Über den Wandel bei der ZGN und aktuelle Umbrüche in der täglichen Arbeit

mit dieser Ausgabe scheidet Professor Dr. med. Christian P. Speer, FRCPE, eine der tragenden Säulen der ZGN, aus dem Editorial Board dieses traditionsreichsten deutschen Journals zur Geburtshilfe und Neonatologie aus. Ohne Professor Speer, der die Zeitschrift über beeindruckende 29 Jahre entscheidend mitgeprägt hat, wird dem Herausgebergremium ein gewissenhafter Verantwortungsträger, weitsichtiger Vordenker und meinungsstarker Diskutant fehlen. Nicht zuletzt der Blick auf die lange Liste an Verdiensten um die Zeitschrift lässt die Bedeutung des von ihm selbstgewählten Endes seiner aktiven Editorenschaft ermessen. Perinatologische Interdisziplinarität klinisch zu leben und dieses Credo in einem modernen Zeitschriftenformat zu institutionalisieren, umreisst seinen wirkmächtigen Beitrag zur erfolgreichen Fortentwicklung der Zeitschrift für Geburtshilfe und Neonatologie (siehe dazu auch die Laudatio auf Seite 125). Unter seiner Ägide prosperierte die Anerkennung der Zeitschrift sowohl im wissenschaftlichen Kontext als auch bei ihrer Leserschaft.

[Individualized Somatic Classification of Newborns Using Birth Weight Percentiles Based On Maternal Body Height and Weight (Results of a Validation Study)]

INTRODUCTION

Birth weight is influenced by maternal anthropometry. The SGA-rate of newborns of short and light mothers (<158 cm,<53 kg) and the LGA-rate of tall and heavy mothers (>177 cm,>79 kg) are overestimated. The LGA-rate of newborns of shorter mothers and the SGA-rate of taller mothers are underestimated. Individualized birth weight percentiles (IBWP) based on 18 maternal groups (6 groups of height combined with 3 groups of weight), sex and weeks of gestation have been published. The aim of this study is to validate IBWP by evaluating SGA-, AGA-, and LGA-rates using perinatal data.

METHODS

The validation study compares IBWP (1995 to 2000, n=2.2 million singletons) with percentile values from two German cohorts (i: 1995 to 2000; n=2.3 million and ii: 2007 to 2011, n=3.2 million singletons) using newborns from the Lower Saxony Perinatal Survey (n=0.56 million singleton newborns, 2001 to 2009). SGA-, AGA-, and LGA-rates were calculated using R statistical analysis.

RESULTS

Common percentile charts based on the total population 1995-2000 and 2007-2011 yielded SGA-rates among shorter mothers of 21.1 to 21.6% and LGA-rates of 2.0 to 3.1%. In taller mothers, SGA-rates were 3.3 to 3.5% and LGA-rates were 26.6 to 27.1%. IBWP achieved SGA-rates of 9.0% and LGA-rates of 11.4 to 11.6% in shorter mothers and SGA- and LGA-rates of 10% in taller mothers.

DISCUSSION

IBWP consider the maternal size for estimation of the fetal growth potential and achieve expected SGA- and LGA-rates of 10%. Consideration of individual growth potential avoids underestimation and overestimation of SGA- and LGA-rates. It aided analyses of birth weight with IBWP simplify the assessment of the nutritional status.

Obesity in pregnant women: a 20-year analysis of the German experience

BACKGROUND/OBJECTIVE

To investigate the longitudinal development of maternal body weight and analyze the influence of obesity on obstetrics during more than two decades in Germany.

SUBJECTS/METHODS

Data collected from the Federal state of Schleswig-Holstein (German Perinatal Survey) were analyzed with regard to the dynamics of maternal anthropometric variables (body weight, BMI) between 1995-7 and 2004-17. In total 335,511 mothers substantiated the presented study-collective. The statistical analysis was performed using IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY.

RESULTS

Maternal BMI advanced significantly over the study period. Among a rise in mean periconceptional body weight (67.6-72.0 kg), the segment of obese women increased disproportionately (in average 9.4-19.2%). Despite the observed trend to late giving birth (mean maternal age 1995: 29.3 vs. 30.7 years in 2017), it was not advanced maternal age but parity that influenced the continuous increase in maternal weight (mean maternal body weight 1995-7: primi- bi-, multiparae 67.4, 68.3 and 69.0 kg vs. 2004-17: primi- bi-, multiparae 70.0, 71.5 and 73.2 kg respectively).

CONCLUSION

Obesity is a major problem on health issues in obstetrics. Advancing maternal BMI, increasing mother's age and derived prenatal risks considerably complicate pregnancy and delivery. It has to be emphasized that its consequences do not end with delivery or childbed, but represent a livelong burden to the mother and their offspring. Hence, multimodal strategies to reduce/control periconceptional body weight are mandatory.

Impact of nicotine and maternal BMI on fetal birth weight

BACKGROUND

According to the World Health Organization, smoking is the most important risk factor for adverse pregnancy outcomes in industrialized nations. As the individual factors (body mass index - BMI (kg/m2) - and cigarette consumption) have been extensively investigated in pregnancy, we aimed to establish how maternal BMI and nicotine interact with regard to perinatal outcomes and birth weight.

METHODS

Data from 110.047 singleton pregnancies, achieved from the German Perinatal Survey in Schleswig-Holstein and registered between 2010 and 2017 were analyzed in August 2018 concerning maternal BMI and smoking. The BMI was taken from the maternity log. Information concerning the smoking status were self-reported and further subdivided into the following four categories: a) non-smokers; b) 1-7 cigarettes/day; c) 8-14 cigarettes/ day; and d) ≥ 15 cigarettes/ day. Furthermore, we classified women by their BMI into underweight, normal weight, overweight and obese. Comparisons between non-smokers and the respective smoking group, and their relationship with maternal BMI were performed by the t-test (birth weight). A P-value ≤0.05 was considered to indicate statistical significance.

RESULTS

A number of 97.092 women (88.2%) were non-smokers and 12.955 (11.8%) were smokers. Furthermore 10.3% of women of normal weight smoked during pregnancy, but both high and low BMI were associated with a high prevalence of smoking. The proportion of smokers was highest (18.1%) among underweight women (BMI ≤ 18.5 kg/m2). A large number of smokers (15.5%) were registered in the obesity group (BMI ≥ 30 kg/m2). Mean birth weight (≥ 37 + 0 gestational age) increased with increasing maternal BMI, and was reduced by smoking for every BMI category. The differences between smokers and non-smokers were always highly significant (p < 0.001). Mean birth weight varied between 2995 g in underweight frequent smokers and 3607 g in obese non-smokers.

CONCLUSION

Both maternal BMI and smoking during pregnancy influences the birth weight and therefore pregnancy outcome. Smoking during pregnancy was significantly associated with low birth weight. Pregnant women should be advised to cease or at least reduce smoking in order to improve the birth weight of the newborn and to minimize child morbidities.

[Cardiocirculatory Incidents During Pregnancy - a Precarious Setting for Resuscitation - Obstetric Emergencies Series, Part 5]

Collapse and sudden cardiac arrest (SCA) threaten people of all sexes. Although their incidence positively correlates with age, even pregnant women can (rarely) be affected by such cardiovascular emergencies. Transient alterations in maternal circulation caused by vena cava compression syndrome and collapse are to be distinguished from SCA. Each of these individual events requires immediate, coordinated, multidisciplinary emergency team deployment. Different algorithms, available for a quick initial assessment and an immediate start of pregnancy-specific cardiopulmonary resuscitation (CPR) up to perimortem cesarean delivery (PMCD), determine the maternal and subsequently the fetal prognosis. Interdisciplinary/interprofessional simulation training units are efficient to qualify specialized emergency teams.

[Perinatal Emergencies in Emergency Medical Aid - Obstetric Emergencies Series, Part 4]

As far as prehospital but in part also clinical obstetrics is concerned, the acute nature of perinatal emergencies is overshadowed by limited diagnostic and therapeutic options. The need for acute and targeted intervention may result from both maternal and fetal indications. As common in emergency services for pregnant women, prehospital primary assessment and logistics management (e.g., transport time/type, choice of destination) define the prognosis. Non-specific emergencies coincident to pregnancy are to be distinguished from perinatal emergencies caused by expecting a child (hypertensive pregnancy disorders, perinatal bleeding, thrombosis, and embolism). In order to cope with rare and unpredictable emergencies, medical teams profit from standardized algorithms to support a high quality of prehospital care. Extensive information and training concepts are essential. The presented series on obstetric emergencies introduces the required knowledge and skills.

[gebABCDE: An algorithm addressing prehospital delivery - Obstetric Emergencies Series, Part 3]

Acute obstetric complications may occur in any situation and at any time during pregnancy. Patients transported to a hospital may require more time than available, so in these cases emergency care must at least begin outside an inpatient perinatological facility. Although diverse maternal threats require different emergency-treatment strategies, rescue teams are particularly challenged when a prehospital delivery appears to be imminent. Under the terms of emergency medical services professional perinatal options (diagnostics, therapy) are generally not available. This makes clinical knowledge of the specific symptoms, differential diagnoses, hazard profiles and their handling mandatory for the emergency medical physician. When limitations concerning the prehospital setting are considered, a systematic management pathway along the obstetrical ABCDE-scheme - _gebABCDE -guides the perinatologically inexperienced emergency physician safely from step to step. Complementary telemedical support is offered by perinatological specialists who can be called directly over an obstetrical telephone hotline for emergency physicians (24/7) - _gebHOTLINE.

[Maternal Emergencies: Methodically qualified - Conclusive Treatment]

Maternal emergencies can significantly affect the outcome of pregnancy and childbirth. Since obstetrical emergencies may happen at any time during pregnancy an emergency transport to a hospital nearby may not always be possible. So, obstetrical emergency-management may already become mandatory in a prehospital setting. Emergency teams attentiveness should not only focus pathological findings directly caused by pregnancy (premature/rash birth, preterm premature rupture of membranes, cord prolapse) but also look at health threats evolving coincidental to partuation (trauma, acute abdomen, uterine rupture, anaphylaxis). The obstetrically inexperienced emergency team coping with prehospital-inherent management limitations is to be sustained by concrete algorithms. Perinatal knowledge combined with clinical pragmatism determine the basis for emergency management: systematically skilled - acting consistently.

[Prehospital Emergency Management of Pregnant Women - Obstetric Emergencies Series, Part 1]

Maternal emergencies during pregnancy are characterized by a concomitant threat to 2 patients. These emergencies can occur during or even before a hospital stay. Due to the rarity of the latter cases, sustainable methods of knowledge transfer should be implemented so emergency teams have sufficient obstetrical information to provide emergency care during pregnancy. In a series of articles, launched here, individual competencies for prehospital emergency management of pregnant women are described. Part one addresses prehospital emergency care of pregnant women, their emergency transport, handover management on hospital admission, and a team approach to perinatal emergency care.

The relationship between maternal age, body mass index, and the rate of preterm birth

Objective:

The aim of the present study was to assess the influence of maternal age and maternal body mass index of early pregnancy on the risk of preterm delivery.

Material and Methods:

The study included 2.1 million liveborn single newborns with documented data at perinatal surveys. Statistical analyses were performed using the SPSS statistics program.

Results:

The risk of preterm births increased in obese women and in women with advanced age.

Conclusion:

Strategies should be developed to reduce preconceptional body mass index, and guidelines are required to help advise women who postponed childbearing.

The CARE Telematics Network for the Surveillance of Influenza in Europe

Since the 1950s, national networks for the surveillance of influenza have been progressively implemented in several countries. New epidemiological arguments have triggered changes in order to increase the sensitivity of existent early warning systems and to strengthen the communications between European networks. The WHO project CARE Telematics, which collects clinical and virological data of nine national networks and sends useful information to public health administrations, is presented. From the results of the 1993-94 season, the benefits of the system are discussed. Though other telematics networks in this field already exist, it is the first time that virological data, absolutely essential for characterizing the type of an outbreak, are timely available by other countries. This argument will be decisive in case of occurrence of a new strain of virus (shift), such as the Spanish flu in 1918. Priorities are now to include other existing European surveillance networks.

[Not Available]

Liebe Leserin, lieber Leser,

Schwangerschaft und Geburt sind als ursprüngliche und sehr intime Lebensabläufe nicht mit Behandlung erfordernden Gesundheitsstörungen gleichzusetzen. Ein möglichst ungestörter Verlauf der Entbindung mit Eins-zu-Eins-Betreuung der Gebärenden durch ihre Hebamme hilft geburtshilfliche Komplikationen und konsekutive Eingriffe zu vermeiden. Prozesszufriedenheit der Schwangeren bzw. der werdenden Eltern wird dabei allerdings nicht nur durch augenscheinlich leicht objektivierbare Qualitätskriterien abgebildet. Geburtshilfliche Sicherheit von Mutter und Kind unter Wahrung größtmöglicher Selbstbestimmung der Schwangeren markieren in diesem Kontext unverrückbare Zielpunkte. Dies umfasst damit auch die grundsätzliche Freiheit der werdenden Mutter, über den Ort der Geburt unabhängig entscheiden zu können. Das individuelle Setting wird dabei vom mütterlichen Bestreben getragen sein, in einer geschützten (häuslichen) Umgebung und in Tuchfühlung mit supportiv wirkenden Personen ihr Kind zur Welt zu bringen. Äußere Stellgrößen wie räumliche Gegebenheiten, Licht, Geräusche, Stimmen nehmen dabei ebenso wie Achtsamkeit auf Intimsphäre, Begleitung oder Bewegungsmöglichkeit den Charakter maßgeblicher Entscheidungsgrößen an.

Diagnosis and Therapy of Female Pelvic Organ Prolapse. Guideline of the DGGG, SGGG and OEGGG (S2e-Level, AWMF Registry Number 015/006, April 2016)

Aims: The aim was to establish an official interdisciplinary guideline, published and coordinated by the German Society of Gynecology and Obstetrics (DGGG). The guideline was developed for use in German-speaking countries. In addition to the Germany Society of Gynecology and Obstetrics, the guideline has also been approved by the Swiss Society of Gynecology and Obstetrics (SGGG) and the Austrian Society of Gynecology and Obstetrics (OEGGG). This is a guideline published and coordinated by the DGGG. The aim is to provide evidence-based recommendations obtained by evaluating the relevant literature for the diagnostic, conservative and surgical treatment of women with female pelvic organ prolapse with or without stress incontinence. Methods: We conducted a systematic review together with a synthesis of data and meta-analyses, where feasible. MEDLINE, Embase, Cinahl, Pedro and the Cochrane Register were searched for relevant articles. Reference lists were hand-searched, as were the abstracts of the Annual Meetings of the International Continence Society and the International Urogynecological Association. We included only abstracts of randomized controlled trials that were presented and discussed in podium sessions. We assessed original data on surgical procedures published since 2008 with a minimum follow-up time of at least 12 months. If the studies included descriptions of perioperative complications, this minimum follow-up period did not apply. Recommendations: The guideline encompasses recommendations for the diagnosis and treatment of female pelvic organ prolapse. Recommendations for anterior, posterior and apical pelvic organ prolapse with or without concomitant stress urinary incontinence, uterine preservation options, and the pros and cons of mesh placements during surgery for pelvic organ prolapse are presented. The recommendations are based on an extensive and systematic review and evaluation of the current literature and include the experiences and specific conditions in Germany, Austria and Switzerland.

Indications and Route of Hysterectomy for Benign Diseases. Guideline of the DGGG, OEGGG and SGGG (S3 Level, AWMF Registry No. 015/070, April 2015)

Background: Official guideline "indications and methods of hysterectomy" to assign indications for the different methods published and coordinated by the German Society of Gynecology and Obstetrics (DGGG), the Austrian Society of Gynecology and Obstetrics (OEGGG) and the Swiss Society of Gynecology and Obstetrics (SGGG). Besides vaginal and abdominal hysterectomy, three additional techniques have been implemented due to the introduction of laparoscopy. Organ-sparing alternatives were also integrated. Methods: The guideline group consisted of 26 experts from Germany, Austria and Switzerland. Recommendations were developed using a structured consensus process and independent moderation. A systematic literature search and quality appraisal of benefits and harms of the therapeutic alternatives for symptomatic fibroids, dysfunctional bleeding and adenomyosis was done through MEDLINE up to 6/2014 focusing on systematic reviews and meta-analysis. Results: All types of hysterectomy led in studies to high rates of patient satisfaction. If possible, vaginal instead of abdominal hysterectomy should preferably be done. If a vaginal hysterectomy is not feasible, the possibility of a laparoscopic hysterectomy should be considered. An abdominal hysterectomy should only be done with a special indication. Organ-sparing interventions also led to high patient satisfaction rates, but contain the risk of symptom recurrence. Conclusion: As an aim, patients should be enabled to choose that therapeutic intervention for their benign disease of the uterus that convenes best to them and their personal life situation.

Pelvic lymph node dissection for nodal oligometastatic prostate cancer detected by 68Ga-PSMA-positron emission tomography/computerized tomography

BACKGROUND

The first evaluation of pelvic extended lymph node dissection (pLND) in oligometastatic prostate cancer (PCa) detected by (68)Ga-PSMA PET/CT.

METHODS

Retrospective analysis of 35 PCa patients underwent (68)Ga-PSMA PET/CT affected by biochemical recurrence (BCR) after curative treatment (n = 23) or before primary therapy of high-risk PCa (n = 12). We performed pLND associated with pathologic imaging in 17 men with nodal oligometastatic PCa.

RESULTS

Indicative lesions for PCa in PET/CT were detected in 91.4% (32 of 35) of patients. Nodal, bone, visceral (pulmonary), and within the prostate suspected disease were detected in 72% (23 of 32), 16% (5 of 32), 6% (2 of 32), and 47% (15 of 32) of patients, respectively. Median serum PSA in patients with pathological radiotracer uptake in recurrent and high-risk PCa patients was 2.9 ng/ml (range 0.18-30) and 19.5 ng/ml (range 6-90), respectively. The median number of removed lymph nodes with pLND in recurrent and high-risk PCa was 10 (range 4-17) and 12 (range 8-29) per patient and the median number of positive lymph nodes was 1 (range 1-2) and 3 (2-3) per patient, respectively. In total, two false positive and one false-negative lymph node were found. Diagnostic accuracies per nodal lesion in total of 213 removed nodes: sensitivity, 94%; specificity, 99%; positive predictive value (PPV), 89%, and negative predictive value (NPV), 99.5%. After pLND, 53% (9 of 17) of patients received androgen deprivation therapy and/or radiation therapy and hormonal therapy, while 47% (8 of 17) of patients remained free of any post-surgery therapy. Follow-up PSA remained less than 0.2 ng/ml in 82% (14 of 17) of patients. After pLND, immediate BCR (PSA never measured less than 0.2 ng/ml) in 18% (3 of 17) of patients was recorded.

CONCLUSIONS

This represents the first study of pLND in the setting of nodal oligometastatic PCa detected by (68)Ga-PSMA PET/CT. The use of (68)Ga-PSMA PET/CT could be to improve the accuracy for the detection of nodal micrometastases. These promising findings need validation in larger studies.

Targeted diagnostic magnetic nanoparticles for medical imaging of pancreatic cancer

Highly aggressive cancer types such as pancreatic cancer possess a mortality rate of up to 80% within the first 6months after diagnosis. To reduce this high mortality rate, more sensitive diagnostic tools allowing an early stage medical imaging of even very small tumours are needed. For this purpose, magnetic, biodegradable nanoparticles prepared using recombinant human serum albumin (rHSA) and incorporated iron oxide (maghemite, γ-Fe2O3) nanoparticles were developed. Galectin-1 has been chosen as target receptor as this protein is upregulated in pancreatic cancer and its precursor lesions but not in healthy pancreatic tissue nor in pancreatitis. Tissue plasminogen activator derived peptides (t-PA-ligands), that have a high affinity to galectin-1 have been chosen as target moieties and were covalently attached onto the nanoparticle surface. Improved targeting and imaging properties were shown in mice using single photon emission computed tomography-computer tomography (SPECT-CT), a handheld gamma camera, and magnetic resonance imaging (MRI).

Virulence and antimicrobial resistance determinants of verotoxigenic Escherichia coli (VTEC) and of multidrug-resistant E. coli from foods of animal origin illegally imported to the EU by flight passengers

The aim of this study was to reveal phenotype/genotype characteristics of verotoxigenic Escherichia coli (VTEC) and multidrug resistant E. coli in food products of animal origin confiscated as illegal import at Austrian, German and Slovenian airports. VTEC isolates were obtained by using ISO guidelines 16654:2001 for O157 VTEC or ISO/ TS13136:2012 for non-O157 VTEC, with additional use of the RIDASCREEN® Verotoxin immunoassay. The testing of 1526 samples resulted in 15 VTEC isolates (1.0%) primarily isolated from hard cheese from Turkey and Balkan countries. Genotyping for virulence by using a miniaturized microarray identified a wide range of virulence determinants. One VTEC isolate (O26:H46) possessing intimin (eae) and all other essential genes of Locus of Enterocyte Effacement (LEE) was designated as enterohemorrhagic E. coli (EHEC). None of the other VTEC strains belonged to serogroups O157, O145, O111, O104 or O103. VTEC strains harbored either stx(1) (variants stx1(a) or stx(1c)) or st(x2) (variants stx(2a), stx(2b), stx(2a/d) or stx(2c/d)) genes. Pulsed field gel electrophoresis (PFGE) and multilocus sequence typing (MLST) demonstrated high genetic diversity and identified three new sequence types (STs): 4505, 4506 and 4507. Food samples collected from the Vienna airport were also tested for E. coli quantities using the ISO 16649:2001, and for detection of multidrug resistant phenotypes and genotypes. The resulting 113 commensal E. coli isolates were first tested in a pre-screening against 6 selected antimicrobials to demonstrate multidrug resistance. The resulting 14 multidrug resistant (MDR) E. coli isolates, representing 0.9% of the samples, were subjected to further resistance phenotyping and to microarray analyses targeting genetic markers of antimicrobial resistance and virulence. Genotyping revealed various combinations of resistance determinants as well as the presence of class 1, class 2 integrons. The isolates harbored 6 to 11 antibiotic resistance genes as well as 1 to 14 virulence genes. In this panel of 14 MDR E. coli two strains proved to carry CTX-M type ESBLs, and one single isolate was identified as enteropathogenic E. coli (EPEC). In general, isolates carrying a high number of resistance determinants had lower number of virulence genes and vice versa. In conclusion, this first pilot study on the prevalence of VTEC and of MDR/ESBL E. coli in illegally imported food products of animal origin suggests that these strains could represent reservoirs for dissemination of potentially new types of pathogenic and MDR E. coli in Europe.

MALDI imaging of predictive ferritin, fibrinogen and proteases in haemophilic arthropathy

Arthropathy as a result of repeated joint bleeding is a severe complication in patients with haemophilia. In the evaluation of synovial tissue specimens, histology alone is non-specific and there is considerable morphological overlap with other joint diseases. Formalin-fixed paraffin-embedded specimens are available in pathological institutes and can be studied to understand the pathogenesis of haemophilic arthropathy. A powerful technique to identify hundreds of proteins in a tissue section combining proteomics with morphology is imaging mass spectrometry (IMS). We determined whether matrix-assisted laser desorption/ionization (MALDI) IMS can be used to identify and map protein signatures in the synovial tissue of patients with haemophilic arthropathy. MALDI IMS was applied to synovial tissue of six patients with haemophilic arthropathy. We detected several peaks predictive in mass with ferritin light (m/z 1608) and heavy chain (m/z 1345), alpha- (m/z 1071) and beta (m/z 1274) haemoglobin subunits, truncated coagulation factor VIII peptide (m/z 1502, 1176), beta- and gamma fibrinogen peptides (m/z 980, 1032, 1117 and 1683), and annexin A2 (m/z 1111, 1268, 1460, 2164). In addition, the distribution of these proteins in synovial tissue sections was demonstrated. MALDI IMS identified and mapped specific proteins in the synovial membrane of patients with haemophilic arthropathy known to be involved in the pathogenesis of other joint diseases. This technique is a powerful tool to analyse the distribution of proteins in synovial tissue sections.

92 NUCLEAR INVAGINATIONS ADAPT TO RABBIT EARLY EMBRYONIC DEVELOPMENT

Nuclear invaginations carrying nuclear pores may facilitate increased mRNA export and protein import to areas inside the nucleus remote from the nuclear border. In this study on rabbit embryos, we investigated whether large early embryonic nuclei and the increased import/export demands around major embryonic genome activation (MGA) at the 8-cell stage affected the quantity of nuclear invaginations carrying nuclear pores. To achieve this objective, we used super-resolution 3-dimensional structured illumination microscopy on 10 pronuclei or nuclei per stage of 23 in vivo-fertilized and in vitro-cultured embryos stained with antibodies for the nucleoporin NUP153 and lamin B and stained with 4′,6-diamidino-2-phenylindole (DAPI) for chromatin. Statistical comparisons between stages were performed using the Wilcoxon rank-sum test. At the zygote stage, the female pronucleus displayed on average 16.5 and the male pronucleus featured on average 15.25 wide and narrow nuclear envelope invaginations, carrying large or tiny amounts of cytoplasm. Subsequent stages showed predominantly wide invaginations targeting nucleoli. The contact areas between nucleoli and invaginations were free of nuclear pores. In contrast, narrow invaginations, which are the almost exclusive type of invaginations during cattle and mouse pre-implantation development, were not in contact with nucleoli. At the 2-cell stage, the number of invaginations increased to an average of 27.3 invaginations per nucleus (P < 0.05) and increased again to peak at the 4-cell stage with 51.2 invaginations per nucleus (P < 0.01). At the 8-cell stage (MGA), the amount of nuclear invaginations was reduced to 25.4 invaginations per nucleus (P < 0.01). The reduced number of nuclear invaginations at the 8-cell stage could be associated with a significant decrease in average nuclear volume from 2593 µm3 at the 4-cell stage to 960 µm3 at the 8-cell stage (P < 0.001) and a subsequent reduced average distance from areas inside the nucleus to the nuclear border. Nuclear invagination numbers continued their decline at the 21-cell stage with 5.2 invaginations per nucleus (P < 0.001), whereas nuclear volumes decreased to 618 µm3 (P < 0.001). The morula stage, with 6.9 invaginations per nucleus (P = 0.9), and the blastocyst stage, with 4.5 invaginations per nucleus (P = 0.5), showed no more significant changes. Large NUP153 cytoplasmic clusters present before MGA may represent a maternally provided NUP153 deposit. MGA may mark the switch from the use of a NUP153 deposit to on-demand production. Additionally, over- and under-representation analyses on mitotic blastomeres revealed that NUP153 association with chromatin is initiated during metaphase before the initiation of the regeneration of the lamina (P < 0.001; chi-squared goodness-of-fit test). In conclusion, rabbit embryonic development is accompanied by stage-dependent changes of the amount of nuclear invaginations carrying nuclear pores. Although cattle and mouse embryos almost exclusively feature narrow invaginations restricted to the nuclear periphery and not in contact with nucleoli, rabbit embryos feature additional wide invaginations that can reach across the nucleus and target nucleoli.

Comparison of placental alpha microglobulin-1 in vaginal fluid with intra-amniotic injection of indigo carmine for the diagnosis of rupture of membranes

AIMS

The purpose of this study was to compare the diagnostic performance of an immunoassay for placental alpha microglobulin-1 (PAMG-1) in vaginal fluid with the intra-amniotic instillation of indigo carmine for the diagnosis of membrane rupture in patients with an equivocal status.

METHODS

A prospective multi-site study was performed involving women reporting signs, symptoms, or complaints suggestive of rupture of membrane (ROM) between 21 and 42 weeks of gestation without obvious leakage of fluid from the cervical os during sterile speculum examination and without confirmation of ROM by traditional methods.

RESULTS

A total of 140 patients were recruited with a prevalence of ROM of 19.3%. The PAMG-1 test had a sensitivity of 100.0% [confidence interval (CI) 0.87-1.0], specificity of 99.1% [(CI) 0.95-0.99], positive predictive value of 96.3% [(CI) 0.82-0.99], negative predictive value of 100.0% [(CI) 0.97-1.0], and ± likelihood ratios of 74.6 [(CI) 20.31-274.51] and 0.0 [(CI) 0.00-0.98].

CONCLUSIONS

The PAMG-1 immunoassay in vaginal fluid yielded results that were comparable to those of the instillation of indigo carmine into the amniotic cavity; therefore, we propose that PAMG-1 is a sensitive and specific test to assess ROM in patients with an equivocal diagnosis based on simple tests. This finding prompts consideration for the use of the noninvasive PAMG-1 test in situations where the use of the invasive dye test is not practical.

[Evaluation of radiation exposure of personnel in an orthopaedic and trauma operation theatre using the new real-time dosimetry system "dose aware"]

AIM

There is a positive correlation between operation time and staff exposure to radiation during intraoperative use of C-arm fluoroscopy. Due to harmful effects of exposure to long-term low-dose radiation for both the patient and the operating team it should be kept to a minimum. AIM of this study was to evaluate a novel dosimeter system called Dose Aware® (DA) enabling radiation exposure feedback of the personal in an orthopaedic and trauma operation theatre in real-time.

METHOD

Within a prospective study over a period of four month, DA was applied by the operation team during 104 orthopaedic and trauma operations in which the C-arm fluoroscope was used in 2D-mode. During ten operation techniques, radiation exposure of the surgeon, the first assistant, the theatre nurse and the anaesthesiologist was evaluated.

RESULTS

Seventy-three operations were analysed. The surgeon achieved the highest radiation exposure during dorsolumbar spinal osteosynthesis, kyphoplasty and screw fixation of sacral fractures. The first assistant received a higher radiation exposure compared to the surgeon during plate osteosynthesis of distal radius fractures (157 %), intramedullary nailing of pertrochanteric fractures (143 %) and dorsolumbar spinal osteosynthesis (240 %). During external fixation of ankle fractures (68 %) and screw fixation of sacral fractures (66 %) radiation exposure of the theatre nurse exceeded 50 % of the surgeon's radiation exposure. During plate osteosynthesis of distal radius fractures (157 %) and intramedullary splinting of clavicular fractures (115 %), the anaesthesiologist received a higher radiation exposure than the surgeon.

CONCLUSION

The novel dosimeter system DA provides real-time radiation exposure feedback of the personnel in an orthopaedic and trauma operation theatre for the first time. Data of this study demonstrate that radiation exposure of the personnel depends on the operation type. The first assistant, the theatre nurse and the anaesthesiologist might be exposed to higher radiation doses than the surgeon. DA might help to increase awareness concerning irradiation in an orthopaedic and trauma operation theatre and might enhance staff compliance in using radiation protection techniques.

Fetal hypoplastic left heart syndrome and maternal liver transplantation for Wilson's disease: a case report

Introduction

Liver transplantation currently represents the only curative treatment for Wilson’s disease. A lifelong immunosuppressive therapy is mandatory. In spite of increased maternal and fetal risks, pregnancies after liver transplantation have been reported with favorable perinatal outcomes. Hypoplastic left heart syndrome is a spectrum of congenital heart defects that results in the inability to support the systemic circulation. Although its etiology remains elusive, the prognosis of this previously fatal condition has dramatically improved over the last 2 decades mainly due to advances in prenatal diagnosis, surgical technique and perioperative care.

Case presentation

We present a case of a Caucasian 26-year-old woman, gravida 2, para 1 at 36⁺⁰ weeks of gestation who had received a liver transplantation due to Wilson’s disease and subsequently delivered a child with hypoplastic left heart syndrome.

Conclusions

This coincidence of medical conditions has not been described in the literature so far and its implications for mother and child as well as the pathophysiological mechanisms are discussed on the basis of a literature review.

S3-Guidelines for the Treatment of Inflammatory Breast Disease during the Lactation Period: AWMF Guidelines, Registry No. 015/071 (short version) AWMF Leitlinien-Register Nr. 015/071 (Kurzfassung)

Breastfeeding is widely acknowledged to be the best and most complete form of nutrition for healthy infants born at term and is associated with numerous benefits in terms of infants' health, growth, immunity and development. However, breastfeeding problems often result in early weaning. Standardized treatment recommendations for breastfeeding-related diseases are necessary to optimize the care offered to breastfeeding women. Evidence and consensus based guidelines for the treatment of puerperal mastitis, sore nipples, engorgement and blocked ducts were developed on the initiative of the National Breastfeeding Committee. These guidelines were developed in accordance with the criteria set up by the Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF), the Association of Scientific Medical Societies in Germany. The recommendations were drawn up by an interdisciplinary group of experts and were based on a systematic search and evaluation of the literature but also took clinical experience into account. Additionally good clinical practice (GCP) in terms of expert opinion was formulated in cases where scientific investigations could not be performed or were not aimed for. This article presents a summary of the recommendations of the S3-guidelines.

The diagnosis of rupture of fetal membranes (ROM): a meta-analysis

AIM

The aim of this study was to compare the performance of tests based on the detection of insulin-like growth factor binding protein 1 (IGFBP-1) and placental α-microglobulin-1 (PAMG-1) in diagnosing rupture of fetal membranes (ROM) across different patient populations.

METHODS

A meta-analysis was conducted on prospective observational or cohort studies investigating ROM tests based on the detection of IGFBP-1 and PAMG-1 meeting the following criteria: (1) performance metrics calculated by comparing results to an adequate reference method; (2) sensitivity thresholds of the investigated tests matching those of the currently available tests; (3) study population, as a minimum, included patients between 25 and 37 weeks of gestation. Sensitivities, specificities, and diagnostic odds ratios were calculated.

RESULTS

Across all patient populations, the analyzed performance measures of the PAMG-1 test were significantly superior compared with those of the IGFBP-1 test. Of particular clinical relevance, PAMG-1 outperformed IGFBP-1 in the equivocal group, which comprised patients with uncertain rupture of membranes (sensitivity, 96.0% vs. 73.9%; specificity, 98.9% vs. 77.8%; PAMG-1 vs. IGFBP-1 tests, respectively).

CONCLUSIONS

Compared with its performance in women with known membrane status, the accuracy of the IGFBP-1 test decreases significantly when used on patients whose membrane status is unknown. In this latter clinically relevant population, the PAMG-1 test has higher accuracy than the IGFBP-1 test.

Normal mammary fibroblasts induce reversion of the malignant phenotype in human primary breast cancer

BACKGROUND/AIM

The tumor microenvironment plays a major role in tumor growth and progression. Its manipulation can lead to a reversion of the malignant phenotype. Here we explored the ability of normal mammary fibroblasts (HMFs) to induce reversion of the malignant phenotype of primary breast carcinoma cells (PBCs) in a three-dimensional (3D) context.

MATERIALS AND METHODS

PBCs were isolated from 13 primary breast carcinomas and cultured in 3D collagen-I gels as mono- or co-culture with HMFs.

RESULTS

In five co-cultures, PBCs exhibited reversion of their malignant phenotype, whereas PBCs in matched monocultures exhibited disorganized growth. Reversion, defined as the restoration of the complete baso-apical polarity axis, was confirmed with established polarity markers. Secretion of the tissue-specific glycoprotein MAM-6 into the acinar lumens and deposition of basement membrane indicated functional differentiation. Gene expression analysis revealed a set of differentially regulated genes which possibly affect the reversion process. These included MAL, ELF5, MAP6, ZMYND11 and SQLE.

CONCLUSION

These findings highlight the significant role of fibroblasts in regulating the carcinoma phenotype.

Evaluation of two different vacuum-assisted breast biopsy systems: Mammotome(R) system 11G/8G vs. ATEC(R) system 12G/9G

BACKGROUND

Breast cancer screening programs have been established worldwide and early detection of breast cancer has increased steadily. The most common way to confirm dignity of non-palpable and sonographically-occult suspicious findings on mammography is the stereotactically-guided vacuum-assisted breast biopsy

PURPOSE

To compare two stereotactically guided vacuum-assisted breast biopsy systems measuring time effectiveness and quality of harvested material in clinical practice.

MATERIAL AND METHODS

One hundred and forty-six patients presenting with suspicious microcalcifications on mammography were included in the study. Biopsies were carried out with either the Mammotome(®) system (11-gauge and 8-gauge) or the ATEC(®) system (12-gauge and 9-gauge). Lesions with a diameter <15 mm on mammography were biopsied with 11-gauge or 12-gauge devices whereas lesions >15 mm were targeted with 8-gauge and 9-gauge. Mammotome(®) system 8-gauge device was used in 34 patients, the 11-gauge system in 37 patients. The ATEC(®) system 9-gauge system was used in 37 patients and 12-gauge in 38 patients. Time was taken, focusing on preparing the system, time of collecting the samples, preparing the samples, and cleaning the site. During the biopsies 24 samples were taken. The histologic quality of the tissue samples was judged by a pathologist in a blinded fashion according to a specimen grading classification concerning tissue fragmentation, artefacts, and the adequacy of the tissue for diagnosis.

RESULTS

The median overall time for the Mammotome(®) system was 879 s (11-gauge) and 934 s (8-gauge) and for the ATEC(®) system 671 s (12-gauge) and 673 s (9-gauge). The ATEC(®) system displays a significantly shorter overall time for small and large biopsy devices (U-test, P < 0.001). Concerning the mean time difference of the overall time comparing small and large systems the ATEC(®) system was 267.6 s faster using the small and 244.8 s faster using the large system. Comparing the histologic quality of tissue samples the Mammotome(®) system shows significantly higher values for the large and the small system (Chi-square test, P < 0.001).

CONCLUSION

Both biopsy systems meet all requirements for daily practice and confirm the diagnosis of suspicious microcalcifications. The ATEC(®) system was observed to be faster but this difference of about 250 s might not be relevant in daily practice. The Mammotome(®) system provides a better histologic quality of tissue samples.

Switch of cadherin expression as a diagnostic tool for Leydig cell tumours

Leydig cell tumours comprise about 3% of all testicular tumours. The pathogenesis of Leydig cell tumours is still poorly understood. We investigated testis with Leydig cell hyperplasia and Leydig cell tumours for their expression pattern of P- and N-cadherin. We could show a switch of expression of P- and N-cadherin in Leydig cell hyperplasia and Leydig cell tumours in comparison with normal Leydig cells. Cadherins could be established as a new immunohistochemical marker for this testicular tumour entity; their possible role in tumour genesis will be discussed.

[The cognitive development of triplets in school age and its impact on the quality of family life--a follow-up study from a perinatal centre]

OBJECTIVE

The aim of this study was to assess the developmental outcome of 7- to 9-year-old triplets and to determine parenting stress and quality of family life.

METHODS

Cognitive development (Wechsler intelligence scales for children III, WISC III) and quality of family life (Kansas family life satisfaction scale, KFLSS; parenting stress index, PSI) of 48 triplets born between 1996 and 1998 at a perinatal centre were compared with controls born at a gestational age ≥37 weeks. Index and control children/mothers were matched by age (birthday: ±14 days/maternal age±2 years).

RESULTS

Triplets and their families showed a mean IQ score and parenting satisfaction and stress within the normal range. Full IQ score (97 SD 16) as well as verbal and performance IQs (102 SD 16; 92 SD 19) were significantly lower than the controls' corresponding data (full IQ 111 SD 15, p<0.001; verbal IQ 116 SD 21, p<0.001; performance IQ 102 SD 17, p=0.001). Parents of triplets tended to show a higher total PSI score (222 SD 39) than the parents of the controls (205 SD 47). The differences reached statistical significance only in the parent domain (triplets 125 SD 24; controls 111 SD 27; p<0.01). Satisfaction with family life was good in triplet families and did not differ significantly in any of the subscales from control parents' satisfaction.

CONCLUSIONS

This study demonstrates a favourable outcome of triplets with respect to their cognitive development and the quality of their families' lives at school age. The difference in children's IQ was statistically, but perhaps not clinically, significant, because the triplets' data were within the normal range.

A randomized phase II study evaluating the combination of carboplatin-based chemotherapy with pertuzumab versus carboplatin-based therapy alone in patients with relapsed, platinum-sensitive ovarian cancer

BACKGROUND

Pertuzumab, a humanized monoclonal antibody targeting human epidermal growth factor receptor (HER)-mediated signalling, has shown activity in ovarian cancer in preclinical models and in the clinic. This randomized phase II study evaluated efficacy and safety of pertuzumab in combination with carboplatin-based chemotherapy in patients with platinum-sensitive, recurrent advanced ovarian cancer.

PATIENTS AND METHODS

Patients were randomized to receive six cycles of chemotherapy (carboplatin and either paclitaxel (Taxol) or gemcitabine) with or without pertuzumab. The primary end point was progression-free survival (PFS) as determined by Response Evaluation Criteria in Solid Tumors and/or by CA 125 measurements. Secondary end points evaluated the response rate, safety profile, duration of response, time to progression and overall survival for both treatment arms.

RESULTS

A total of 149 patients received either chemotherapy with pertuzumab (arm A, n=74) or chemotherapy alone (arm B, n=75). There was no significant difference either in median PFS or in the secondary end points between the two arms. No differences were seen in an exploratory biomarker analysis of HER3 mRNA expression between the two arms. Pertuzumab was well tolerated, with no increase in cardiac adverse events compared with chemotherapy alone.

CONCLUSIONS

The addition of pertuzumab to carboplatin-based chemotherapy did not substantially prolong PFS in unselected patients with platinum-sensitive ovarian cancer.

Rare Benign Entities of the Breast - Myoid Hamartoma and Capillary Hemangioma

Hamartomas can occur in different areas of the breast, but they are rarely found in the breast. Myoid hamartomas with smooth muscle cells of the type described here are particularly unusual. The pathogenesis of this benign entity with its tendency to growth and recurrence is not clear. Excision is the therapy of choice. Capillary hemangiomas are rare vascular malformations of the breast which, in contrast to cavernous hemangiomas, usually remain clinically occult. It is important to differentiate these benign findings from malignant angiosarcoma. The possible heterogeneities between myoid hamartoma and capillary hemangioma using current breast imaging methods for the differential diagnosis (high-resolution ultrasound, duplex sonography, shear wave elastography, digital mammography, minimally invasive intervention) are discussed together with an overview of the literature.

Routine Cervical Cerclage in Higher Order Multiple Gestation — Does It Prolong the Pregnancy?

Preterm birth following cervical dilatation is the greatest threat to infants of a multiple pregnancy. Lacking reliable data concerning the effect of prophylactic cerclage, we compared a study group to controls for maternal and perinatal outcome. Sixteen of 94 triplet-, 9 of 18 quadruplet/quintuplet-pregnancies, treated with prophylactic cerclage, were retrospectively compared to those without cervical cerclage respectively. Kruskal-Wallis test and Mann-Whitney-U test were performed as non-parametric one way analysis of variance. For the analysis of frequencies Chi Square test or Fisher’s exact test were performed. Odds ratio with 95% confidence interval was used to compare the need for intravenous tocolysis as well as perinatal morbidity and mortality. Gestational age at delivery was not different from the controls in all studied groups. Birth weight revealed a 200g dominance for the “no cerclage-triplets”, while this significant difference was inverted for quadruplets/quintuplets (1245g vs. 1069g). With respect to gestational age at birth, need for hospitalisation or medical intervention no benefit was achieved. Moreover, perinatal outcome analysed by arterial pH, APGAR-Score and perinatal mortality was not altered by a prophylactic cerclage. Perinatal morbidity for quadruplets and quintuplets was even higher in cerclage pregnancies. Therefore, these retrospective results disclaim a positive impact of cervical cerclage on pregnancy management or perinatal outcome in multifetal pregnancies.