Teaching undergraduate students gynecological and obstetrical examination skills: the patient's opinion.

INTRODUCTION: Our study assesses the patients' opinion about gynecological examination performed by undergraduate students (UgSts). This assessment will be used in improving our undergraduate training program. A positive opinion would mean a lower chance of a patient refusing to be examined by a tutor or student, taking into account vaginal examination (VE). MATERIALS AND METHODS: We performed a prospective cross-sectional survey on 1194 patients, consisting of outpatient and inpatient at the departments of obstetrics and gynecology from November 2015 to May 2016. The questionnaire consisted of 46 questions. Besides demographic data, we assessed the mindset of patients regarding the involvement of undergraduate student (UgSt) in gynecological and obstetrical examinations. We used SPSS version 23 for the statistical analysis. For reporting the data, we followed the STROBE statement of reporting observational studies. RESULTS: The median age was 38 years having a median of one child. 34% presented due to obstetrical problems, 38% due to gynecological complaints, and 19% due to known gynecological malignancies. Generally, we retrieved a positive opinion of patients towards the involvement of students in gynecological and obstetrical examination under supervision in 2/3 of the cases. CONCLUSIONS: There is no reason to exclude medical UgSts from gynecological and obstetrical examinations after obtaining a written or oral consent.

Introduction of a student tutor-based basic obstetrical ultrasound screening in undergraduate medical education.

BACKGROUND: While there is an increasing interest in incorporating ultrasound in undergraduate medical education and the use of student tutors in conveying this medical skill to assist faculty members, little is known about undergraduate ultrasound teaching in obstetrics and gynecology. METHODS: After a 3 week training of the student tutors, the student tutors joined an undergraduate ultrasound educational program to teach practical round students. After being certified, the student tutors organized a pre-test, gave a presentation about ultrasound, and then supervised the hands on ultrasound course under faculty staff supervision for round students. Finally, the practical round students had to answer a post-test with image recognition. The practical round students had to evaluate the course using a Likert scale. RESULTS: 111 students joined this ultrasound course. The objective theoretical and practical multiple-choice questions' (MCQ) test showed a statistically significant improvement (50 vs. 90%, p < 0.05). The practical round students expressed a high acceptance (Likert 1.7) and subjective medical skill learning (Likert 1.8). The students also positively graded the student tutors (Likert 1.3). CONCLUSION: Student tutor-based undergraduate obstetrical and gynecological ultrasound course is a useful method to teach a medical skill and is well accepted by students.

Impact of different intraoperative CO2 pressure levels (8 and 15 mmHg) during laparoscopic hysterectomy performed due to benign uterine pathologies on postoperative pain and arterial pCO2 : a prospective randomised controlled clinical trial.

OBJECTIVE: To compare the effects of two different intraoperative CO2 pressures (8 and 15 mmHg) during laparoscopic hysterectomy for benign uterine pathologies in terms of postoperative abdominal and shoulder pain, laparoscopy-mediated vegetative alterations, pain medication requirement, arterial CO2 pressure (pCO2 ), surgical parameters, and safety. DESIGN: Prospective randomised controlled study. SETTING: German university hospital. POPULATION: Female patients undergoing laparoscopic hysterectomy for benign uterine pathologies. METHODS: Patients were randomised to a standard pressure (SP; 15 mmHg, control) or low-pressure (LP; 8 mmHg, experimental) group. MAIN OUTCOME MEASURES: Primary outcomes were postoperative abdominal and shoulder pain intensities, measured via numeric rating scale (NRS) and vegetative parameters (fatigue, nausea, vomiting, bloating) at 3, 24, and 48 hours postoperatively. Secondary outcomes were pain medication requirement (mg) and arterial pCO2 (mmHg). Surgical parameters and intra- and postoperative complications were also recorded. RESULTS: In total, 178 patients were included. Patients in the LP group (n = 91) showed significantly lower postoperative abdominal and shoulder pain scores, fewer vegetative alterations, lower pain medication requirements, a shorter postoperative hospitalization, and lower intra- and postoperative arterial pCO2 values compared with the SP group (n = 87; P ≤ 0.01). No differences in intra- and postoperative complications were observed between groups. CONCLUSIONS: Low-pressure laparoscopy seems to be an effective and safe technique for the reduction of postoperative pain and laparoscopy-induced metabolic and vegetative alterations following laparoscopic hysterectomy for benign indications. TWEETABLE ABSTRACT: Low-pressure laparoscopy seems to be an effective and safe technique for reduction of pain following laparoscopic hysterectomy.

Pilot study: placental biomarker predictive capability (sFlt-1, PlGF and their ratio) of postpartum maternal outcome.

BACKGROUND: Prenatal measurement of placental biomarkers was able to improve screening and diagnosis of preeclampsia. Little is known about the clinical role of placental biomarkers in the postpartum period. METHODS: This study is a prospective monocentric trial that included a total of 30 women with preeclamptic pregnancies. Serum placental biomarkers including soluble fms-like tyrosine kinase 1 (sFlt-1) and placental growth factor (PlGF) were measured before and 2 h after delivery by Enzyme-Linked Immunosorbent Assay (ELISA) using commercially available kits according to manufacturer's instructions and correlated with the postpartum outcome. RESULTS: Postpartum higher serum PlGF level was associated with postpartum elevation of the systolic blood pressure. Yet, the placental biomarkers were not able to predict general worsening of postpartum preeclampsia or other individual clinical or laboratory parameters. CONCLUSION: Serum concentrations of sFlt-1 and PlGF or their ratio in our study cohort did not completely predict the occurrence of postpartum preeclampsia. Yet, postpartum higher serum PlGF level was associated with postpartum elevation of the systolic blood pressure.

Diagnostic Methods of Ectopic Pregnancy and Early Pregnancy Loss: a Review of the Literature.

This review article presents recent evidence on early pregnancy loss and ectopic pregnancy. In the light of recent evidence, the ß-hCG discriminatory zone may be extended in clinically stable cases without evidence of bleeding. A possible cut-off is 4300 mIU/ml, which corresponds to when a sonographer should detect an intrauterine pregnancy. Embryonic demise can be confirmed when a transvaginal ultrasound finding shows no heartbeat in an embryo of more than 7 mm CRL, no embryo in a gestational sac having a mean sac diameter of more than 25 mm, or no appearance of an embryo within 7-10 days after the primary examination. These are considered definitive signs of embryonic demise. Suggestive signs of embryonic demise require closer monitoring of the pregnancy.

Conversion of intraperitoneal cytology during laparoscopic surgery of uterine cancer.

INTRODUCTION: The laparoscopic surgery of uterine cancer is an oncological safe treatment option in early stage cancer. However, there are no data about whether laparoscopy can lead to intraperitoneal tumor cell dissemination. We aimed in our study to detect a possible cytological conversion during laparoscopic procedures. METHODS: In this prospective study, we included all patients receiving laparoscopic treatment at the early stage endometrial and cervical cancer in the Department of Obstetrics and Gynecology at the University of the Saarland and obtained peritoneal wash for cytological examination at the beginning and at the end of laparoscopic surgery. All patients received stage-adjusted operative and adjuvant therapy. RESULTS: We enrolled 43 patients [endometrial cancer (n = 24) and cervical cancer (n = 19)]. At the beginning of the operation, one patient with endometrial cancer and one patient with cervical cancer showed a positive cytology. One tumor cell conversion from negative to positive cytology during surgery was detected in a patient suffering from endometrial cancer stage FIGO Ia. The median duration of surgery was 191.8 ± 79.3 min. The average time of follow-up was 16.5 ± 10.3 month. At the end of data evaluation at December 2014, two patients (8.6 %) are suffering from recurrent disease, two patients died, none of these patients had a positive cytology. All patients with positive cytology are free of cancer. CONCLUSION: During laparoscopic surgery of early stage endometrial and cervical cancer, only one conversion of cytology was detected, which proves that laparoscopy does not appear to increase the intraoperative tumor cell dissemination or rate of positive cytological results.

Introduction of basic obstetrical ultrasound screening in undergraduate medical education.

PURPOSE: Teaching ultrasound procedures to undergraduates has recently been proposed to improve the quality of medical education. We address the impact of applying standardized ultrasound teaching to our undergraduates. METHODS: Medical students received an additional theoretical and practical course involving hands-on ultrasound screening during their mandatory practical training week in obstetrics and gynecology. The students' theoretical knowledge and fetal image recognition skills were tested before and after the course. After the course, the students were asked to answer a course evaluation questionnaire. To standardize the teaching procedure, we used Peyton's 4-Step Approach to teach the skills needed for a German Society of Ultrasound in Medicine Level 1 ultrasound examiner. RESULTS: The multiple-choice question scores after the course showed statistically significant improvement (50 vs. 80 %; P < 0.001). The questionnaire revealed that students were satisfied with the course, felt that it increased their ultrasound knowledge, and indicated that they wanted more sonographic hands-on training in both obstetrics and gynecology and other medical fields. CONCLUSION: Using practical, hands-on medical teaching is an emerging method for undergraduate education that should be further evaluated, standardized, and developed.

Opposite extremes in ethylene/nitric oxide ratio induce cell death in suspension culture and root apices of tomato exposed to salt stress.

The plant hormone ethylene or the gaseous signalling molecule nitric oxide (NO) may enhance salt stress tolerance by maintaining ion homeostasis, first of all K+/Na+ ratio of tissues. Ethylene and NO accumulation increased in the root apices and suspension culture cells of tomato at sublethal salt stress caused by 100 mM NaCl, however, the induction phase of programmed cell death (PCD) was different at lethal salt concentration. The production of ethylene by root apices and the accumulation of NO in the cells of suspension culture did not increase during the initiation of PCD after 250 mM NaCl treatment. Moreover, cells in suspension culture accumulated higher amount of reactive oxygen species which, along with NO deficiency contributed to cell death induction. The absence of ethylene in the apical root segments and the absence of NO accumulation in the cell suspension resulted in similar ion disequilibrium, namely K+/Na+ ratio of 1.41 ± 0.1 and 1.68 ± 0.3 in intact plant tissues and suspension culture cells, respectively that was not tolerated by tomato.

Prenatal diagnosis and management of an intestinal volvulus with meconium ileus and peritonitis.

Fetal intestinal volvulus is a rare but serious finding with a high risk of potential life threatening fetal complications. Delay in diagnosis or treatment can increase mortality and morbidity. We report a case of mild fetal bowel dilatation at 30 weeks of gestation and intestinal volvulus presented by the 'whirl-sign', intestinal perforation and meconium peritonitis with fetal ascites and polyhydramnios at 33 weeks of gestation. This case emphasizes the role of examination of the bowel in third trimester ultrasound and the importance of quick decision to delivery and interdisciplinary perinatal management at suspected fetal volvulus with bowel necrosis and intraabdominal bleeding.

NMR investigation of chloromethane complexes of cryptophane-A and its analogue with butoxy groups.

Host-guest complexes between cryptophane-A as host and dichloromethane and chloroform as guests are investigated using (1)H and (13)C NMR spectroscopy. Moreover, a related cryptophane, with the methoxy groups replaced by butoxy units (cryptophane-But), and its complexes with the same guests were also studied. Variable temperature spectra showed effects of chemical exchange between the free and bound guests, as well as of conformational exchange of the host. The guest exchange was studied quantitatively by exchange spectroscopy or line shape analysis. Extraction of kinetic and thermodynamic parameters led to the characterization of the affinity between guests and hosts. On the other hand, the host exchange was investigated by means of (13)C Carr-Purcell-Meiboom-Gill (CPMG) relaxation dispersion which aims at the determination of the transverse relaxation rate R2, the inverse of the transverse relaxation time T2, as a function of the repetition of the π pulses in a CPMG train. The variation of the measured transverse relaxation rate with the repetition rate νCPMG indicated conformational exchange occurring on the microsecond-millisecond time scale. Structural information was obtained through measurements of cross-relaxation rates, both within the host and between the host and the guest protons. The NMR results were supported by DFT calculations.

Host-guest complexes between cryptophane-C and chloromethanes revisited.

Cryptophane-C is composed of two nonequivalent cyclotribenzylene caps, one of which contains methoxy group substituents on the phenyl rings. The two caps are connected by three OCH(2)CH(2)O linkers in an anti arrangement. Host-guest complexes of cryptophane-C with dichloromethane and chloroform in solution were investigated in detail by nuclear magnetic resonance techniques and density functional theory (DFT) calculations. Variable temperature proton and carbon-13 spectra show a variety of dynamic processes, such as guest exchange and host conformational transitions. The guest exchange was studied quantitatively by exchange spectroscopy measurements or by line-shape analysis. The conformational preferences of the guest-containing host were interpreted through cross-relaxation measurements, providing evidence of the gauche+2 and gauche-2 conformations of the linkers. In addition, the mobility of the chloroform guest inside the cavity was studied by carbon-13 relaxation experiments. Combining different types of evidence led to a detailed picture of molecular recognition, interpreted in terms of conformational selection.

NMR investigation of guest-host complex between chloroform and cryptophane C.

Guest-host complex between cryptophane C, possessing two non-equivalent caps, and chloroform is investigated by NMR spectroscopy. The kinetics of the chloroform exchange between the bound and free sites is determined by (1)H exchange spectroscopy. Moreover, the preferential orientation of chloroform molecule with respect to the cryptophane C frame is examined by the NOESY and ROESY experiments. The experimental findings are compared to the results of quantum chemical calculations.

Analysis of perioperative morbidity according to whether the uterine cavity is opened or remains closed during abdominal myomectomy--results of 423 abdominal myomectomy cases.

UNLABELLED: For women who desire pregnancy or who wish to retain their uterus, myomectomy is the standard approach for the treatment of fibroids. Abdominal myomectomy seems to be the best choice when there are large subserosal or intramural fibroids (> 5-7 cm), or submucosal fibroids > 3 cm or when multiple fibroids (> 3) are to be removed. When submucosal myomas are present or multiple fibroids are to be removed, opening the uterine cavity during the surgical procedure is more likely to happen. There is lack of published evidence about whether there is any difference in perioperative morbidity and management of those cases where the uterine cavity is opened during the surgical procedure compared with those where the uterine cavity remains closed. METHODS: We undertook a retrospective review of 423 abdominal myomectomies via either an opened or closed uterine cavity. As a primary outcome we assessed the overall perioperative morbidity rate and as a secondary outcome we compared the necessity of pre and postoperative transfusions, intraoperative bleeding, febrile morbidity, unintended surgical interventions, life-threatening events, need for relaparotomies and duration of hospital stay between the opened and non opened uterine cavity groups. RESULTS: The overall perioperative morbidity rate was significantly higher in those cases where the uterine cavity was opened during surgery; however the difference was caused only by the increased risk of intraoperative bleeding. All the other variables, such as febrile morbidity, number of relaparotomies, unintended surgical procedures and life-threatening events did not differ between the two groups. CONCLUSION: Although there is an increased risk of intraoperative bleeding it seems that entering the uterine cavity during abdominal myomectomy can be considered as safe a procedure as in those cases where the uterine cavity remains closed.

Snake alpha-neurotoxin binding site on the Egyptian cobra (Naja haje) nicotinic acetylcholine receptor Is conserved.

Evolutionary success requires that animal venoms are targeted against phylogenetically conserved molecular structures of fundamental physiological processes. Species producing venoms must be resistant to their action. Venoms of Elapidae snakes (e.g., cobras, kraits) contain alpha-neurotoxins, represented by alpha-bungarotoxin (alpha-BTX) targeted against the nicotinic acetylcholine receptor (nAChR) of the neuromuscular junction. The model which presumes that cobras (Naja spp., Elapidae) have lost their binding site for conspecific alpha-neurotoxins because of the unique amino acid substitutions in their nAChR polypeptide backbone per se is incompatible with the evolutionary theory that (1) the molecular motifs forming the alpha-neurotoxin target site on the nAChR are fundamental for receptor structure and/or function, and (2) the alpha-neurotoxin target site is conserved among Chordata lineages. To test the hypothesis that the alpha-neurotoxin binding site is conserved in Elapidae snakes and to identify the mechanism of resistance against conspecific alpha-neurotoxins, we cloned the ligand binding domain of the Egyptian cobra (Naja haje) nAChR alpha subunit. When expressed as part of a functional Naja/mouse chimeric nAChR in Xenopus oocytes, this domain confers resistance against alpha-BTX but does not alter responses induced by the natural ligand acetylcholine. Further mutational analysis of the Naja/mouse nAChR demonstrated that an N-glycosylation signal in the ligand binding domain that is unique to N. haje is responsible for alpha-BTX resistance. However, when the N-glycosylation signal is eliminated, the nAChR containing the N. haje sequence is inhibited by alpha-BTX with a potency that is comparable to that in mammals. We conclude that the binding site for conspecific alpha-neurotoxin in Elapidae snakes is conserved in the nAChR ligand binding domain polypeptide backbone per se. This conclusion supports the hypothesis that animal toxins are targeted against evolutionarily conserved molecular motifs. Such conservation also calls for a revision of the present model of the alpha-BTX binding site. The approach described here can be used to identify the mechanism of resistance against conspecific venoms in other species and to characterize toxin-receptor coevolution.

The gene encoding proline dehydrogenase modulates sensorimotor gating in mice.

Hemizygous cryptic deletions of the q11 band of human chromosome 22 have been associated with a number of psychiatric and behavioural phenotypes, including schizophrenia. Here we report the isolation and characterization of PRODH, a human homologue of Drosophila melanogaster sluggish-A (slgA), which encodes proline dehydrogenase responsible for the behavioural phenotype of the slgA mutant. PRODH is localized at chromosome 22q11 in a region deleted in some psychiatric patients. We also isolated the mouse homologue of slgA (Prodh), identified a mutation in this gene in the Pro/Re hyperprolinaemic mouse strain and found that these mice have a deficit in sensorimotor gating accompanied by regional neurochemical alterations in the brain. Sensorimotor gating is a neural filtering process that allows attention to be focused on a given stimulus, and is affected in patients with neuropsychiatric disorders. Furthermore, several lines of evidence suggest that proline may serve as a modulator of synaptic transmission in the mammalian brain. Our observations, in conjunction with the chromosomal location of PRODH, suggest a potential involvement of this gene in the 22q11-associated psychiatric and behavioural phenotypes.