Teledidactic Versus Hands-on Teaching of Abdominal, Thoracic, and Thyroid Ultrasound-The TELUS II Study.

BACKGROUND: The worldwide COVID-19 pandemic has initiated a change in medical education and the development of new teaching concepts has become inevitable to maintain adequate training. OBJECTIVE: This pilot study aims to compare teledidactic teaching with traditional face-to-face teaching for abdominal, thoracic, and thyroid ultrasound. DESIGN: Concurrently, a teledidactic and a face-to-face ultrasound course were held. The students completed seven 90-min modules using mobile ultrasound probes (Butterfly IQ). Each module consisted of a lecture, a demonstration of probe guidance, and independent training. PARTICIPANTS: A total of thirty medical students took part in the study and were randomly assigned to a teledidactic and a face-to-face group. MAIN MEASURES: An objective structured assessment of ultrasound skills (OSAUS) was performed as a pre-test and as the final exam and ultrasound images obtained during the exam were evaluated using the brightness mode quality ultrasound imaging examination (B-QUIET) scale. KEY RESULTS: No significant difference between the two cohorts on the OSAUS final exam was shown (p > 0.05 in all modules). There was a significant difference in the assessment of the images in the focused assessment with sonography for trauma (FAST) (p 0.015) and aorta (p 0.017) modules. Students in the teledidactic group performed better in both modules, scoring 33.59 (± 2.61) out of 44 in the module FAST (face-to-face group 30.95 (± 1.76)) and aortic images averaged 35.41 (± 2.61) points (face-to-face group 32.35 (± 3.08)). CONCLUSIONS: A teledidactic course for abdominal and thoracic ultrasound examinations is equally effective to traditional face-to-face teaching in this pilot study. Digital implementation with a portable ultrasound machine could be a great opportunity to promote ultrasound education worldwide and over great distances.

Prevalence of joint, entheseal, tendon, and bursal findings in young, healthy individuals by musculoskeletal ultrasound.

OBJECTIVE: The purpose of this study was to determine the prevalence of joint, enthesis, bursa, and tendon ultrasound findings in large and medium joints of young, healthy individuals. METHOD: Ultrasound assessment of large and medium joints, bursae, tendons, and entheses was performed in healthy individuals below the age of 30 years. Participants also underwent bioelectrical impedance analysis and conducted supervised weight training to determine maximum strength. The prevalence of ultrasound findings was calculated and a binary logistic regression model was applied to evaluate factors associated with the present findings. RESULTS: Fifty-one healthy individuals (52.9% female) with a mean age of 23.7 years were included in this study. Joint effusion in at least one joint was observed in 72.6% of the individuals (n = 37) and entheseal pathology in at least one enthesis was detected in 27.5% (n = 14). A binary logistic regression model indicated a significant association between reported hours of sports activity per week and the prevalence of effusion in the knee (p = 0.017). In addition, associations were observed between entheseal pathology in at least one entheseal site and body mass index (BMI) (p = 0.015) as well as fat mass index (p = 0.026). CONCLUSION: Joint effusion in large and medium joints, as well as entheseal hyperperfusion, bursal effusion, and tendon sheath effusion, are found in healthy individuals. Hours of sports activity per week, BMI and fat mass index showed significant associations with the findings in joints and entheses.

Impact of COVID-19 on gynaecological patient care: results of patient's survey with 327 patients.

PURPOSE: The pandemic SARS-CoV-2 poses new and unprecedented challenges for health care systems on a national and global level. Although the current situation has been going on for more than 1 year, there is limited data on the impact of the pandemic on general hospital and medical practice care. This survey captures the perspective of patients with gynaecological diseases of this impact. METHODS: Using a paper-based questionnaire, 327 patients were asked about medical care and their experiences during the pandemic at the University Hospital Bonn and the University Hospital Charité Berlin. The study was performed from the 1st June to 30th September 2020. RESULTS: A total of 327 patients participated in the study: 156 stated to have been tested for coronavirus, and 1 patient reported a positive test. 41.3% of the patients felt insecure about the current situation, 30.4% were concerned about the risk of infection during the hospital stay. The pandemic-specific measures in hospitals and medical practices unsettled 6.8% of patients. 18.1% of patients feared that their gynaecological disease would not be treated adequately due to the pandemic. 55.7% of patients reported that their confidence in their physicians has increased during the pandemic. CONCLUSION: The results show that patients' confidence in the healthcare system and the physicians acting significantly increased during the COVID-19 crisis. Transparent and comprehensive information policy regarding actions and restrictions within the COVID-19 crisis eases patients concerns and improves patients' confidence in their physicians, which is crucial for a successful treatment's outcome.

Vesicoamniotic shunting for fetal megacystis in the first trimester with a Somatex® intrauterine shunt.

PURPOSE: The objective was to evaluate the feasibility of vesicoamniotic shunting (VAS) in the first trimester with the Somatex® intrauterine shunt and report on complications and neonatal outcome. METHODS: Retrospective cohort study of all VAS before 14 weeks at two tertiary fetal medicine centres from 2015 to 2018 using a Somatex® intrauterine shunt. All patients with a first trimester diagnosis of megacystis in male fetuses with a longitudinal bladder diameter of at least 15 mm were offered VAS. All patients that opted for VAS after counselling by prenatal medicine specialists, neonatologists and pediatric nephrologists were included in the study. Charts were reviewed for complications, obstetric and neonatal outcomes. RESULTS: Ten VAS were performed during the study period in male fetuses at a median GA of 13.3 (12.6-13.9) weeks. There were two terminations of pregnancy (TOP) due to additional malformations and one IUFD. Overall there were four shunt dislocations (40%); three of those between 25-30 weeks GA. Seven neonates were born alive at a median GA of 35.1 weeks (31.0-38.9). There was one neonatal death due to pulmonary hypoplasia. Neonatal kidney function was normal in the six neonates surviving the neonatal period. After exclusion of TOP, perinatal survival was 75%, and 85.7% if only live-born children were considered. CONCLUSION: VAS in the first trimester is feasible with the Somatex® Intrauterine shunt with low fetal and maternal complication rates. Neonatal survival rates are high due to a reduction in pulmonary hypoplasia and the rate of renal failure at birth is very low. VAS can be safely offered from the late first trimester using the Somatex® intrauterine shunt.

Cost-effectiveness of prostate cancer screening: a simulation study based on ERSPC data.

BACKGROUND: The results of the European Randomized Study of Screening for Prostate Cancer (ERSPC) trial showed a statistically significant 29% prostate cancer mortality reduction for the men screened in the intervention arm and a 23% negative impact on the life-years gained because of quality of life. However, alternative prostate-specific antigen (PSA) screening strategies for the population may exist, optimizing the effects on mortality reduction, quality of life, overdiagnosis, and costs. METHODS: Based on data of the ERSPC trial, we predicted the numbers of prostate cancers diagnosed, prostate cancer deaths averted, life-years and quality-adjusted life-years (QALY) gained, and cost-effectiveness of 68 screening strategies starting at age 55 years, with a PSA threshold of 3, using microsimulation modeling. The screening strategies varied by age to stop screening and screening interval (one to 14 years or once in a lifetime screens), and therefore number of tests. RESULTS: Screening at short intervals of three years or less was more cost-effective than using longer intervals. Screening at ages 55 to 59 years with two-year intervals had an incremental cost-effectiveness ratio of $73000 per QALY gained and was considered optimal. With this strategy, lifetime prostate cancer mortality reduction was predicted as 13%, and 33% of the screen-detected cancers were overdiagnosed. When better quality of life for the post-treatment period could be achieved, an older age of 65 to 72 years for ending screening was obtained. CONCLUSION: Prostate cancer screening can be cost-effective when it is limited to two or three screens between ages 55 to 59 years. Screening above age 63 years is less cost-effective because of loss of QALYs because of overdiagnosis.

[PSA screening 2013: background and perspectives]. / PSA-Screening 2013: Hintergründe und Aussichten.

In the healthcare political discussions on treatment measures, the controversy over prostate-specific antigen (PSA) screening has taken a leading role in comparison to, for example the relatively undisputed role of breast and colon screening. This has fortunately led to an in-depth critical analysis of the available data. One advantage is the benefit on survival which increases with longer follow-up observation times. When carrying out studies the quantitative extent of this benefit can become obscured by prescreening, prevalent screening, lack of compliance, contamination and healthy screen bias. Nevertheless, the European randomized screening study of prostate cancer (ERSPC) study, for example, showed sufficient statistical power to confirm a screening benefit after 9 or 11 years (evidence level A). However, even for prostate cancer the internal problems of preventive medicine of overdiagnosis and overtherapy are also partially dependent on the age range of the screening population and the screening frequency (28-52%). Unnecessary deficits in the quality of life reduce the benefit of survival in these patients. By using a PSA fine tuning and risk stratification, approximately one third of diagnoses and therapies can be avoided. Additionally, the active surveillance of tumors unsuitable for treatment together with an improved quality of therapy should become of greater importance.

[Status of care for prostate cancer in 2008]. / Stand der Prostatakarzinomvorsorge im Jahr 2008.

Prostate cancer as the second most frequent cause of death due to malignancy in men increasingly represents a problem for health care policy that is further intensified by demographic developments."Not every prostate carcinoma identified early must be treated, but those that require therapy must be detected early!" is the current key message in individual screening programs. This means that the measures undertaken for early detection have to be discussed with the patients to inform them about their disease risk, the need for timely initiation of curative treatment, and on possible side effects. On the other hand,"overtreatment" should be avoided. Study results on the general screening benefit with level A evidence are first expected around 2010. Interim analyses with metastasis rate as the endpoint show a benefit of screening in comparison to the control group. Results of trials with level B evidence support the benefit of individual screening. The"overdiagnosis" of latent carcinomas (2-20%) as a consequence of prostate cancer screening should be dealt with by increasing the use of more precise models for active surveillance. Studies that militate against screening should be considered inadequate upon closer scrutiny since they were conducted in a patient cohort that was too old, the follow-up period was too short, and inappropriate endpoints were set.

[Prostate specific antigen in individual cancer checkups and in therapeutic treatment]. / Prostata-spezifisches Antigen in der individuellen Krebsvorsorge und im Therapieverlauf.

UNLABELLED: Prostate specific antigen (PSA) has become the most important tumor marker in Oncology. Its importance ranges from early detection of prostate cancer until therapy decision making in hormone refractory cancer To prevent initial PSA "terrorism" in early detection the patient must be well informed about risk of prostate cancer and therapeutic options inclusively possible side effects. Does the man at risk agree further evaluation by biopsy has to be performed directly above a PSA cutoff 4.0 ng/ml. A high percentage of free PSA is not allowed to prolong diagnostic procedure. A diagnostic "grey zone" does not exist anymore. In the PSA range 2.0-3.9 ng/ml, yearly measurement is to propose. PSA levels below 2.0 ng/ml allow control every second year About 2-9% of newly detected cancers are clinically insignificant. Models based on PSA, Gleason Score and tumor load of biopsies are helpful in identifying these men for "watchful waiting" in curative intent. IN CONCLUSION: "Not every early detected cancer must be cured, but cancer where cure is necessary, must be early detected!" After primary therapy (operation/radiotherapy) one third of men will document a PSA only relapse. 30% of them will develop clinical symptoms and possible die from disease. PSA and especially PSA doubling time is a promising marker to identify these men at risk for whom salvage radiotherapy, salvage prostatectomy or hormonal therapy can be an option. However the benefit in survival must be weight against a possible loss in quality of life.

Prostate cancer screening: results of a prospective trial in Canton Aargau, Switzerland.

INTRODUCTION: Prostate cancer is the most commonly diagnosed cancer in Swiss men and the second leading cause of cancer related death among them (e.g. CH: 1,267 in year 1998). With the population at risk constantly growing these absolute numbers are expected to further increase. While there is no question that aggressive treatment of localised tumour is required for definitive cure of prostate cancer, the application of screening for early stage disease remains controversial. Since 1998 the Clinic of Urology in Kantonsspital Aarau has participated in the ERSPC (European Randomised Study of Screening for Prostate Cancer) study, which is designed to provide data on prostate cancer screening within a prospective randomised controlled setting. METHODS: Men aged between 55 and 70 years were enrolled in the study. From n = 18,361 men invited by a letter to participate, 7,124 (38.8%) agreed and gave their informed consent to be randomised in either a PSA measurement (n = 3,562, group 1) or a control group (n = 3,562, group 2). Men in group 1 with a PSA level ?3.0 ng/ml, n = 372 (10.5%) then underwent ultrasound guided transrectal sextant biopsy of the prostate. RESULTS: Prostate cancer was detected at presentation in every fourth man biopsied (n = 89). Neither the free-to-total PSA ratio nor the PSA density could significantly spare biopsies while sustaining a high sensitivity level. The overall cancer detection rate amounted to 2.5% in PSA tested men. In 7% (n = 5) distant disease was already present. 93% of men with clinically organ confined disease underwent prostatectomy (n = 59) or radiotherapy (n = 22), whilst only (n = 3) chose to follow a policy of watchful waiting. In 92% the histology of the prostatectomy specimens revealed aggressive cancer characteristics according to the criteria of Epstein et al. CONCLUSIONS: Although the clinically relevant tumour characteristics and the relatively low cancer detection rate of 2.5% (less than the lifetime mortality risk of 3% and the morbidity risk of 8%) seem to justify screening in terms of adequate diagnosis and treatment, follow-up until 2008 is needed to prove the benefit in mortality for the prostate cancer screening group over the control group. Furthermore, information from the ongoing ERSPC study is needed in order to assess uncertainties i.e. the degree of overdiagnosis caused by repeated screening and the quality of life adjusted gain in life years. For daily practice a "PSA grey zone" of 4-10 ng/ml can no longer be postulated as only 70% of men in this range presented with organ confined disease. Once the PSA level exceeds 4.0 ng/ml. prostate biopsy should be performed immediately.

[PSA-screening for prostate cancer--yes or no?]. / PSA-screening für das Prostata-Karzinom-- ja oder nein?

Prostate cancer is a mayor health care problem, especially in the industrialised countries of the Western world. At this time it is the second most common cancer reason for death (CH: 1500 men/year) which will even get more importance in the future by demographic developments. While there is no doubt that in individuals early detection of organ confined disease with localised treatment the prostate cancer can be eradicated and individual men be cured there are uncertainties whether mass screening a population will contribute to reducing prostate cancer related mortality. Its value has not been proved definitively by prospective randomised controlled studies. Most of Medical Societies recommend a "well informed" decision by family physicians, where the men between 50-70 years know about the benefits and harms including: risk of cancer, diagnostic procedures, therapeutic consequences and possible side effects. After agreement of early detection a biopsy has to be done directly above a PSA level of 4.0 ng/ml or a suspicious digital rectal examination. A PSA "grey zone" 4-10 ng/ml can not further be postulated. The ratio of free/total PSA gives no support to prolong biopsy in this moment, because an elevated benign prostate with a higher production of free PSA can mask the tumor in the peripheral zone. Results of the ERSPC and the PLCO trials are expected to give information about the benefits and harms of mass screening in 2006/8.

Features and preliminary results of prostate cancer screening in Canton Aargau, Switzerland.

OBJECTIVE: To report the results from Switzerland's participation in the ERSPC from 1998; importantly, epidemiological data showed that Switzerland has one of the highest rates of morbidity and mortality from prostate cancer in the world. The local study protocol was accepted by the ethical committee and after the successful pilot study phase, the centre joined the ERSPC. SUBJECTS AND METHODS: From September 1998 to June 2003 10 300 men accepted an invitation for the study and were then randomized 1:1 into an active screening arm (assessed by testing prostate-specific antigen, PSA) or a control group (no intervention). The re-screening interval is 4 years and is ongoing (beginning in September 2002). The study protocol includes offering a prostate biopsy when the total PSA is >3.0 ng/mL (the main study protocol in agreement with ERSPC requirements) or when the total PSA is 1-3 ng/mL and the free-to-total PSA ratio <20% (side study protocol). RESULTS: During the first 3 years of screening 3562 men aged 55-70 years were screened; 395 (11.1%) of all participants had a total PSA of >3 ng/mL and 251 (7.4%) were eligible for the side-study. In all, 599 (17.2%) of 3562 accepted a prostate biopsy (93% of 646); 120 cases of prostate cancer were detected (3.4% detection rate). The incidence was 2.5% in main study group (positive predictive value, PPV, 24%) and 0.9% in side study group (PPV 13.6%). In radical prostatectomy specimens the cancers were mostly 'significant' (92% in main study group and 87% in side-study group). CONCLUSIONS: A randomized screening study for prostate cancer is feasible in Switzerland. A longer follow-up is needed to address within the ERSPC the primary hypothesis (that there will be a reduction in mortality in the active screening arm) and to determine the level of over/under-diagnosis and over/undertreatment in the active screening and control arms, respectively.

Prospective detection of clinically relevant prostate cancer in the prostate specific antigen range 1 to 3 ng./ml. combined with free-to-total ratio 20% or less: the Aarau experience.

PURPOSE: Little is known about the incidence rate and clinical relevance of prostate cancer in a low prostate specific antigen (PSA) level. In a prospective PSA based screening study we investigated the incidence and clinicopathological features of prostate cancer that occurred within PSA range 1 to 3 ng./ml. when the free-to-total ratio was 0.20 or less. MATERIALS AND METHODS: Men participating in the Aarau, Switzerland, section of the European Randomized Study of Screening for Prostate Cancer between October 1998 and July 2000 were included in the study. As a side study, all men with PSA between 1 and 3 ng./ml. and free-to-total ratio 0.20 or less were invited to undergo further evaluation with ultrasound guided sextant prostate biopsy. RESULTS: Overall, 168 (7.8%) participants fulfilled inclusion criteria. A total of 158 (94%) patients underwent prostate biopsy, and prostate cancer was detected in 17 (10.8%). There were no statistically significant differences between prostate cancer and benign prostatic hyperplasia in regard to patient age (60.7 versus 59.8 years), prostate volume (23.9 versus 23.0 cc), PSA (1.98 versus 1.86 ng./ml.), free-to-total ratio (0.161 versus 0.160), PSA density (0.089 versus 0.076 ng./ml.) or PSA transition zone density (0.33 versus 0.24 ng./ml., respectively). Median Gleason score was 5 on prostate biopsy versus 6 on retropubic prostatectomy specimen. Of the 14 patients who underwent surgery there were positive lymph nodes in 1, stage pT3b Gleason 7 disease in 1, and pathologically organ confined Gleason 5 in 2, Gleason 6 in 5 and Gleason 7 in 5. Mean tumor volume was 1.01 cc (range 0.02 to 5.17). There were 2 (14.3%) insignificant (less than 0.2 cc, Gleason grade 3 or less), 1 (7.1%) minimal (less than 0.5cc, Gleason grade 3 or less) and 11 (78.6%) clinically relevant and potentially harmful cancers. CONCLUSIONS: There is a significant number of prostate cancer cases diagnosed at PSA as low as 1 to 3 ng./ml. A majority of these tumors are clinically significant. This free-to-total ratio range may be helpful for identifying prostate cancer. The "window of opportunity" for detection of curable cancer may change in populations with higher life expectancy towards lower PSA. Lack of specificity and characterization of tumor aggressiveness remains an unsolved issue for PSA.

Retroperitoneal laparoscopic nephropexy.

Laparoscopic nephropexy is a suitable and clinically established procedure for the treatment of symptomatic nephroptosis. The availability of a minimally invasive therapy can facilitate decisions regarding the indication after careful selection of patients.

Human glandular kallikrein as a tool to improve discrimination of poorly differentiated and non-organ-confined prostate cancer compared with prostate-specific antigen.

OBJECTIVES: Human glandular kallikrein (hK2) possesses 80% structure identity with prostate-specific antigen (PSA) and is secreted by identical prostate epithelial cells. Although increasing with pathologic stage, PSA is not clinically sufficient to predict histologic grade and pathologic stage of prostate cancer (PCa) in individual cases. To address this issue, serum hK2 in various PCa grades was investigated. METHODS: Sera from 122 consecutive patients with PCa, graded as well-differentiated (G1, n = 35); moderately differentiated (G2, n = 61), and poorly differentiated (G3, n = 26) PCa, was studied. In patients who underwent radical prostatectomy (n = 42), 24 had organ-confined (pT2a-b) and 18 extracapsular (pT3a or greater) disease. hK2 was measured by an indirect immunofluorometric assay with a functional sensitivity of 0.03 ng/mL. Total PSA (tPSA), free PSA (fPSA), and PSA bound to alpha(1)-antichymotrypsin (PSA-ACT) were also measured. Multivariate logistic regression analysis was used for evaluation of the best combinations of tumor markers. RESULTS: Median hK2 and tPSA increased twofold from G1 to G2 tumors (hK2 0.07 versus 0.14 ng/mL, P <0.002; tPSA 6.1 versus 12.1 ng/mL, P <0.0002). Between G2 and G3 tumors, hK2 increased threefold (0.14 versus 0.43 ng/mL, P <0.02), and tPSA showed no significant increase (12.1 versus 26.5 ng/mL, P <0.18). The f/t PSA ratio decreased between G1 and G2 cancers (0.15 vs. 010, P <0.001); no difference was found between G2 and G3 tumors (0.10 versus 0.11, P = 0.93). However, the hK2/fPSA ratio distinguished between G1 and G3 tumors and G2 and G3 tumors (0.085 [G1] and 0.11 [G2] versus 0.22 [G3], P <0.0002 and P <0.002, respectively). Using multivariate regression analysis, the fPSA/(tPSA x hK2) ratio differentiated G2 and G3 tumors (P <0.01). In the tPSA range of 3 to 15 ng/mL, hK2, the hK2/fPSA ratio, and the fPSA/(tPSA x hK2) ratio differentiated between the G1/G2 and G3 tumors, and tPSA, the f/t PSA ratio, and PSA-ACT did not. In radical prostatectomy cases, hK2 (0.06 versus 0. 156, P <0.005) and the fPSA/(tPSA x hK2) ratio (2.104 versus 0.828, P <0.005) discriminated between pT2a-b and pT3a or greater PCa. CONCLUSIONS: hK2 significantly improved the identification of poorly differentiated (G3) tumors compared with PSA. By multivariate logistic regression analysis, the hK2/fPSA and fPSA/(tPSA x hK2) ratios further improved the detection of PCa grade. This improvement was also seen with the intermediate range of tPSA. hK2 was also helpful in the prediction of organ-confined disease. Thus, hK2 may be a useful tool for more accurate prediction of tumor grade or stage and allow better clinical decision-making.