Staged neurosurgical approach for giant and progressive neonatal arachnoid cysts: a case series and review of the literature.

OBJECTIVES: Prenatally diagnosed complex arachnoid cysts are very rare. While the true prenatal incidence is still unknown, they account for approximately 1% of intracranial masses in newborns. They rarely exhibit rapid growth or cause obstructive hydrocephalus, but if they increase to such a dimension during pregnancy, the ideal management is not well established. We present our detailed perinatal experience, covering prenatal diagnosis, a compassionate delivery process, and neonatal stabilization. Finally, a thorough postnatal neurosurgical intervention was performed. Initially, our focus was on the gradual reduction of cyst size as a primary effort, followed by subsequent definitive surgical treatment. METHODS: This case series shows the treatment course of three fetuses with antenatally diagnosed large arachnoid cysts. We present pre- and postnatal management and imaging, as well as the surgical treatment plan and the available clinical course during follow-up. RESULTS: Two girls and one boy were included in the current review. All three cases presented with prenatally diagnosed complex arachnoid cysts that increased in size during pregnancy. The mean gestational age at delivery was 35 weeks (range 32 to 37 weeks), and all patients were delivered by a caesarian section. Increasing head circumference and compression of brain structures were indications for delivery, as they are associated with a high risk of excess intracranial pressures and CSF diapedesis, as well as traumatic delivery and maternal complications. All cysts were supratentorial in location; one expanded into the posterior fossa, and one was a multicompartment cyst. All children underwent an initial surgical procedure within the first days of life. To relieve cyst pressure and achieve a reduction in head circumference, an ultrasound-guided or endoscopic-assisted internal shunt with drainage of the cyst to the ventricles or subdural/subarachnoid space was inserted. Definite surgical therapy consisted of cyst marsupialization and/or cysto-peritoneal shunt implantation. All children survived without severe neurodevelopmental impairments. CONCLUSION: With the cases presented, we demonstrate that the slow reduction of immense cyst size as an initial procedure until optimal requirements for final surgical treatment were achieved has proven to be optimal for neurological outcome. Special emphasis has to be taken on the delicate nature of premature newborn babies, and surgical steps have to be thoroughly considered within the interdisciplinary team.

Epinephrine-induced Effects on Cerebral Microcirculation and Oxygenation Dynamics Using Multimodal Monitoring and Functional Photoacoustic Microscopy.

BACKGROUND: The administration of epinephrine after severe refractory hypotension, shock, or cardiac arrest restores systemic blood flow and major vessel perfusion but may worsen cerebral microvascular perfusion and oxygen delivery through vasoconstriction. The authors hypothesized that epinephrine induces significant microvascular constriction in the brain, with increased severity after repetitive dosing and in the aged brain, eventually leading to tissue hypoxia. METHODS: The authors investigated the effects of intravenous epinephrine administration in healthy young and aged C57Bl/6 mice on cerebral microvascular blood flow and oxygen delivery using multimodal in vivo imaging, including functional photoacoustic microscopy, brain tissue oxygen sensing, and follow-up histologic assessment. RESULTS: The authors report three main findings. First, after epinephrine administration, microvessels exhibited severe immediate vasoconstriction (57 ± 6% of baseline at 6 min, P < 0.0001, n = 6) that outlasted the concurrent increase in arterial blood pressure, while larger vessels demonstrated an initial increase in flow (108 ± 6% of baseline at 6 min, P = 0.02, n = 6). Second, oxyhemoglobin decreased significantly within cerebral vessels with a more pronounced effect in smaller vessels (microvessels to 69 ± 8% of baseline at 6 min, P < 0.0001, n = 6). Third, oxyhemoglobin desaturation did not indicate brain hypoxia; on the contrary, brain tissue oxygen increased after epinephrine application (from 31 ± 11 mmHg at baseline to 56 ± 12 mmHg, 80% increase, P = 0.01, n = 12). In the aged brains, microvascular constriction was less prominent yet slower to recover compared to young brains, but tissue oxygenation was increased, confirming relative hyperoxia. CONCLUSIONS: Intravenous application of epinephrine induced marked cerebral microvascular constriction, intravascular hemoglobin desaturation, and paradoxically, an increase in brain tissue oxygen levels, likely due to reduced transit time heterogeneity.

Effect of pentaerythritol tetranitrate (PETN) on the development of fetal growth restriction in pregnancies with impaired uteroplacental perfusion at midgestation-a randomized trial.

BACKGROUND: Fetal growth restriction is strongly associated with impaired placentation and abnormal uteroplacental blood flow. Nitric oxide donors such as pentaerythritol tetranitrate are strong vasodilators and protect the endothelium. Recently, we demonstrated in a randomized controlled pilot study a 38% relative risk reduction for the development of fetal growth restriction or perinatal death following administration of pentaerythritol tetranitrate to pregnant women at risk, identified by impaired uterine perfusion at midgestation. Results of this monocenter study prompted the hypothesis that pentaerythritol tetranitrate might have an effect in pregnancies with compromised placental function as a secondary prophylaxis. OBJECTIVE: This study aimed to test the hypothesis that the nitric oxide donor pentaerythritol tetranitrate reduces fetal growth restriction and perinatal death in pregnant women with impaired placental perfusion at midgestation in a multicenter trial. STUDY DESIGN: In this multicenter, randomized, double-blind, placebo-controlled trial, 2 parallel groups of pregnant women presenting with a mean uterine artery pulsatility index >95th percentile at 19+0 to 22+6 weeks of gestation were randomized to 50-mg Pentalong or placebo twice daily. Participants were assigned to high- or low-risk groups according to their medical history before randomization was performed block-wise with a fixed block length stratified by center and risk group. The primary efficacy endpoint was the composite outcome of perinatal death or development of fetal growth restriction. Secondary endpoints were neonatal and maternal outcome parameters. RESULTS: Between August 2017 and March 2020, 317 participants were included in the study and 307 were analyzed. The cumulative incidence of the primary outcome was 41.1% in the pentaerythritol tetranitrate group and 45.5% in the placebo group (unadjusted relative risk, 0.90; 95% confidence interval, 0.69-1.17; adjusted relative risk, 0.90; 95% confidence interval, 0.69-1.17; P=.43). Secondary outcomes such as preterm birth (unadjusted relative risk, 0.73; 95% confidence interval, 0.56-0.94; adjusted relative risk, 0.73; 95% confidence interval, 0.56-0.94; P=.01) and pregnancy-induced hypertension (unadjusted relative risk, 0.65; 95% confidence interval, 0.46-0.93; adjusted relative risk, 0.65; 95% confidence interval, 0.46-0.92; P=0.01) were reduced. CONCLUSION: Our study failed to show an impact of pentaerythritol tetranitrate on the development of fetal growth restriction and perinatal death in pregnant women with impaired uterine perfusion at midgestation. Pentaerythritol tetranitrate significantly reduced secondary outcome parameters such as the incidence of preterm birth and pregnancy-induced hypertension in these pregnancies.

Intraoperative arterial pressure management: knowns and unknowns.

Preventing postoperative organ dysfunction is integral to the practice of anaesthesia. Although intraoperative hypotension is associated with postoperative end organ dysfunction, there remains ambiguity with regards to its definition, targets, thresholds for initiating treatment, and ideal treatment modalities.

Single-cell transcriptomic analysis of the immune cell landscape in the aged mouse brain after ischemic stroke.

BACKGROUND: Ischemic stroke is a medical emergency that primarily affects the elderly. A complex immune response in the post-stroke brain constitutes a key component of stroke pathophysiology. This study aimed to determine how stroke affects immune cell populations in the aged brain based on molecular profiles of individual cells. METHODS: Single-cell RNA sequencing and a new transient ischemic stroke mouse model with late reperfusion were used. RESULTS: We generated, for the first time, a composite picture of immune cell populations in the stroke aged brain at single-cell resolution. We discovered at least 6 microglial subsets in the stroke aged brain, including a potentially stroke-specific subtype. Moreover, we identified major cell subpopulations formed by infiltrated myeloid cells after stroke, and revealed their unique molecular profiles. CONCLUSIONS: This study provided the first scRNA-seq data set for immune cells in the stroke aged brain, and offered novel insights into post-stroke immune cell heterogeneity.

"An uncomfortable topic": Health professionals' perspectives on child protection capacities, training offers and the potential need for action in Germany.

BACKGROUND: Child maltreatment, due to its high prevalence and often long-lasting (health and/or psycho-social) consequences, is one of the main reasons for global health inequalities. The medical field offers many opportunities to support affected children. This gives physicians and other health professionals the opportunity to provide protective measures and therapies to affected children at an early stage. However, the level of training concerning child protection is often too low among health professionals. This can affect the quality of care as well as providing the appropriate treatment and thus, the long-term (health) burden. The present work aims to survey the state of knowledge and capacities of health professionals regarding child protection in medicine and elicit health professionals' perspectives who absolved a child protection online course on a potential need for action in Germany. METHODS: From June 2016 until February 2021, 3,360 health professionals were interviewed. Using quantitative and qualitative items, the questionnaire assessed demographic and professional background information as well as assessments regarding the awareness of child protection, abilities in child protection among health professionals and training offers in medicine. RESULTS: The analysis indicates that the topic of child protection in medicine is not as present as the high prevalence of child maltreatment would imply. The majority (94.0%; n = 3.159) of the health professionals stated that they need more knowledge and capacities regarding child protection in medicine. More than half of the health professionals assessed the importance of the issue of child protection as low among health professionals. The reasons cited included child protection as an uncomfortable topic, an unwillingness among managers, and a lack of training on the topic. CONCLUSIONS: There is too little awareness and importance regarding child protection in the medical field in Germany. Hence, it is difficult to ensure adequate care for those affected. Child protection topics should be mandatory in the training curricula of all health professionals, and quality standards for prevention and intervention should be implemented in medical institutions. Furthermore, networking in child protection has to be improved, and medical campaigns should address the topic to sensitize health professionals and society to the issue and to destigmatize the topic.

The femur too short? 1373 fetuses with short femur during second-trimester screening.

PURPOSE: A short fetal femur in prenatal diagnosis might be an indicator for intrauterine growth retardation (IUGR), a genetically determined small child (SGA) with or without associated fetal malformations and/or an adverse fetal outcome. METHODS: 1373 singleton pregnancies with a femoral length < 5th percentile detected between 1999 and 2015 during second-trimester screening in a tertiary prenatal diagnostic center were subjected to a descriptive retrospective analysis with regard to fetal characteristics as well as pregnancy outcome. RESULTS: 685 (49.9%) fetuses presented an isolated short femur, while 688 (50.1%) showed additional abnormalities. 293 (42.6%) of those were SGA babies without any malformation, while 395 (57.4%) had one or more severe anomaly of the following organ systems: 157 (11.5%) cardiovascular, 101 (7.4%) musculoskeletal, 82 (6.0%) urogenital, 72 (5.2%) cerebrocephalic, 50 (3.6%) gastrointestinal, and 5 (0.4%) thoracic. 75 (5.5%) of the fetuses showed chromosomal aberrations of which Trisomy 13, 18 and 21 were found in 2, 13 and 27 of the cases, respectively. Fetuses with associated malformations had a significantly lower live birth rate than those without (64.2% vs. 98.1%, p < 0.001); in addition, a higher rate of preterm births 36.6% vs. 11.3%, p < 0.001) and SGA babies (51.4% vs. 30.4%, p < 0.001) were observed in the first collective. CONCLUSION: Diagnosis of a short fetal femur should lead to an extended organ screening; in the case of associated abnormalities, additional genetic testing has to be offered, as well as intensified pregnancy monitoring in pregnancies at risk for IUGR and/or preterm birth.

Novel and flexible ultrasound simulation with smartphones and tablets in fetal echocardiography.

PURPOSE: Evaluation of a novel ultrasound-simulation-app for training fetal echocardiography as a possible useful addition for students, residents and specialist doctors. Furthermore, comparison to a conventional learning-method with special attention on orientation and recognition of physiological structures. METHODS: Prospective two-arm study with the participation of 226 clinical students. 108 students were given an extract from a textbook on fetal echocardiography (PDF-group, n = 108) for 30 min to study. 118 students were able to use the new ultrasound-simulator-app (Simulator-group, n = 118) to learn for 30 min. The knowledge of the students was examined both before and after the learning-period by having them identify sonographic structures in videos using single-choice selection. RESULTS: There were no significant differences between the two groups regarding age (p = 0.87), gender (p = 0.28), and the number of previously performed ultrasound-examinations (p = 0.45). In the Simulator-group, there was a significantly higher learning effect regarding the proportion of students with an increase of correct answers in the video test examination (p = 0.005). At the end of learning, the students in the Simulator-group needed significantly less time to display the structures in the app's simulation (median initially 10.9 s vs. 6.8 s at the end; p < 0.001). CONCLUSIONS: The novel ultrasound-simulation-app seems to be a useful addition and improvement to ultrasound training. Previous difficulties such as simultaneously having patients, ultrasound-machines, and professors at disposal can thus be avoided. This means that another important step towards remote learning can be taken, which has been proven increasingly essential lately, due to the COVID-19 pandemic.

[Burnout Symptoms Among Child and Adolescent Psychiatric/Psychotherapy Professionals During the 2020/2021 Winter Lockdown of the Covid-19 Pandemic]. / Burnout-Symptome bei Fachkräften in der Kinder- und Jugendpsychiatrie/Psychotherapie während des Winter-Lockdowns 2020/2021 der COVID-19-Pandemie.

Burnout Symptoms Among Child and Adolescent Psychiatric/Psychotherapy Professionals During the 2020/2021 Winter Lockdown of the Covid-19 Pandemic Abstract. Question: Professionals in clinics and Departments of Child and Adolescent Psychiatry/Psychotherapy are often confronted with stress during their daily work. Such psychological pressure can cause stress symptoms such as burnout. This article examines the consequences of burnout symptoms at the institutional level, such as staff turnover. Method: We examined the connection between burnout symptoms and the institutional consequences of presenteeism, absenteeism, turnover tendency, and reduced quality of job performance during the winter lockdown (2020/2021) of the Covid-19-pandemic at psychiatric hospitals or departments for children and adolescents in Germany using a sample of N = 172 professionals. Results: The results show that signs of burnout symptoms impact the turnover tendency, presenteeism, and job performance of professionals. In addition, evidence emerged that professionals were more stressed during the winter lockdown (2020/2021) of the Covid-19 pandemic, and that this influenced turnover tendency, presenteeism, and absenteeism as well as the quality of job performance. Conclusion: Work-related stress of professionals should be addressed early to protect clinics and departments for child and adolescent psychiatry/psychotherapy from potential consequences, and to ensure care connectivity and quality of care.

Argon Inhalation for 24 h After Closed-Head Injury Does not Improve Recovery, Neuroinflammation, or Neurologic Outcome in Mice.

BACKGROUND/OBJECTIVE: In recent years, the noble gas argon (Ar) has been extensively studied for its organ protection properties. While mounting in vitro and in vivo evidence indicates that argon provides neuroprotection in ischemic brain injury, its neuroprotective potential in traumatic brain injury (TBI) has not been evaluated in vivo. We tested the hypothesis that prolonged inhalation of 70% or 79% argon for 24 h after closed-head injury (CHI) improves neurologic outcome and overall recovery at 36 days post-injury. We also compared effects of the 30% or 21% residual oxygen on argon's potential neuroprotective capacity. METHODS: Adult male C57/black mice (n = 240) were subjected to closed-head traumatic brain injury, followed by inhalation of 70% argon or nitrogen (30% oxygen), or 79% argon or nitrogen (21% oxygen) for 24 h. Neurologic outcome (rotarod, neuroscore, and Morris water maze) was evaluated for up to 36 days post-injury. Histologic parameters of neurologic degeneration (Fluoro-Jade staining) and inflammation (F4/80 microglia immunostaining) were assessed in subgroups at 24 h and on post-injury day 7. RESULTS: Our CHI protocol consistently resulted in significant brain injury. After argon inhalation for 24 h at either concentration, mice did not show significant improvement with regard to neuroscores, rotarod performance, Morris water maze performance, or overall recovery (body weight), compared to nitrogen controls, up to 36 days. At 7 days post-injury, histologic markers of neurodegeneration and inflammation, particularly in the hippocampus, consistently demonstrated significant injury. Notably, recovery was reduced in mice treated with the higher oxygen concentration (30%) after CHI compared to 21%. CONCLUSIONS: Prolonged argon treatment did not improve neurologic outcome, overall recovery (weight), nor markers of neurodegeneration or neuroinflammation after significant CHI compared to nitrogen. While neuroprotective in predominately ischemic injury, argon did not provide protection after TBI in this model, highlighting the crucial importance of assessing argon's strengths and weaknesses in preclinical models to fully understand its organ protective potential in different pathologies and gas mixtures.

CVN-AD Alzheimer's mice show premature reduction in neurovascular coupling in response to spreading depression and anoxia compared to aged controls.

We compared the efficacy of neurovascular coupling and substrate supply in cerebral cortex during severe metabolic challenges in transgenic Alzheimer's [CVN-AD] and control [C57Bl/6] mice, to evaluate the hypothesis that metabolic insufficiency is a critical component of degeneration leading to dementia. We analyzed cerebral blood flow and metabolic responses to spreading depression (induced by K+ applied to the cortex) and anoxia across aging in CVN-AD + C57Bl/6 genotypes. In the CVN-AD genotype progression to histological and cognitive hallmarks of dementia is a stereotyped function of age. We correlated physiology and imaging of the cortex with the blood flow responses measured with laser doppler probes. The results show that spreading depression resulted in a hyperemic blood flow response that was dramatically reduced (24% in amplitude, 70% in area) in both middle-aged and aged CVN-AD mice compared to C57Bl/6 age-matched controls. However, spreading depression amplitude and conduction velocity (≈6 mm/min) did not differ among groups. Anoxia (100% N2 ) showed significantly decreased (by 62%) reactive blood flow and autoregulation in aged AD-CVN mice compared to aged control animals. Significantly reduced neurovascular coupling occurred prematurely with aging in CVN-AD mice. Abbreviated physiological hyperemia and decreased resilience to anoxia may enhance early-onset metabolic deficiency through decreased substrate supply to the brain. Metabolic deficiency may contribute significantly to the degeneration associated with dementia as a function of aging and regions of the brain involved.

[Protection Against Violence and Abuse in Medical Institutions - Reasons, Prevalence and Implications for Practice]. / Schutz vor Gewalt und Übergriffen in medizinischen Institutionen ­ Ursachen, Häufigkeiten und Implikationen für die Praxis.

Protection Against Violence and Abuse in Medical Institutions - Reasons, Prevalence and Implications for Practice Reported cases of (sexual) abuse in institutions as well as the results of surveys show that violence against children and adolescents, but also against adults, occurs also in medical institutions. There are still few studies on the frequency of these cases. However, the cases that have come to public attention show that medical institutions bear systemic risk factors for such assaults. On the other hand, medical institutions also play an important role in child protection, since many children and adolescents affected by maltreatment including sexual abuse come into contact with the medical system. It is necessary that medical institutions deal with this problem and develop respective institutional protection concepts. A protection concept is a system of measures that ensure better protection against assaults within an organisation. Important steps are analysis of risk factors, structural changes, the creation of plan of procedures and the development of an institutional attitude that assaults are not tolerated. Although the development of protection concepts takes time and resources, it has many advantages for institutions, such as an increased sense of security for professionals, because they know how to proceed in such situation. Now that the obligation to draw up protection concepts is anchored in the quality management guideline of the Federal Joint Committee (G-BA), all hospitals and practices must set out to develop appropriate concepts.

[The Influence of Personal Resources on Job Satisfaction Among Professionals in the Inpatient Care of Burdened Children and Adolescents]. / Der Einfluss von personalen Ressourcen auf die Arbeitszufriedenheit bei Fachkräften in der stationären Betreuung von belasteten Kindern und Jugendlichen.

The Influence of Personal Resources on Job Satisfaction Among Professionals in the Inpatient Care of Burdened Children and Adolescents Professionals in the inpatient care of burdened and partially traumatized children and adolescents are confronted with high demands in their everyday work. If these professionals do not have the necessary resources to carry out their work, their job satisfaction can be affected negatively. In the present study, the connections between the personal resources action competence, emotional competence, self-efficacy and self-care and job satisfaction were investigated on a sample of N = 543 professionals working in the (inpatient) care of children and adolescents. The survey was conducted as part of the accompanying research of an online course called "Trauma informed Care". Correlations as well as a multiple regression were calculated for the connections between personal resources and job satisfaction. Moderate to strong correlations were identified between personal resources and job satisfaction. The regression model revealed self-efficacy, followed by self-care, to be the most important predictor of job satisfaction. Less importance could be ascribed to emotional competence as a predictor of job satisfaction. Action competence showed no effects in the model. The results indicate the importance of personal resources for job satisfaction. These should be promoted in a targeted manner to increase job satisfaction and thus counteract the tendency of fluctuation and shortage of professionals in the area of child and youth welfare and thereby ensuring high quality care of the vulnerable population.

Argon Inhalation for 24 Hours After Onset of Permanent Focal Cerebral Ischemia in Rats Provides Neuroprotection and Improves Neurologic Outcome.

OBJECTIVES: We tested the hypothesis that prolonged inhalation of 70% argon for 24 hours after in vivo permanent or temporary stroke provides neuroprotection and improves neurologic outcome and overall recovery after 7 days. DESIGN: Controlled, randomized, double-blinded laboratory study. SETTING: Animal research laboratories. SUBJECTS: Adult Wistar male rats (n = 110). INTERVENTIONS: Rats were subjected to permanent or temporary focal cerebral ischemia via middle cerebral artery occlusion, followed by inhalation of 70% argon or nitrogen in 30% oxygen for 24 hours. On postoperative day 7, a 48-point neuroscore and histologic lesion size were assessed. MEASUREMENTS AND MAIN RESULTS: After argon inhalation for 24 hours immediately following "severe permanent ischemia" induction, neurologic outcome (neuroscore, p = 0.034), overall recovery (body weight, p = 0.02), and infarct volume (total infarct volume, p = 0.0001; cortical infarct volume, p = 0.0003; subcortical infarct volume, p = 0.0001) were significantly improved. When 24-hour argon treatment was delayed for 2 hours after permanent stroke induction or until after postischemic reperfusion treatment, neurologic outcomes remained significantly improved (neuroscore, p = 0.043 and p = 0.014, respectively), as was overall recovery (body weight, p = 0.015), compared with nitrogen treatment. However, infarct volume and 7-day mortality were not significantly reduced when argon treatment was delayed. CONCLUSIONS: Neurologic outcome (neuroscore), overall recovery (body weight), and infarct volumes were significantly improved after 24-hour inhalation of 70% argon administered immediately after severe permanent stroke induction. Neurologic outcome and overall recovery were also significantly improved even when argon treatment was delayed for 2 hours or until after reperfusion.

Prenatally Diagnosed Single Umbilical Artery (SUA) - Retrospective Analysis of 1169 Fetuses.

PURPOSE: The incidence of a fetal single umbilical artery (SUA) is about 0.5 % and has been associated with an increased risk of congenital malformations, fetal aneuploidy and intrauterine growth restriction (IUGR). MATERIALS AND METHODS: A retrospective analysis of 1169 women with singleton pregnancies diagnosed with fetal SUA between 1997 and 2014 in a specialized practice for prenatal diagnostics has been performed. Data was obtained on maternal and fetal findings as well as pregnancy outcome. RESULTS: 989 (84.6 %) fetuses showed an isolated SUA (iSUA) while 180 (15.4 %) presented with SUA and additional structural and/or chromosomal abnormalities. Structural malformations were distributed as follows: 9.0 % cardiovascular, 3.5 % urogenital, 2.9 % musculoskeletal, 3.0 % gastrointestinal and 2.1 % cerebral. 2.1 % of the fetuses had chromosomal aberrations. 50.8 % (49.2 %) of the fetuses were female (male) and right vs. left SUA was found in 64.2 % (35.8 %) of the cases. Fetuses with SUA and additional abnormalities showed lower rates of live births (85.0 % vs. 98.5 %, p < 0.001), a lower median birth weight (2825 g vs. 3220 g, p < 0.001), higher rates of preterm delivery before week 34 + 0 (13.7 % vs. 3.8 %, p < 0.001) and weighed less than the 5th growth percentile in 21.6 % vs. 9.3 % (p < 0.001) of the fetuses with iSUA. In 5.1 % (60) of the children, chromosomal or structural abnormalities were detected post-partum. CONCLUSION: Once fetal SUA is diagnosed, intense sonoanatomy of the fetus is required and, if associated malformations are found, genetic testing must be offered. In iSUA intermittent biometry is recommended for the early detection of IUGR but additional genetic testing is not necessarily recommended.

[Improving child protection in healthcare: peer counseling, education, and research using the example of abusive head trauma]. / Kinderschutz im Gesundheitswesen verbessern: Fachberatung, Weiterbildung und Forschung am Beispiel des misshandlungsbedingten Kopftraumas.

Too often, diagnosis of maltreatment is missed by healthcare professionals - thus denying children in danger from necessary protection. Insufficient knowledge and insecurities towards professional confidentiality and how to approach child protection services may be the reasons for the failure to protect children effectively.In this article, we present how a comprehensive concept by the competence center of child protection in medicine of the state of Baden-Wurttemberg consisting of peer counseling, peer education, and research can add to the prevention of maltreatment. One component is peer counseling through a telephone helpline that is accessible 24/7, the medical child protection hotline. The requests to the helpline are analyzed and add to the generation of tailored content for the education of doctors, psychotherapists, nurses, and other healthcare professionals. As an example, we present the online course "Child protection in medicine - a basic course for all health professionals" (so far available only in German). One common issue when the child protection hotline is called for counseling is abusive head trauma. Research shows that sometimes a diagnosis of abusive head trauma might be missed. This condition is most prevalent in children under the age of 2 and represents one of the most severe forms of physical abuse with high mortality.Inquiries to the medical child protection hotline are constantly increasing, but making the service known nationwide to all healthcare professionals still poses a challenge. The online course is widely used and being constantly improved. The comprehensive concept of peer counseling, education, and research is an important contribution to the improvement of the prevention of child maltreatment.

CCSchool: a multicentre, prospective study on improving continuum of care in children and adolescents with mental health problems associated with school problems in Germany.

BACKGROUND: Most psychiatric disorders in childhood and adolescence cause impairment in academic performance. Early interventions in school are thought to reduce the burden of disorder and prevent chronicity of disorder, while a delay in reachable help may result in more severe symptoms upon first time presentation, often then causing upon first-time presentation immediate need of inpatient care. METHODS: The study aims at reducing hospitalization rates and increasing social participation and quality of life among children and adolescents by establishing collaborations between schools, mental health care services and youth welfare services. CCSchool offers children and adolescents, aged six to 18 years, who present with psychiatric problems associated to school problems, a standardized screening and diagnostic procedure as well as treatment in school if necessary. Students can participate in CCSchool in three federal states of Germany if they a) show symptoms vindicating a mental health diagnosis, b) present with confirmed school problems and c) have a level of general functioning below 70 on the children global assessment of Functioning (C-GAF). Intervention takes place in three steps: module A (expected n = 901, according to power calculation) with standardized diagnostic procedures; module B (expected n = 428) implies a school-based assessment followed by a first intervention; module C (expected n = 103) offering school-based interventions with either four to six sessions (basic, 80% of patients) or eight to 12 sessions (intensive, 20% of patients). Primary aim is to evaluate the effectiveness of CCSchool, in reducing the need of hospitalization in children with mental health problems. The analyses will be conducted by an independent institute using mainly data collected from patients and their caregivers during study participation. Additionally, claims data from statutory health insurances will be analysed. Relevant confounders will be controlled in all analyses. DISCUSSION: Evaluation may show if CCSchool can prevent hospitalizations, enhance social participation and improve quality of life of children and adolescents with mental health problems by providing early accessible interventions in the school setting. TRIAL REGISTRATION: Deutsches Register Klinischer Studien, Trial registration number: DRKS00014838 , registered on 6th of June 2018.

Value of endometrial thickness assessed by transvaginal ultrasound for the prediction of endometrial cancer in patients with postmenopausal bleeding.

PURPOSE: Histological confirmation of endometrial cancer by dilatation/curettage (D/C) in women with postmenopausal bleeding (PMB) can be challenging due to anesthesiological and/or surgical risks. Thus, less invasive methods for diagnostics are required to identify patients with minimal risk for endometrial cancer (EC) to avoid unnecessary surgical intervention. The objective of this single-center cohort study was to assess the diagnostic validity of transvaginal ultrasound (TVUS) measurements of endometrial thickness (ET) in patients with PMB for the detection of EC. METHODS: A retrospective analysis of data from patients presenting between January 2005 and August 2014 at the Department of Obstetrics and Gynecology, University Hospital Ulm, Germany, with PMB and subsequent D/C was performed. Complete data with TVUS documentation of ET and histological results of tissue samples were available from 254 patients. In addition, data on age, body mass index (BMI), ASA-score, diabetes, hypertension, and hematological laboratory values (for a smaller subsample) were recorded. To identify independent risk factors, a multivariate logistic regression with endometrial cancer as binary response variable (yes/no) was performed. Diagnostic efficacy data for different ET cutoff points (≤1 to ≤26 mm) were obtained by a receiver operator characteristic (ROC) curve analysis. RESULTS: The multivariate logistic regression revealed a significant independent predictive value for age and ET. However, none of the analyzed ET cutoff points showed optimal diagnostic validity, as all cutoff points with sensitivity rates above 90% (≤1 to ≤5 mm) had false positive rates of 70% and higher. CONCLUSIONS: There is no ET cutoff point that provides good diagnostic accuracy and/or reliably excludes the presence of endometrial cancer in patients with PMB. Thus, our data analysis supports the actual German approach of histological evaluation of any PMB to confirm or exclude EC.