[Spinal anesthesia in high-volume, low-concentration technique for Caesarean sections : Retrospective analysis]. / Spinalanästhesie zur Sectio caesarea in "High-volume-low-concentration"-Technik : Retrospektive Analyse.

BACKGROUND: Nowadays Caesarean sections are mainly undertaken using spinal anesthesia; therefore, it is important to minimize potential side effects and risks associated with this technique. Currently, many studies have been conducted to optimize the dose of local anesthetics to avoid hypotension, which often occurs during spinal anesthesia. AIM: In a retrospective study design the high-volume, low-concentration technique with up to 12 ml isobaric bupivacain 0.1% (1 mg/ml) and sufentanil (1 µg/ml), which has been used at the University Hospital Würzburg for many years was analyzed with respect to reliability and side effects. The use of this technique so far is unique among university hospitals in Germany. MATERIAL AND METHODS: Of the 1424 anesthesia protocols from 2001 to 2007 a total of 1368 were analyzed. Demographic data and parameters, such as location of puncture, dose and extent of anesthesia, hemodynamic stability and additional medication were recorded. A decrease of systolic blood pressure of more than 20% of the initial value was defined as hypotension. RESULTS: The median volume used for spinal anesthesia was 9 ml, containing 9 mg bupivacaine and 9 µg sufentanil. The rate of hypotension was 48.8 %. No significant differences in hypotension between lower and higher volumes were detectable. In 0.84% (n=12) of the cases the procedure had to be changed to general anesthesia and additional analgesia was administered in 3 cases (0.22%). CONCLUSION: The high-volume, low-concentration technique is an effective approach for spinal anesthesia with a small number of cases needing general anesthesia or additional analgesics. The rate of hypotension was moderate compared to other studies; however, because of the retrospective and non-randomized study design the dependence of this rate on dose and given volume should be interpreted with caution.

[Exercise scenario of a highly contagious, life-threatening disease in intercontinental aviation : a case report in the context of the International Health Regulations (IHR)]. / Übungsszenario für eine hochkontagiöse, lebensbedrohliche Erkrankung in der interkontinentalen Personenluftfahrt : Eine Kasuistik vor dem Hintergrund der internationalen Gesundheitsvorschriften (IGV).

BACKGROUND: The International Health Regulations (IHR) 2005 were conformed to German law on July 20, 2007 and described in detail by the Implementing Act (IHR DG). According to these legal bases, "designated airports" must maintain special capacities for protection against health threats, and are also responsible for performing regular IHR exercises. OBJECTIVES: Representation of the optimization of established operational concepts of various professions to manage infectious biological threats without obstruction of international travel, and mediation of experience to IHR professionals. MATERIALS AND METHODS: An exercise based on the case scenario of a travel-related febrile illness was performed at Munich International Airport on November 11, 2013. Preparations took 6 months and the exercise itself lasted nearly 12 h. The follow-up lasted an additional 9 months. A qualitative and quantitative evaluation of the exercise was completed. RESULTS: From an Individual Medicine and Public Health perspective, modular work structures and risk communication functioned adequately. The medical examination of passengers was also well managed. Areas requiring further optimization included arrival/departure times of external actors, transport of the index patient to hospital and protective measures for individual participants. Overall, a defined biological threat scenario representing a double infection with two highly pathogenic germs was handled satisfactorily without affecting international air travel. CONCLUSIONS: Modular supply components are an effective and forward-looking means in protection against threats occurring at airports. Key success factors include sufficient staff mobility, immediate self-protection of actors involved, effective risk communication and a strong overall coordination and monitoring of the situation.

[Umbilical Absent and Reverse End-Diastolic Flow Velocity Waveforms Already Present Prior to Viability do not Exclude Long-Term Foetal Surveillance: A Report of Two Cases]. / Langzeitüberwachung nach dopplersonografischem Nachweis eines umbilikalen Null- und Rückflusses vor extrauteriner Lebensfähigkeit - 2 Kasuistiken.

The finding of absent or reverse end-diastolic flow velocities (AREDV) in the umbilical artery already prior to viability corresponds to the most severe end of the clinical spectrum of placental insufficiency. However, there is little or no experience or published literature with regard to perinatal outcome. We report 2 cases in which structurally and chromosomally normal foetuses showed severe early onset retardation but were continuing to grow. These gestations could be prolonged by 62 and 64 days, respectively. Perinatal outcome was good in both following Caesarean section at 32+3 and 31+5 gestational weeks respectively.

[Prognostic factors of perinatal short-term outcome in severe placental insufficiency using Doppler sonography to assess end-diastolic absent and reverse blood flow in umbilical arteries]. / Prognosefaktoren des perinatalen Kurzzeitergebnisses bei schwerer Plazentainsuffizienz mit dopplersonografisch enddiastolischem Null- und Rückfluss in der Art. umbilicalis.

Significant placental insufficiency, indicated by Doppler ultrasound findings of absent or reverse end-diastolic flow velocities (AREDV), is associated with increased morbidity and mortality. Analysis of blood flow in the ductus venosus should assist in early intrauterine recognition of threatened foetuses. 58 high-risk pregnancies with umbilical AREDV were repeatedly examined (n=364). Doppler findings were correlated with neonatal signs of deterioration (ratio of normoblasts to leukocytes, pH, base excess, Apgar score), as well as short-term morbidity [need for intubation, duration of assisted respiration, evidence of respiratory distress syndrome (RDS), bronchopulmonary dysplasia (BPD), necrotising enterocolitis (NEC), intraventricular haemorrhage (IVH grade III+IV)] against the analysis of the blood flow findings (normal or increased pulsitility, absence or reverse end-diastolic flow) in the umbilical arteries (AU), the middle cerebral arteries (ACM) and ductus venosus (DV) relating these to birth weight and the duration of the pregnancy. The median period of observation was 12.8 days, 48% of the foetuses showed an abnormal ductus venosus flow and 26% an absent venous or reverse end-diastolic flow. The median date of delivery was 30 weeks, with a mean birth weight of 816 g. 93% were live births with 12% dying postnatally. Although the criteria for postnatal morbidity (BPD, NEC, IVH III+IV) and mortality did not correlate with changes in arterial and venous Doppler parameters in our group, there was a significant relationship between the normoblast count, known to be a marker of chronic hypoxia. The Apgar 10 minte score, umbilical arterial pH and base excess were correlated with changes in the DV flow curves. Healthy survival started, irrespective of arterial or venous blood flow criteria, from 27+0 weeks of pregnancy. If born between 27.0 and 30+6 weeks, the infants were more likely to be healthy the less the blood flow had been compromised. A birth weight of 590 g (sensitivity 62.5%; specificity 93.5%) and gestational age of 28+5 weeks (sensitivity 87.5%; specificity 90.3%) were shown to be cut-off points between healthy survival and survival with serious neonatal complications.

[Ductus venosus blood flow prior to intrauterine foetal death in severe placental insufficiency can be unaffected as shown by doppler sonography]. / Die Ductus venosus Dopplerflusskurve vor intrauterinem Fruchttod bei schwerer Plazentainsuffizienz mit dopplersono-grafisch enddiastolischem Null- und Rückfluss in der Art. Umbilicalis.

Significant placental insufficiency with Doppler ultrasound findings of absent or reverse end-diastolic flow velocities (AREDV) is associated with increased morbidity and mortality. An analysis of blood flow in the ductus venosus assists in the early recognition of threatened foetuses. However, the prognostic value of multivessel Doppler assessment for the timing of delivery is being questioned. Four high-risk pregnancies with umbilical AREDV were repeatedly examined prior to intrauterine foetal demise. Our results demonstrate that ductus venosus Doppler flow velocimetry can be normal prior to intrauterine foetal death.

Thrombopoietin modulates the proliferation, migration and cytokine profile of decidual cell subsets during early gestation.

During early gestation, a considerable increase in different leukocyte subsets can be observed in the decidualized endometrium concomitantly to the invasion of cytotrophoblast cells (CTB). To date, it is still in question which factors induce this accumulation of immune cells and whether it is evoked by an in situ proliferation or by a migratory process. Studies on hepatoblastoma cells identified thrombopoietin (TPO) as a novel factor, which elicits dose-dependent chemotactic and chemokinetic effects. However, the impact and function of TPO on decidual cells has not been clarified yet. This study analyses the expression and function of TPO and its receptor c-Mpl in decidua during early gestation. Applying western blot analysis, we detected that TPO is expressed by decidual immune cells (uNK cells and CD14+ monocytes) as well as CTB and decidual stromal cells (DSCs). Expression of the different isoforms of c-Mpl was found in uNK cells, CD14+ monocytes and DSC. Studying the signalling pathway proteins in the uNK cells, an activation of STAT3/Tyr by TPO, was detected. The investigation of the proliferative effects of TPO on the decidual cell subsets revealed that TPO enhances the proliferation of uNK cells and CTB. No change of the proliferative activity after TPO incubation was found in DSC and even a decrease in CD14+ monocytes. In addition, TPO was observed to induce significantly the migratory activity of uNK cells, CD14+ monocytes and CTB. Investigating the effects of TPO on the cytokine profile of the isolated decidual cells, we observed a decrease in the secretion of IL-8, IL-10 and IL-1ß of isolated uNK cells, CD14+ monocytes and CTB, although these changes did not reach statistical significance. Thus, we here identified TPO as a novel factor modulating the proliferation, migration and possibly cytokine secretion of decidual cell subsets.

Studies on the role of osteopontin-1 in endometrial cancer cell lines.

BACKGROUND: Osteopontin-1 is a well characterized protein in many tumour entities. Multiple roles in the processes invasion, metastasis and angiogenesis of tumours are attributed to osteopontin-1. The putative role of osteopontin-1 has not been characterized for endometrial cancer. MATERIAL AND METHODS: We investigated multiple endometrial cancer cell lines for osteopontin-1 mRNA- and protein-expression. Osteopontin-1 dependent effects were analysed in vitro by siRNA inhibition. RESULTS: All endometrial cell lines expressed osteopontin-1. Expression of osteopontin-1 was successfully inhibited by specific siRNA. Cells with reduced osteopontin-1 expression showed decreased migration in the Boyden chamber assay and invasion was reduced in the wound-healing assay. Osteopontin-1 seems to play a role in apoptotic processes of endometrial cancer cells. Inhibition of osteopontin-1 expression was associated with an increased susceptibility for radiation therapy. CONCLUSION: Osteopontin-1 seems to play a role in endometrial cancer. Inhibition of osteopontin-1 expression leads to a higher susceptibility for radiation therapy. Our results suggest that a reduced expression of osteopontin-1 in endometrial cancer could inhibit the development of invasion and metastasis in these cells.

XY gonadal dysgenesis--development of a germ cell tumor: case report.

Gonadal dysgenesis (GD) is a rare congenital malformation that affects about one in 3,000 births. The authors present a case of a 17-year-old woman with primary amenorrhea and poor breast development. They conducted a laparoscopic surgery and bilaterally removed hypoplastic streak gonads. Histopathology of the ovaries revealed bilateral streak gonads with gonadoblastomas and a right-sided dysgerminoma.

MIC-1 (a multifunctional modulator of dendritic cell phenotype and function) is produced by decidual stromal cells and trophoblasts.

BACKGROUND: Macrophage inhibitory cytokine-1 (MIC-1) is a multifunctional cytokine produced in high amounts by placental tissue. Inhibiting trophoblast invasion and suppressing inflammation through inhibition of macrophage activation, MIC-1 is thought to provide pleiotropic functions in the establishment and maintenance of pregnancy. So far, little is known about the decidual cell subsets producing MIC-1 and the effect of this cytokine on dendritic cells (DCs), which are known to play a distinct role in the development of pro-fetal tolerance in pregnancy. METHODS: To identify the decidual cell types expressing and secreting MIC-1, immunohistochemical staining, PCR experiments, western blot analysis and ELISAs were performed. Immature DCs (iDCs) were generated from peripheral blood-derived monocytes and differentiated in the presence of MIC-1 or dexamethasone (Dex) for control. Migratory and proliferative activity of DCs after MIC-1 exposure was investigated by migration and proliferation assay. Cytokine secretion after MIC-1 exposure was tested in isolated uNK cells, isolated CD14+ monocytes, monocyte-derived iDCs and mature DCs. Subsequently, the phenotype of DCs was studied using FACS analysis. To test the T-cell stimulatory capacity of pre-incubated DCs, mixed lymphocyte reaction was applied. Finally, the expression of the tryptophan-catabolizing enzyme indoleamine 2,3-dioxygenase (IDO) after the exposure of MIC-1 to maturing DCs was analysed by western blot. RESULTS: Immunohistochemical staining, PCR and western blot experiments demonstrated that MIC-1 is mainly expressed by trophoblast cells and decidual stromal cells. Analysis of the MIC-1 secretion of decidual cell types by ELISA again characterized trophoblast and stromal cells as main producers. The migratory activity of iDCs was significantly induced by MIC-1. No changes in proliferative activity of DCs were observed after MIC-1 pre-incubation. The secretion of pro- or anti-inflammatory cytokines was not affected significantly by MIC-1. Studying the phenotype of DCs after MIC-1 exposure by FACS analysis, we observed that MIC-1 suppresses the expression of typical maturation molecules such as CD25 and CD83 as well as of CD86 during cytokine-induced DC maturation similar to Dex. In addition, T-cell stimulatory capacity of DCs was significantly reduced after MIC-1 exposure. MIC-1 was also able to increase slightly the expression of IDO (a key immunomodulatory enzyme promoting periphereal tolerance) in maturing DCs. CONCLUSIONS: We have identified MIC-1 as a novel factor (secreted by decidual cells in early pregnancy) that could promote the increase of a tolerogenic subtype of DC in decidua.

[Sonographic abnormalities of the fetal CNS in the second trimester screening--clarifications according to the new maternity directives]. / Sonografische Auffälligkeiten des fetalen ZNS im Zweittrimesterscreening--Abklärung nach neuen Mutterschaftsrichtlinien.

Malformations of the central nervous system are among the most frequent congenital anomalies. At best, a qualified and standardised screening of the foetal brain is possible between the 18th and the 22nd week. The newly decided modification of the maternity directives envisages an extended screening upon request. This extended screening refers to the central nervous system and the representation of the ventricles, the evaluation of the head shape and the cerebellum and the back. The examination of the foetal brain should be carried out in a structured way. Three axial planes, the transventricular, the transthalamic and the transcerebellar planes, suffice to represent and measure all structures which are of importance for the screening. In case of ventricular anomalies, anomalies of the head shape, anomalies of the cerebellum and irregularities of the dorsal skin outlined in the second screening a further diagnostic procedure should be initiated. This diagnostic work-up should include a detailed neurosonography, a diagnostic evaluation of the organs and eventually further examination in the form of a caryotyping, determination of the infectology or a foetal MRI. The present article offers an overview of possible CNS abnormalities which could be recognised during the second screening according to the extended maternity directives and describes which differential diagnostics should be considered. In detail, anomalies of the head size (microcephaly, macrocephaly), of the head size (brachycephaly, dolichocephaly, cavities of the cranium, banana sign, etc.,), ventricular abnormalities, anomalies of the cerebellum (cerebellum hypoplasia, abnormal cerebellum shape) and abnormalities of the intermediate line and the intracerebral space requirements are discussed.

[Severe maternal hepatopathies in the peripartum period--a case series with review of the literature focusing on pathogenesis and differential diagnosis]. / Lebensbedrohliche, maternale Leberaffektionen in der späten Schwangerschaft und im Wochenbett--eine Fallserie mit Überblick über Pathogenese und differenzialdiagnostische Abgrenzung.

BACKGROUND: A severe hepatopathy constitutes a serious threat during pregnancy and poses considerable challenges to the treating physicians. A broad spectrum of pregnancy-dependent or independent diseases like HELLP-syndrome, liver infection or acute fatty liver of pregnancy (AFLP) is characterized by these affections of the liver. In this study, we present a series of 3 cases with life-threatening hepatopathies and discuss the current state of the literature. A special focus is placed on pathogenesis and differential diagnosis. METHODOLOGY: Pathological, radiological and gynaecological/surgical procedures were performed according to the current German guidelines. Laboratory tests were conducted in the clinics' routine diagnostics section. The existing literature was reviewed via the US National Library of Medicine database "PubMed.gov". RESULTS: The first patient had been afflicted by a fulminant HELLP syndrome causing delivery after 32 weeks of pregnancy. Consecutively, she suffered a sub-total liver infarction followed by a severe coagulopathy and septic peritonitis. The second patient was diagnosed with HELLP syndrome at 36 weeks of pregnancy. The initially mild syndrome exacerbated after delivery leading to haemorrhagic shock and acute renal failure. In the third case, a woman with asymptomatic hepatitis B delivered in the 36th week of pregnancy. Post partum, her pre-existing condition worsened fulminantly resulting in sub-acute liver dystrophy and massive coagulopathy. DISCUSSION AND CONCLUSION: Whenever a hepatopathy occurs during pregnancy, several divergent diagnoses with severe implications and different aetiopathologies have to be considered. Diagnostic and therapeutic strategies have to be weighed quickly to enable a fast, interdisciplinary cooperation in order to prevent fatal outcomes.

[Acute foeto-foetal transfusion syndrome--case report and review of the literature]. / Akutes fetofetales Transfusionssyndrom--Fallbericht und Literaturübersicht.

The perinatal morbidity and mortality risk in monochorionic twin pregnancies are 3-5-fold increased compared to those of dichorionic twin pregnancies. Partially, this is due to the higher rate of preterm delivery but also to the twin-to-twin transfusion syndrome (TTTS). Caused by unidirectional blood flow via placental anastomoses, the TTTS leads to weight differences of more than 20% between monochorial twins. The blood donor often shows oligohydramnios, whereas the recipient shows polyhydramnios. Lewi et al. demonstrated, in a study with 202 monochorionic twin pregnancies, a 9% rate of severe TTTS. The mortality of this complication is about 90% when untreated. In contrast to the chronic TTTS, little is known about the acute intrapartal one, which is characterised by anaemia and hypovolaemia of the donor and polyglobulia of the recipient without significant weight differences between the two. In most cases, anaemia occurred after normal delivery of the first twin. Still, there are no means or signs for early detection. We describe the case of a 30-year-old primigravida with a monochorionic diamniotic twin pregnancy. During pregnancy, no evidence of TTTS could be detected. At 37 + 1 weeks gestation labour was induced with prostaglandin-containing gel. Both foetuses showed cephalic presentation. The CTG of the first twin showed a conspicuous heart rate. After labour the first twin presented with anaemia and hypovolaemic shock, the APGAR was 2/7/8. The infant's haemoglobin was 13.7 g/dL. After delivery, the second twin with APGAR 10/10/10 showed a haemoglobin of 19.6 g/dL, which is in the upper normal range. Their birth weights differed by merely 10.4%. Acute TTTS is frequently characterised by anaemia and hypovolaemia of the second twin. In our case of a monochorionic twin delivery with acute TTTS the donor was born first. Early diagnosis and neonatal intervention is essential for reducing postnatal morbidity and mortality.

The post-reproductive Fallopian tube: better removed?

Recently, the distal Fallopian tube has attracted considerable attention not only as site of origin for serous cancer in women with BRCA mutations, but also as the anatomical location where the majority of serous ovarian cancers apparently develop. Consequently, the Fallopian tube may be the unique location where early 'ovarian' cancers can be found--which would contradict the long-standing impression that the ovaries and the Fallopian tubes are always simultaneously involved. Based on the dismal prognosis associated with ovarian cancer and our inability to screen for early-stage disease, we discuss the rationale for introducing salpinges-hysterectomy as new clinical standard for women in need of hysterectomy and further weigh the arguments for and against bilateral salpingectomy as a sterilization method. There is no known physiological benefit of retaining the post-reproductive Fallopian tube during hysterectomy or sterilization, especially as this does not affect ovarian hormone production. On the other hand, the consequences associated with a surgical menopause provide a rationale for preserving the ovaries in premenopausal women. Prophylactic removal of the Fallopian tubes during hysterectomy or sterilization would rule out any subsequent tubal pathology, such as hydrosalpinx, which is observed in up to 30% of women after hysterectomy. Moreover, this intervention is likely to offer considerable protection against later tumour development, even if the ovaries are retained. Thus, we recommend that any hysterectomy should be combined with salpingectomy. In addition, women over 35 years of age could also be offered bilateral salpingectomy as means of sterilization.

Pleomorphic adenoma of the breast initially misdiagnosed as metaplastic carcinoma in preoperative stereotactic biopsy: a case report and review of the literature.

Pleomorphic adenoma (PA) is a benign mixed tumor found commonly in the salivary glands but rarely in the breast. PA might be misinterpreted clinically and pathologically as a malignant tumor. The differential diagnoses include fibroadenoma, phyllodes tumor and metaplastic carcinoma. Metaplastic carcinoma is the most important entitiy with respect to differential diagnoses, as surgical overtreatment, i.e., mastectomy may be the result. We describe one of the first cases of PA initially misdiagnosed as metaplastic carcinoma (osteoid-chondroid type) in a preoperative stereotactic biopsy and review the literature regarding this entity.

[Obstetric management of fetal growth retardation]. / Geburtshilfliches Management bei fetaler Retardierung.

Intrauterine growth restriction (IGUR) can have different etiologies, but placental insufficiency is the clinically most relevant. Fetuses with IUGR have a significantly higher morbidity and mortality than normally grown fetuses of the same gestational age. It is important to distinguish a growth restricted fetus from a normal, small fetus and from a fetus being small because of a disease, e.g., an aneuploidy. This differentiation requires the knowledge of the gestational age and the use of multiple imaging modalities. Serial assessments of fetal growth by ultrasound are necessary to recognize declining growth. Doppler sonography can detect changes in the uteroplacentar and the fetal perfusion. Blood vessels of clinical relevance are the uterine arteries, the umbilical artery, the middle cerebral artery and the ductus venosus. When no fetal anomalies can be detected, fetal growth is parallel to the percentiles and Doppler sonography measurements are normal, IUGR is unlikely. In most IUGR fetuses, a typical sequence of circulatory changes and ultrasound findings can be observed. As there is no evidence-based treatment option for IUGR until now, obstetric management consists in defining the optimal time of delivery. This means weighing the risks of prematurity against the risks of a potentially hostile intrauterine environment.

[Early diagnosis of gestational diabetes by amniotic fluid insulin levels?]. / Frühdiagnose eines Gestationsdiabetes durch die Fruchtwasserinsulinkonzentration?

BACKGROUND: Gestational diabetes mellitus (GDM) occurs in 3-5% of all pregnant women. As there is no general screening in Germany, many cases remain undetected. Maternal as well as foetal morbidity are increased in GDM. The aim of this study was to investigate whether amniotic fluid insulin or C-peptide levels, collected by genetic amniocentesis in early pregnancy, are predictive for gestational diabetes. Patients at risk for developing GDM might be identified and treated very early. PATIENTS AND METHODS: 260 patients having a genetic amniocentesis were included in this prospective trial. Insulin and C-peptide levels were identified in frozen amniotic fluid samples. All patients should undergo an oral glucose tolerance (oGTT) test at 24-28 weeks of gestation. Only cases with normal genetic screening, normal foetal sonomorphology and birth at term were included in this trial. 90 of 260 patients having an amniocentesis underwent the oGTT and fulfilled all inclusion criteria. RESULTS: GDM was diagnosed in 8 patients, in another 6 patients only one glucose level was out of the normal range. Neither amniotic fluid insulin nor C-peptide levels showed significant differences between normal and GDM pregnancies. The insulin and C-peptide levels did not correlate with blood glucose levels or with foetal weight. CONCLUSIONS: In contrast to literature reports, according to these data no relationship between amniotic fluid insulin or C-peptide levels and gestational diabetes can be assumed. Amniotic fluid insulin or C-peptide levels are not predictive for GDM.

[Late interruption of pregnancy due to foetal disease: is an inductive method for the generation of ethical principles applicable?]. / Spätabbruch von Schwangerschaften bei fetalen Erkrankungen: Führt ein induktives Verfahren der Normgewinnung zu ethischer Klarheit?

BACKGROUND: The current study investigates if an inductive method for the generation of ethical principles can be applied to the crucial moral question if late interruption of pregnancy due to fetal disease is ethically adequate. METHODS: This method originates from the US American philosopher John Rawls and puts a group of so-called competent moral investigators in the beginning of the decision process. These competent moral investigators should be objective, tolerant and sensitive. Thus, real cases which lead to an intuitive, unanimous and clear decision of the competent moral investigators are analysed for the underlying ethical principles. The ethical principles thus detected are then applied to more complicated cases which could not be assessed clearly. RESULTS: In the current study, the case of foetal trisomy 18 and foetal palate cleft could be clearly judged with a yes and a no, respectively, with regard to an approval of late interruption of pregnancy. The underlying ethical principle leading to these decisions is the utilitaristic principle of minimising harm for mother and fetus. DISCUSSION: We then tried to apply this principle to a case of foetal trisomy 21, however, no clear decision for an approval or a disapproval of the interruption of pregnancy could be found as it was not possible to assess foetal interests.

[Myocardial infarction in the 34th week of gestation: case report]. / Myokardinfarkt in der 34. Schwangerschaftswoche.

Acute myocardial infarction during pregnancy is a rare event that is often associated with a very high maternal mortality, estimated to be from 19 to 37%. During the last decades the incidence of myocardial infarction during pregnancy has increased . The main contributing factor could be a higher prevalence of the metabolic syndrome. The strongest predictors correlated with a myocardial infarction are hypertension, diabetes mellitus and advanced maternal age. In addition, improved diagnostic tools could explain the elevated incidence of myocardial infarction during pregnancy. In general gestation is not considered a risk factor for myocardial infarction but gravidity is accompanied by an increase in oestrogen and progesterone levels. It is generally accepted that oral contraceptives increase the risk of coronary heart disease. We present a case where a 37-year-old gravida was admitted to hospital with diffuse thoracic pain. In the patient's history, we found several putative reasons for the thoracic pain that pointed to a musculoskeletal cause. Based on an elevation of ischaemic heart markers and continuous non-specific thoracic pain we performed a primary Cesarean section. In the coronary angiography procedure that followed, a thrombotic occlusion of the ramus diagonalis was diagnosed. We here describe the differential diagnosis as well as the problems associated with diagnosing myocardial infarction in the third trimester of pregnancy.

Whole blood-derived miRNA profiles as potential new tools for ovarian cancer screening.

BACKGROUND: Screening is an unsolved problem for ovarian cancer (OvCA). As late detection is equivalent to poor prognosis, we analysed whether OvCA patients show diagnostically meaningful microRNA (miRNA) patterns in blood cells. METHODS: Blood-borne whole miRNome profiles from 24 patients with OvCA and 15 age- and sex-matched healthy controls were biostatistically evaluated. RESULTS: Student's t-test revealed 147 significantly deregulated miRNAs before and 4 after Benjamini-Hochberg adjustment. Although these included miRNAs already linked to OvCA (e.g., miR-16, miR-155), others had never before been connected to specific diseases. A bioinformatically calculated miRNA profile allowed for discrimination between blood samples of OvCA patients and healthy controls with an accuracy of >76%. When only cancers of the serous subtype were considered and compared with an extended control group (n=39), accuracy, specificity and sensitivity all increased to >85%. CONCLUSION: Our proof-of-principle study strengthens the hypothesis that neoplastic diseases generate characteristic miRNA fingerprints in blood cells. Still, the obtained OvCA-associated miRNA pattern is not yet sensitive and specific enough to permit the monitoring of disease progression or even preventive screening. Microarray-based miRNA profiling from peripheral blood could thus be combined with other markers to improve the notoriously difficult but important screening for OvCA.

The moral status of the embryo: an attempt at an analysis with the aid of David Hume's ethics.

This article applies the moral sentimentalism founded by David Hume to the moral status of the embryo. It will attempt to explain the paradoxical fact that in Germany abortion is common and socially accepted while preimplantation genetic diagnosis is banned with the aid of an approach based on moral sentimentalism. David Hume established the thesis that the human being is guided by the emotions and not by reason when making moral decisions. Scientific innovations often create a feeling of anxiety. Consequently, the initial moral judgment about it is negative. Due to this habit, the innovation is often accepted after a phase of indifference. This phenomenon has been observed in the case of heart transplantation, as well as for IVF. Consequently, the apparent contradiction in the varying degrees of the embryo's worthiness of protection in the womb and in the Petri dish is due to the simple fact that these are different stages of habituation. Therefore, the ethics of Hume cannot stipulate the embryo's moral status for once and for all; however, they can paradoxically raise the ongoing current debate to a more rational level through the insight that the underlying moral concepts are not based on reason alone.