Impact of (forensic) expert opinions according to the Istanbul Protocol in Germany-results and insights of the in:Fo-project.

As part of a third-party funded project, expert opinions according to the Istanbul Protocol (IP) standards were compiled in Germany on a larger scale for the first time. The assessment process was initiated for 130 project participants. Statistical analysis on numerous variables was performed to test the impact of the expert opinions, foremost of the forensic medical expert opinions, on the individuals' asylum proceedings. The variables were drawn from forensic medical expert opinions and reports of findings, questionnaires for the study participants' counsellors in the project and a query on the asylum status of the study participants. Regression analysis and bivariate analysis on two dependent variables-subjective impact on the asylum procedure from the counsellors' point of view and objective change in the asylum status-were performed to test for an influence on asylum procedures. No statistically significant results were obtained for the objective change of the study participants' asylum status. For the subjective dependent variable, a positive prediction was possible when simultaneously controlling for the independent variables introduction of a forensic medical expert opinion and highest IP grade; a negative prediction was possible when simultaneously controlling for the independent variables introduction of a forensic medical expert opinion and use of IP grading. Apart from the statistical analysis, a positive effect of the assessment on the psychosocial well-being of the study participants could be demonstrated. The results differed from other European studies which demonstrated a correlation between the objective outcome of an asylum procedure (asylum status) and, for example, specific types of violence or the number of documented injuries. Differences also occurred in the use of the plausibility grades proposed by the IP, which questions their use in cases in which the reported torture happened a relevant time ago. Therefore, compiling individually worded evaluations instead of using the IP grading system-if possible, by an experienced forensic physician-is recommended in this scenario. Still, the assessment of alleged torture experiences should follow the IP guidelines, since psychological assessments are of especially high importance in cases with healed physical injuries and since the results also demonstrated a positive effect on the psychosocial well-being of the study participants.

Noninvasive CSF shunt patency evaluation by superb microvascular imaging.

Occlusion of a ventriculoperitoneal shunt system is a potentially life-threatening complication in patients suffering from hydrocephalus. However, there is no imaging established as standard approach in this acute setting. In the present study, we evaluate the use of superb microvascular imaging for investigation of the patency of ventriculoperitoneal shunt systems. Simulation of low flow rates of cerebrospinal fluid through a small diameter CSF shunt system was performed in a dedicated phantom in order to proof the principle of superb microvascular imaging (SMI) being feasible for the measurement of slow CSF flow through the dedicated CSF shunt system. SMI is able to detect low flow rates in CSF shunt systems effectively and fast. Visualization of a Duplex ultrasound flow and Doppler wave pattern in the VP shunt system after the reservoir has been pressed confirms patency. SMI is an effective method for evaluating CSF shunt patency and diagnosing shunt obstruction. This bears the potential to facilitate evaluation of clinically symptomatic VP shunt patients in an acute setting. Further evaluation of ultrasound flow patterns is granted.

[Muscular injuries of athletes : Importance of ultrasound]. / Muskelverletzungen des Sportlers : Stellenwert des Ultraschalls.

CLINICAL/METHODICAL ISSUE: Muscular injuries represent the most common musculoskeletal lesions. Especially in professional athletes an imaging clarification is essential in order to define the exact location of the lesion, the affected muscles, the extent and degree of the injury as well as to define possible concomitant complications. The best possible therapy can be initiated and a necessary rest period for a low risk resumption of sporting activity can be individually specified. STANDARD RADIOLOGICAL METHODS/METHODICAL INNOVATIONS: Due to technical improvements, for example mobile devices and thus increased rapid availability as well as relative cost-effectiveness compared to other modalities, the imaging evaluation of muscle injury would nowadays be unthinkable without ultrasound. PERFORMANCE: The article discusses general prerequisites for the performance of muscle ultrasound as well as a standardized examination algorithm of muscle injuries beginning with general and leading to special tips and tricks. ACHIEVEMENTS/PRACTICAL RECOMMENDATIONS: Despite the known investigator dependence, ultrasound enables a reliable and unerring imaging clarification of muscle injuries. For this reason, ultrasound should be considered as the first-line diagnostic imaging modality when dealing with muscle trauma.

[Ultrasound-guided interventions on the peripheral nervous system]. / Ultraschallgesteuerte Interventionen am peripheren Nervensystem.

CLINICAL/METHODICAL ISSUE: Up to the advent of high-resolution ultrasound, interventions on the peripheral nervous system, including local anesthesia and pain treatment were performed without visual guidance, which in some cases led to treatment failure or local tissue and nerve damage. METHODICAL INNOVATIONS: Progress in the field of ultrasound has enabled the functional visualization, anesthesia and anti-inflammatory or neurolytic treatment of many peripheral nerves, such as the brachial plexus, nerves of the upper and lower extremities and various nerves of the trunk. Contrast medium-guided biopsies have also become feasible. ACHIEVEMENTS: This article discusses the general prerequisites for such interventions and details the visualization and the interventional algorithms for interventions on the brachial plexus, on large nerves often affected by compression neuropathies, such as the median, ulnar, sciatic and femoral nerves and small nerves, such as the lateral cutaneous nerves of the thigh. Furthermore, contrast medium-aided biopsies of intraneural and perineural masses are discussed. Finally, the treatment of stump neuromas via phenol instillation is described. PRACTICAL RECOMMENDATIONS: Innovations in high-resolution ultrasound allow the reliable and safe diagnosis and treatment of various pathologies of the peripheral nervous system with few side effects. Compared to older methods, which did not use visual guidance ultrasound provides higher success rates and lower adverse event rates in many instances.

Doppler-guided haemorrhoidal artery ligation with suture mucopexy compared with suture mucopexy alone for the treatment of Grade III haemorrhoids: a prospective randomized controlled trial.

AIM: Novel minimally invasive techniques aimed to reposition the haemorrhoidal zone have been established for prolapsing haemorrhoids. We present a prospective randomized controlled trial to evaluate the efficacy of additional Doppler-guided ligation of submucosal haemorrhoidal arteries (DG-HAL) in patients with symptomatic Grade III haemorrhoids. The trial was registered as ClinicalTrials.gov identifier NCT02372981. METHOD: All consecutive patients with symptomatic Grade III haemorrhoids were randomly allocated to one of the two study arms: (i) Group A, DG-HAL with mucopexy or (ii) Group B, mucopexy alone. End-points were postoperative pain, faecal incontinence, bleeding, residual prolapse and alterations of the vascularization of the anorectal vascular plexus. Vascularization of the anorectal vascular plexus was assessed by transperineal contrast enhanced ultrasound. Patients recorded their symptoms in a diary maintained for a month. RESULTS: Forty patients were recruited and randomized to the two study groups. Patients in Group A had less pain in the first two postoperative weeks. At the 12-month follow-up, two patients in Group A (10%) and one in Group B (5%) showed recurrent Grade III haemorrhoids (P = 0.274). No significant morphological changes were observed in the transperineal ultrasound findings between the preoperative assessment and the assessment at 1 and 6 months in either group (P > 0.05). CONCLUSION: Mucopexy techniques for treating prolapsing haemorrhoids are effective, but DG-HAL does not add significantly to the results achieved by mucopexy. Repositioning the haemorrhoidal zone is the key to success, and mucopexy should be placed at the sites of the largest visible prolapse.

Ultra-endurance exercise induces stress and inflammation and affects circulating hematopoietic progenitor cell function.

Although amateur sports have become increasingly competitive within recent decades, there are as yet few studies on the possible health risks for athletes. This study aims to determine the impact of ultra-endurance exercise-induced stress on the number and function of circulating hematopoietic progenitor cells (CPCs) and hematological, inflammatory, clinical, metabolic, and stress parameters in moderately trained amateur athletes. Following ultra-endurance exercise, there were significant increases in leukocytes, platelets, interleukin-6, fibrinogen, tissue enzymes, blood lactate, serum cortisol, and matrix metalloproteinase-9. Ultra-endurance exercise did not influence the number of CPCs but resulted in a highly significant decline of CPC functionality after the competition. Furthermore, Epstein-Barr virus was seen to be reactivated in one of seven athletes. The link between exercise-induced stress and decline of CPC functionality is supported by a negative correlation between cortisol and CPC function. We conclude that ultra-endurance exercise induces metabolic stress and an inflammatory response that affects not only mature hematopoietic cells but also the function of the immature hematopoietic stem and progenitor cell fraction, which make up the immune system and provide for regeneration.

Ultrasound imaging of the axillary nerve and its role in the diagnosis of traumatic impairment.

PURPOSE: The axillary nerve (AN) is frequently injured during shoulder trauma and imaging is required to define the site and extent of nerve injury. However, the AN has a rather complex course through several soft tissue compartments of the shoulder and axilla. Therefore, imaging of the nerve with MRI and sonography is troublesome. Thus detection and sonographic assessment bases on thorough knowledge of local topography. MATERIALS AND METHODS: This investigation aimed at defining reliable anatomical landmarks for AN-sonography in 5 volunteers and later validating the proposed sonographic examination protocol in 10 unselected patients. RESULTS: With strict adherence to the proposed examination algorithm, sonography of the AN was feasible in all volunteers and patients. Furthermore, sonographic findings correlated nicely with the golden standard "surgical exploration" concerning severity and topography of neural impairment. CONCLUSION: Based on our study results we propose our algorithm for AN-sonography as the first-line imaging tool for the assessment of axillary nerve trauma.

Transperineal ultrasonography as a complementary diagnostic tool in identifying acute perianal sepsis.

BACKGROUND: Successful anal fistula care in complex cases can be assisted by specialized imaging which accurately defines the site of the internal fistula opening and the fistula type. There are currently limited data concerning the clinical indications for and accuracy of transperineal ultrasound (TP-US) in acute perianal sepsis. The aims of this study were to compare the anatomical interpretation of TP-US images with magnetic resonance imaging (MRI) and surgical findings in an unselected patient cohort presenting with acute perianal sepsis. METHODS: Sixty-seven consecutive patients with acute anorectal sepsis referred from the surgical department were examined using TP-US and Gadolinium-enhanced MRI with both examiners blinded to the surgical results. Fistulae were categorized by the Parks' classification of fistula type. RESULTS: Thirty-six abscesses were detected by MRI, 38 by TP-US and 30 by surgical examination. Operatively discordant cases showed only ischiorectal panniculitis. TP-US was more accurate in the diagnosis of superficial sepsis and MRI in the diagnosis of deep-seated perirectal infection. TP-US and MRI show concordance with operative findings in fistula diagnosis with a tendency for TP-US to overdiagnose trans-sphincteric fistulae and MRI to over diagnose extra-sphincteric fistulae. Comparison of TP-US with MRI showed good agreement for perianal abscess diagnosis (τ = 0.82) and for fistula diagnosis (τ = 0.68). For fistulae, TP-US showed moderate agreement with surgery (τ = 0.43) with only fair agreement between MRI and surgery (τ = 0.29). CONCLUSIONS: Transperineal ultrasound complements other imaging modalities in the anatomical diagnosis of acute perianal abscesses and fistulae. It has specific advantages over other techniques and is accurate in the detection of superficially located perirectal sepsis showing concordance with MRI and surgical findings.

Treatment with the nitric oxide donor SNP increases triiodothyronine levels in hyper- and hypothyroid Sprague-Dawley rats.

Nitric oxide pathway might play a crucial role in the pathophysiology of thyroid dysfunctions. This study aimed to investigate the impact of nitric oxide (NO) on hypothyroid and hyperthyroid Sprague-Dawley rats under controlled diet. Furthermore, the effects of the nitric oxide donor sodium nitroprusside (SNP) on thyroid dysfunctions were also assessed. Sprague-Dawley rats (n=107) were subdivided into normal diet and high-fat diet (HFD) groups and grouped into controls, hypothyroid, hyperthyroid, and SNP treated groups. Hypothyroidism was induced through propylthiouracil, whereas hyperthyroidism by triiodothyronine (T3). After 12 weeks of T3 treatment, serum nitric oxides (NOX), endogenous asymmetric dimethylarginine (ADMA), body weight and food intake were analyzed. Hypothyroid rats showed decreased serum T3 levels, hyperthyroid rats increased T3 compared to controls. Diet had no impact on T3. Thyroid dysfunctions were accompanied by changes in calorie intake and body weight. Serum NOX was significantly reduced in normal diet hypothyroid rats. SNP administration compensated the decrease and markedly increased T3. NO synthase inhibitor ADMA levels were significantly higher in the HFD control group than in the normal diet controls. ADMA was declined in both hypothyroid groups and increased in normal diet hyperthyroid rats. An association of thyroid dysfunctions with reduced bioavailability of NO and alterations of ADMA levels could be established. Treatment with the NO donor SNP resulted in an increase of serum T3 levels. These results demonstrate that the NO pathway is implicated in thyroid dysfunctions, which may be of clinical relevance.

Prognosis and prognostic factors in non-traumatic acute-onset compressive mononeuropathies--radial and peroneal mononeuropathies.

BACKGROUND AND PURPOSE: Little is known about the natural history of non-traumatic compressive mononeuropathies. To improve patient management, prognostic factors and outcome in patients with non-traumatic peroneal and radial mononeuropathies were studied. METHODS: Retrospective clinical, electrophysiological and sonographic data of patients with non-traumatic peroneal and radial mononeuropathies were evaluated. Clinical, electrophysiological and sonographic evaluations had to take place 2-12 weeks after symptom onset and follow-up had to be for >6 months. RESULTS: Twenty-five patients with peroneal mononeuropathy and 58 with radial mononeuropathy were included. Mean follow-up was 8.9 ± 2.4 months. Approximately 90% of patients recovered to a muscle strength of British Medical Research Council grade 4 or 5. Multiple logistic regression analysis revealed conduction block on nerve conduction studies, younger age and less severe initial weakness as indicators for a good prognosis. Peripheral nerve ultrasound was not prognostic in the 40 patients where it was available. CONCLUSIONS: The present study shows a good prognosis for spontaneous recovery after non-traumatic acute-onset compressive peroneal and radial mononeuropathies. Patients with denervation on needle electromyography, older age and severe initial weakness have a poorer prognosis and should be closely monitored to facilitate timely surgery whenever weakness persists. Peripheral nerve ultrasound seems to be of limited prognostic value in these mononeuropathies.

Thickened hyperechoic outer epineurium, a sonographic sign suggesting snapping ulnar nerve syndrome?

PURPOSE: Snapping ulnar nerve syndrome (dislocation of the ulnar nerve over the medial epicondyle) is one of many causes of ulnar neuropathy at the elbow. This preliminary study was performed to search for sonographic signs suggesting the presence of this condition. METHODS AND MATERIALS: We retrospectively investigated 11 patients with snapping ulnar nerve syndrome (SNAP) in comparison with an age-matched group of 20 patients with idiopathic cubital tunnel syndrome (SNU). Patients were grouped according to the presence of paretic or merely sensory deficits. Nerve cross section area (CSA) and thickness of outer epineurium (ET) was measured and correlated with neurological findings. Statistical differences were evaluated with the Mann-Whitney U-Test. RESULTS: 5 SNAP (10 SNU) patients had sensory symptoms only, 6 SNAP (10 SNU) patients had paretic deficits. CSA in sensory SNU was 0.14 cm(2), in paretic SNU 0.19 cm(2), in sensory SNAP 0.15 cm(2) and in paretic SNAP 0.14 cm(2). ET in sensory SNU was 0.85 mm, 0.8 mm in paretic SNU, 1.05 mm in sensory SNAP and 1.1 in paretic SNAP. Differences in CSA were not significant depending on symptoms or group, differences in ET were not significant depending on symptoms but on group (SNAP versus SNU) at α = 0.05. CONCLUSION: A thickened, hyperechoic outer epineurium in a patient with ulnar neuropathy at the elbow might be a statistically significant differential feature of snapping ulnar nerve syndrome and should be involved in a further functional sonographic evaluation during flexion/extension of the elbow.

Reduced urinary glutamate levels are associated with the frequency of migraine attacks in females.

BACKGROUND AND PURPOSE: Recent evidences indicate that glutamatergic homeostasis disorders are implicated in the pathogenesis of migraine. In particular, plasma and cerebrospinal fluid glutamate levels seem to be altered in migraine patients. However, the impacts of glutamate on migraine and especially on aura symptoms, alterations in the frequency of migraine attacks as well as investigations on glutamate on migraine-related metabolic dysfunctions, like hyperinsulinaemia, and an atherogenic lipid profile remain elusive to date. The aim of the present study was to investigate the impact of glutamate on migraine and related metabolic dysfunctions. METHODS: We investigated the urinary glutamate levels of female migraineurs (n = 48) in the interictal phase and healthy controls (n = 48). Parameters of the insulin- and lipid metabolism, inflammatory parameters and anthropometric parameters were additionally determined. RESULTS: Urinary glutamate levels of female migraineurs were significantly decreased with respect to the control group. Logistic regression revealed an odds ratio of 4.04 for migraine. We found a significant correlation with the time-period of patients' last attack and a significant inverse correlation with the annual frequency of migraine attacks. Other parameters of the insulin- and lipid metabolism, anthropometric and inflammatory parameters showed no significant correlation with glutamate levels. CONCLUSION: We show here that female migraineurs exhibit decreased urinary glutamate levels which are associated with a 4.04-fold higher risk for migraine and correlated with patients' frequency of migraine attacks.

Seasonality of Clostridium difficile infections in Southern Germany.

Between 2000 and 2009, the total number of patients with Clostridium difficile infections increased considerably in Southeastern Germany. A clear seasonality was observed with a higher number of affected patients occurring in the winter months (January-March). Moxifloxacin and erythromycin-resistant C. difficile PCR ribotypes 001 (72%) and 027 (4·6%) were the most commonly isolated strains.

Punched nerve syndrome: ultrasonographic appearance of functional vascular nerve impairment.

PURPOSE: The mechanical impact of a neighboring vessel on a "punched" nerve segment is thought to be one possible cause of compression neuropathy but has not been proven definitively. We report on 9 subjects with unclear clinical mononeuropathies in whom we could clearly define peripheral nerve impairment by such vessels on real-time high-resolution ultrasound (HRUS). MATERIALS AND METHODS: Nine subjects with unclear mononeuropathy based on clinical neurological examination were referred to our department for HRUS assessment. The shape, inner and outer echotexture, size and diameter, and overall integrity of these nerves were assessed including an exact analysis of the surrounding soft tissues to search for potentially extraneural pathology. This included duplex imaging to identify even tiny atypical vascular structures. RESULTS: In all patients duplex HRUS showed the pulsatile and "punching" character of the relevant vessels and the direct mechanical impact of these vessel. The involved nerve segments appeared enlarged with a hypoechoic change of echotexture including at least partial masking of their inner fascicular texture. CONCLUSION: Although rare, a "punching" vessel can be the cause of a compression neuropathy. Therefore, duplex HRUS must be included in every HRUS examination of patients with otherwise unclear mononeuropathy.

Susceptibility loci for polycystic ovary syndrome on chromosome 2p16.3, 2p21, and 9q33.3 in a cohort of Caucasian women.

In a recent genome-wide association study investigating Han Chinese PCOS women 3 loci that are strongly associated with PCOS were identified on chromosome 2p16.3 (rs13405728), 2p21 (rs13429458), and 9q33.3 (rs2479106). The aim of the study was to investigate the impact of rs13405728, rs13429458, and rs2479106 variants on PCOS susceptibility in a Caucasian cohort of PCOS and control women. Metabolic, endocrine, and anthropometric measurements and oral glucose tolerance tests were performed in 545 PCOS and 317 control women. The rs13405728, rs13429458, and rs2479106 polymorphisms were genotyped. There was no significant difference in genotype frequencies of rs13405728 and rs13429458 variants between PCOS and controls. There was a trend towards an association of the rs2479106 variant with PCOS susceptibility (p=0.053). PCOS women with the rs2479106 GG genotype had significantly higher WHR than PCOS women carrying the AG and AA genotype (p=0.034 and p=0.020, respectively). Moreover, QChol/HDL and LDL levels were significantly higher in PCOS women carrying the rs2479106 GG genotype when compared to those carrying the AA genotype (p=0.024 and p=0.035, respectively). PCOS women carrying the G allele of rs13405728 had significantly higher AUCgluc, glucose-30 min, and AUCins levels than those carrying the AA genotype (p=0.039, p=0.047, and p=0.044, respectively). In PCOS women, rs13405728 genotypes are associated with glucose and insulin metabolism. Moreover, rs2479106 genotypes were associated with increased WHR levels and an adverse serum lipid profile. Further, we observed a trend towards decreased PCOS susceptibility within carriers of the rs2479106 G-allele. Further studies in large Caucasian PCOS cohorts are warranted to confirm our findings.

Increased matrix metalloproteinase activity is associated with migraine and migraine-related metabolic dysfunctions.

OBJECTIVE: Matrix metalloproteinases (MMPs) and their inhibitors (TIMPs) are discussed to be involved in the pathophysiology of migraine. Moreover, MMPs may also be involved in migraine-related metabolic alterations like an atherogenic lipid profile and hyperinsulinemia. The aim of this study was to investigate the impact of MMPs and TIMPs on migraine with and without aura and related metabolic dysfunctions. METHODS: MMP activity, six MMPs and three TIMPs, parameters of the insulin and lipid metabolism as well as anthropometric parameters were determined in 124 non-obese subjects. RESULTS: We found highly significant increased MMP activity in migraine patients independent of aura symptoms, which was associated with migraine with an odds ratio of 7.57. Interestingly, none of the determined MMPs and TIMPs showed significant different serum levels between migraine patients and healthy controls. We found significant correlations between MMP activity and parameters of the insulin and lipid metabolism, like Homeostasis Model Assessment index (HOMA index), cholesterol, triglycerides, and oxidized LDL. CONCLUSION: We show here that increased MMP activity is tightly associated with migraine and migraine-related hyperinsulinemia and atherogenic lipid alterations. Our findings represent a new pathophysiological mechanism, which may be of clinical relevance, especially in regard to therapeutic approaches using MMP inhibitors.

Oxidative stress is associated with migraine and migraine-related metabolic risk in females.

BACKGROUND AND PURPOSE: Oxidative stress is discussed to be implicated in the pathophysiology of migraine. However, data are in part controversial and the possible underlying mechanisms remain elusive to date. The aim of this study was to investigate the oxidative stress status of female patients with migraine and its implications on migraine-related metabolic alterations. METHODS: Oxidative stress markers malondialdehyde (MDA), 4-hydroxy-2-nonenal (HNE), carbonylated proteins, parameters of associated nitric oxide stress, inflammation, lipid- and glucose-metabolism were determined in the interictal phase in female patients with migraine and controls. RESULTS: We found significantly increased HNE levels in female migraineurs compared with controls. Logistic regression analyses of HNE revealed an odds ratio for migraine of 4.55. HNE showed significant correlations with the nitric oxide pathway, the insulin- and the lipid-metabolism. CONCLUSIONS: We show here that increased oxidative stress is associated with migraine and contributes to migraine-related metabolic risk like nitrosative stress, an atherogenic lipid profile and hyperinsulinemia. Our data suggest that oxidative stress may represent a key event in the pathophysiology of migraine and a suitable therapeutic target.

Recognition of Clostridium difficile PCR-ribotypes 001, 027 and 126/078 using an extended MALDI-TOF MS system.

During the last decade, Clostridium difficile infection (CDI) increased markedly inside as well as outside of hospitals. In association with the occurrence of new hypervirulent C. difficile strains, CDI became more important. Until now typing of C. difficile strains has been enabled by PCR-ribotyping. However, this method is restricted to specialized laboratories combined with high maintenance cost. Therefore, we tested MALDI-TOF mass spectrometry for typing of C. difficile to provide a fast method for surveillance of CDI. Using a standard set of 25 different C. difficile PCR ribotypes a database was made by different mass spectra recorded in the SARAMIS software (AnagnosTec, Zossen, Germany). The database was validated with 355 C. difficile strains belonging to 29 different PCR ribotypes collected prospectively from all submitted feces samples in 2009. The most frequent PCR ribotypes were type 001 (70%), 027 (4.8%) and 078/126 (4.7%). All three types were recognized by MALDI-TOF MS. We conclude that an extended MALDI-TOF system was capable to recognize specific markers for ribotypes 001, 027 and 078/126 allowing an effective identification of these strains.

Optimizing ultrasound-guided biopsy of musculoskeletal masses by application of an ultrasound contrast agent.

PURPOSE: We report on a novel approach to the work-up of musculoskeletal lesions with addition of an ultrasound contrast agent followed by focal ultrasound-guided biopsy. MATERIALS AND METHODS: In this pilot study 25 patients (age: 12-75) with unclear musculoskeletal tumors underwent grayscale ultrasound, color Doppler, contrast-enhanced ultrasound and subsequent ultrasound-guided biopsy. Grayscale and color Doppler ultrasound were performed with a 12-5 MHz broadband linear transducer and contrast-enhanced ultrasound with a 9-3 MHz broadband linear transducer (iU22®, Philips, USA) using a second-generation contrast agent (SonoVue®, Bracco, Italy). After the definition of the target area by contrast-enhanced ultrasound, guided biopsies were performed with a spring-loaded tru-cut™ biopsy needle using the coaxial technique. RESULTS: The definition of enhancing and viable tumor regions resulted in a diagnostic yield of the subsequent biopsy of 100%. Seventeen tumors were classified as malignant and eight as benign, which was finally confirmed by histological work-up or the further clinical follow-up. CONCLUSION: This pilot study with a limited series of patients improved the diagnostic yield of ultrasound-guided biopsy to 100%, which is at least rather promising. Our easy-to-use algorithm should reduce the rate of inconclusive histology results mainly caused by sampling errors to an unrivaled minimum.