniques enables identification and localization of the microorganisms within the tissue, confirming their clinical relevance.Methods: In a prospective cohort study, we compared 31 women with preterm premature rupture of membranes or preterm labour and preterm delivery by caesarean section with a control group of 26 women undergoing elective caesarean section at term. Fetal membranes and placental tissue were analysed by FISH and broad range 16S rRNA- gene PCR and sequencing.Results: For 20 women in the preterm group, caesarean section was performed because of a clinical diagnosis of chorioamnionitis. Microorganisms were detected in the tissues by both molecular techniques in 11 out of 20 women. Among those, Ureaplasma spp. was most abundant, with five cases that remained culture-negative and would have been missed by routine diagnostic procedures. Other infections were caused by Staphylococcus aureus, Streptococcus mitis or Escherichia coli. FISH and PCR were negative for all women without suspected chorioamnionitis and for the control group.Conclusions: Combination of FISH with broad- range PCR and sequencing permitted unambiguous identification of the causative microorganisms in chorioamnionitis. The high prevalence of Ureaplasma spp. should lead to a re-evaluation of its clinical significance and possible therapeutic consequences. (C) 2016 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

Purpose: Worldwide, preterm birth annually affects more than 15 million infants. Despite increasing knowledge of the risk factors and mechanisms associated with preterm labor, the preterm birth rate has risen in most industrialized countries. The ability to identify women at high risk for spontaneous preterm birth is crucial yet remains difficult. The aim of the present study was to assess the value of cervical length measurements in combination with sonoelasto-graphy and interleukin 6 (IL-6) concentrations in cervicovaginal secretions to identify women at risk for preterm birth.Materials and Methods: 36 pregnant women with signs of threatened preterm birth were enrolled in our prospective cohort study. Cervical length measurement, sonoelastography, and IL-6 levels from cervicovaginal swab samples were measured.Results: The preterm birth rate was found to be 33.3 % in our study cohort. Maternal age did not differ between the preterm and term birth groups. Measurement of the cervical length alone was found to have a sensitivity of 0.7 and a specificity of 0.8, whereas cervical sonoelastography had a sensitivity of 0.66 and a specificity of 0.82. By using a combination of both methods, the sensitivity and specificity were found to be 0.9 and 0.7, respectively. IL-6 levels were not found to differ between women with term deliveries and women with preterm births.Conclusion: Both, cervical sonoelastography and cervical length measurement are valuable tools in identifying women with threatened preterm birth. The highest correlation with the outcome preterm birth was achieved using a combination of both cervical length measurement and cervical sonoelastography.

Zielsetzung: Die Differentialdiagnose eines akuten Leberversagens in der Schwangerschaft bei einer multimorbiden Patientin.

Background: 64% of young medical professionals in Germany do not feel adequately prepared for the practical requirements of the medical profession. The goal of "outcome-orientated training" is to structure medical curricula based on the skills needed when entering the work-force after completing undergraduate medical education, and thus to bridge the gap between the skills graduates have attained and those necessary for a career in the medical profession. Outcome frameworks (OFs) are used for this purpose. In preparation for developing the National Competence-Based Catalogue of Learning Objectives for Medicine (NKLM) - the German OF - the "Consensus Statement of Practical Skills in Undergraduate Medical Education" (which structures the teaching and acquisition of practical skills in Germany and which strongly influenced the "Clinical-Practical Skills" chapter of the NKLM) was published in 2011.It is not uncommon for at least a decade to elapse between the definition and implementation of an OF and the students' graduation, which can further increase the gap between necessary and acquired skills. Thus, the purpose of this paper is to posit theses for future development in healthcare and to apply these theses to a current OF.Methodology: Partially structured interviews with experts were used to generate theses pertaining to general, future development in healthcare. These theses were assessed by physician experts based on the likelihood of implementation by the year 2025. The 288 learning goals of the consensus statement were assessed for their relevance for medical education in the interim.Results: 11 theses were generated for the development of medicine, and these theses were assessed and discussed by 738 experts. These theses include the increase in diseases associated with old age, the increasing significance of interprofessional cooperation, and the growing prevalence of telemedicine applications. Of the 288 learning goals of the consensus statement, 231 of the goals were assessed as relevant, and 57 were deemed irrelevant for the short-term future.Discussion: The theses on the future of healthcare, which were generated in this study and which were validated by numerous experts, provide indications of future developments of overall requirements for medical school graduates. For example, when applied to the content of the "Clinical-Practical Skills" NKLM chapter, they largely validate the future relevance of developing practical skills while also providing indications for their further development as applied to the consensus statement.

Junior doctors do not feel well prepared when they start into postgraduate training. High self-efficacy however is linked to better clinical performance and may thus improve patient care. What factors affect self-efficacy is currently unknown. We conducted a simulated night shift in an emergency room (ER) with final-year medical students to identify factors contributing to their self-efficacy and thus inform simulation training in the ER.

Wir berichten von einer 28-jährigen Erstgravida, die sich im 2. Trimenon mit plötzlich aufgetretener Blutungsneigung und Thrombozytopenie von 2/nl bei der Erstmanifestation einer ITP vorstellte. Die initiierte Therapie mit intravenösen Immunglobulinen (IVIG) und Steroiden konnte erneute Blutungsereignisse und rezidivierende Thrombozytopenien langfristig nicht verhindern, sodass eine vorzeitige Entbindung per Sectio nach Applikation der Lungenreifeinduktion in 32 + 3 SSW nicht vermeidbar war. Die Blutungskomplikationen konnten nur durch multiple Thrombozytentransfusionen beherrscht werden. Aufgrund postpartaler Therapierefraktärität der ITP wurde ein Thrombopoetin-Rezeptoragonist (TPO-RA) appliziert, der zum Anstieg der Thrombozytenzahl führte, die später mithilfe von Prednisolon allein stabilisiert werden konnte.

Fragestellung: Das Ziel der prospektiven Studie war die Darstellung der Sectionarbe 6 Wochen postpartum mittels B-Bild Sonografie abdominell, transvaginal sowie mittels MR/US-Bildfusion. Eignet sich die Fusion dabei zur standardisierten und reproduzierbaren Lokalisation der Narben als auch zur Dickenmessung der Uteruswand?

Fragestellung/Ziel: Die Bedeutung von Mikroorganismen als Ursache für Entzündungsreaktionen, vorzeitige Wehen/vorzeitigen Blasensprung und Frühgeburtlichkeit ist unklar. Die mikrobiologische Routinediagnostik beim Amnioninfektionssyndrom (AIS) beruht auf dem kulturellen Nachweis von Mikroorganismen in Abstrichen von Placenta und Eihäuten.

AIM:Accurate prediction of the risk of spontaneous preterm birth is crucial for the clinical management of patients with preterm labor. The aim of the study was to investigate whether cervical sonoelastography improves prediction of spontaneous preterm birth compared with cervical length measurement and a fetal fibronectin (fFN) test.METHODS:A prospective cohort study was conducted including 64 patients with preterm labor at 23-34 weeks of gestation. Patients had an fFN test and transvaginal cervical length measurement, followed by real-time cervical sonoelastography. The ratio of nondeformable tissue to the total area of a designed region of interest was analyzed and related to the gestational week of delivery.RESULTS:Cervical sonoelastography and fFN test show a significant correlation with spontaneous preterm delivery (P=0.007, P=0.001), resulting in 72.7%/36% sensitivity and 73%/95% specificity. The positive predictive value (PPV) was 61.5%/81.8% and the negative predictive value was 81.8%/70%. The cervical length was not different in cases with and without term delivery (P=0.165).CONCLUSIONS:Cervical sonoelastography is a promising technique that can complement routine diagnostic procedures to improve prediction of preterm birth. The PPV is improved by an fFN test.

Abstract Purpose: Microcalcifications in the breasts can point to breast cancer. However, there is great morphologic variety, and microcalcifications do not always correlate with malignancy. We conducted a prospective study to compare ultrasound and mammography in the detection of microcalcifications following sonographic diagnosis of a hypoechoic focal lesion in women with dense breast composition. Materials and Methods: A total of 104 lesions potentially associated with microcalcifications (82 malignant and 23 benign lesions) were included in the study. The breast was examined by ultrasound (9 MHz, Aplio XG/500) with additional use of MicroPure imaging for the demonstration and evaluation of microcalcifications. The presence of a focal lesion was verified and microcalcifications were counted at ultrasound and mammography by blinded readers. The sensitivity and specificity were determined, and ROC analysis and AUC analysis were performed. Results: The women had a median age of 51 years. The average number of microcalcifications detected by sonography (2.12 ± 2.77) and mammography (3.59 ± 6.35) was not significantly different (p > 0.05). Correlation of the techniques was adequate (Pearson’s r = 0.616, p < 0.0001; Spearman‘s rho = 0.654, p < 0.0001). The intraclass correlation coefficient was K = 0.382 ± 0.072 (p < 0.0001), also indicating adequate agreement of both techniques. The sensitivity and specificity were 70 %/30 % for MicroPure and 45 %/55 % for mammography. The positive predictive value of mammography was superior to that of MicroPure (88 % vs. 78 %). Conclusion: The sonographic detection of microcalcifications with MicroPure imaging in breasts with a hypoechoic focal lesion correlates well with digital mammography.

The relevance of microorganisms in preterm birth is still under discussion. Using a diagnostic fluorescence in situ hybridization probe panel, we visualized Staphylococcus aureus and Streptococcus mitis group in two cases of acute chorioamnionitis. This technique provides spatial resolution and quantity of bacteria, clarifying the epidemiology and pathogenic pathways of acute chorioamnionitis.