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This paper reports on the case of a 19 year old asylum seeker from Eritrea who presented with hemoptysis, a positive tuberculosis screening (Enzyme Linked Immuno Spot Assay - EliSpot) and mushy faeces submitted with a suspected diagnosis of tuberculosis. Laboratory testing revealed thrombopenia, leukopenia and eosinophilia, while the chest X-ray was inconspicuous. Acid-proof rod bacteria were neither evident in bronchoscopy samples nor in expectorated sputum samples. However, sonographic findings showed a profound splenomegaly, and laboratory testing revealed a Schistosoma mansoni infection. This case demonstrates that in asylum seekers with suspected tuberculosis endemic diseases of the home country need to be considered as alternative diagnoses.

We describe the case of a 78-year-old patient who presented for ablation of a wide complex tachycardia with right bundle branch block (RBBB) morphology. A pacemaker spike at the QRS onset indicated supraventricular tachycardia with AV synchronous ventricular pacemaker activation.Correct positioning of the ventricular lead in the right ventricular apex was confirmed by fluoroscopy and echocardiography, excluding malpositioning of the right ventricular lead.In the electrophysiological study we diagnosed atrial tachycardia with 1:1 AV stimulation by the pacemaker. The ECG, however, presented negative concordance in the precordial leads. Only after shifting the precordial leads V1 and V2 from the 4th to the 2nd intercostal space were all 12 ECG leads in accordance with the clinical tachycardia.Thus, it is suspected that malpositioning of the ECG electrodes generated an apparent RBBB morphology of the clinical tachycardia. Malpositioning of ECG electrodes switches the lead characteristics from horizontal (anterior-posterior) to frontal (cranial-caudal) plane properties. In this situation, the precordial leads V1 and V2 with positive vector in V1 and V2 imitate aVL (V2) and aVR (V1) and can produce an apparent RBBB morphology.

Making an incorrect histopathological diagnosis of an endometrial lesion may lead to unwanted loss of fertility and therapy-associated morbidity; therefore, endometrial carcinomas need to be correctly typed and differentiated from hyperplastic precursors, benign lesions and artifacts. Typical diagnostic pitfalls are described in this article. Misdiagnosing endometrial lesions can be avoided by paying thorough attention to gross as well as microscopic features and by taking crucial differential diagnoses into consideration. These are, in particular, well-differentiated endometrioid adenocarcinoma of the endometrium versus atypical endometrial hyperplasia, myoinvasive endometrioid adenocarcinoma versus atypical polypoid adenomyoma and endometrioid carcinoma versus serous carcinoma of the endometrium with a predominantly glandular pattern. It is also important to consider the possibility of a false positive diagnosis of atypical endometrial hyperplasia or carcinoma in cases of biopsy-induced artifacts.

Diagnostic problems of thyroid cytology are frequently discussed, but relevance and causes of discrepant cytological and histological diagnoses are rarely studied in detail.Investigation of causes and relevance of discrepant diagnoses.The analysis includes 297 patients who had thyroid resection after prior fine needle aspiration (FNA) and is based on the cytological and histological reports. In special cases, cytological and histological specimens were re-examined.Malignant tumors were found in 45 patients (15.1 %). In 5 patients the cytological diagnosis was "false negative". Three of these 5 tumors were papillary carcinomas (PTC) of ≤10 mm, one an obviously nonmalignant papillary proliferation of the thyroidal epithelium and one a malignant lymphoma complicating autoimmune thyreoiditis (AIT). In 11 of the 35 patients with a FNA diagnosis "suspicious of malignancy" or "malignant," 1 AIT, 4 goiter nodules, and 6 adenomas were diagnosed histologically. However, since distinct nuclear atypia was found in three of five false positive diagnoses, there still remains doubt in their benignity.Carcinomas of ≤10 mm incidentally detected in the resected thyroid tissue may not be relevant to the patient and do not reduce the high negative predictive value of FNA. The final diagnosis on the resected tissue should include the cytological findings. Discrepant findings should be commented in the report to the clinician.

A 73-year-old non-atopic patient had developed at the age of 29 shortness of breath on exertion, general malaise, enlarged axillary lymph nodes and nodular cutaneous eruptions. Based on the presence of bihilar lymphadenopathy, the diagnosis of sarcoidosis was made at that time without any histological investigations and without taking detailed case history. Administration of systemic steroids resulted in remission. However, 12 years later, there was a relapse with alterations of lung parenchyma, followed by a more chronic course of the disorder. Since this relapse, an obstructive-restrictive ventilation defect requiring treatment has persisted till today. About five years ago and at the insistence of the patient, clarifying diagnostics were performed. The case shows the important role of a detailed case history including occupational history. Its failure not only led to disadvantages to the patient but also to incorrect social insurance handling and missing appropriate preventive measures with regard to co-workers.

Urinalysis including dipstick tests and urinary microscopy represent a non-invasive, technically simple and economic screening tool. Notably, the repetitive detection and analysis of hematuria and proteinuria harbors a high sensitivity for detection of renal and systemic diseases. Due to its semiquantitative nature, urinalysis should only be interpreted after comprehensive consideration of diagnostic and technical limitations, which will be reviewed in this article.Die Urinuntersuchung mittels Streifentest und Mikroskopie stellt eine nicht-invasive, technisch einfach durchführbare und kostengünstige Screening-Untersuchung dar. Insbesondere die repetitive Analyse bezüglich Erythrozyturie und Proteinurie weist eine hohe Sensitivität auf und ermöglicht die Früherfassung von nephrologischen und systemischen Leiden. Aufgrund der semiquantitativen Natur der Untersuchung sind die Resultate aber nur unter Kenntnis der diagnostischen und technischen Limiten zu interpretieren, auf welche in diesem Übersichtsartikel näher eingegangen wird.L'analyse d'urines utilisant la bandelette urinaire et l'examen au microscope est une méthode de dépistage non-invasive, techniquement simple et peu coûteuse. Notamment, une érythrocyturie et une protéinurie persistantes sont des paramètres particulièrement sensibles d'une pathologie rénale ou multisystémique. A cause de sa nature semi-quantitative, l'analyse d'urines doit être interprétée en bonne connaissance de ses limites diagnostiques et techniques, qui seront revues en détail dans cet article.

Hyperkalemia can be a challenge for the general practitioner as it can prove to be benign as well as life-threatening. From a diagnostic point of view, four possibilities have to be differenciated: a pre-analytical cause, potassium release through cell lysis, a potassium shift, a reduced renal excretion of potassium. The first differential diagnosis can often be carried out by a thorough medical history, in particular the medication intake. Also, the first clinical and laboratory investigations can take place at the general practitioner's clinic. If the hyperkalemia proves to be a true hyperkalemia or cannot be explained by poly-medication and known diseases of the patient, not yet identified renal, endocrine or cardiac diseases should be searched for. If a serious condition is identified as the cause of hyperkalemia the patient should be referred to a specialized clinic.Die Hyperkaliämie kann eine Herausforderung in der Hausarztpraxis darstellen, da sie sowohl benigne wie auch lebensbedrohlich sein kann. Differenzialdiagnostisch sind vier Möglichkeiten zu unterscheiden: die präanalytische Ursache, die Kaliumfreisetzung durch Zelllyse, den Kaliumshift oder die reduzierte renale Kaliumausscheidung. Die erste Differenzialdiagnostik erfolgt in vielen Fällen bereits durch eine genaue Anamnese insbesondere der Medikamenteneinnahme. Auch die ersten klinischen und laborchemischen Abklärungsschritte können in der Hausarztpraxis erfolgen. Wenn die Hyperkaliämie nicht als «Laborente» (Pseudohyperkaliämie) enttarnt werden oder durch Polymedikation und Grunderkrankungen hinreichend erklärt werden kann, muss nach bisher noch nicht bekannten nephrologischen, endokrinologischen und kardialen Erkrankungen gefahndet werden. Sollten sich gravierende Grundkrankheiten als Ursache zeigen, ist die Zuweisung zu den entsprechenden Spezialisten angezeigt.Une hyperkaliémie peut représenter un challenge au cabinet médical car elle peut aussi bien s'avérer bénigne que menaçante pour la vie du patient. Sur le plan diagnostique, quatre possibilités sont à différencier: une cause pré-analytique, la libération de potassium par une lyse cellulaire, un déplacement du potassium, une diminution de l'excrétion rénale du potassium. Le premier diagnostic différentiel s'effectue souvent par une anamnèse précise, en particulier une anamnèse médicamenteuse. De même, les premières investigations cliniques et de laboratoire peuvent être faites au cabinet médical. Si l'hyperkaliémie ne s'avère pas être une pseudohyperkaliémie ou si une polymédication et la maladie de base ne suffisent pas à l'expliquer, une cause rénale, endocrinologique ou cardiaque – jusque-là méconnue – doit être recherchée. Si la cause de l'hyperkaliémie est une affection grave, le patient devrait être adressé à une consultation spécialisée.

Mit dem Begriff follikulotrope Mycosis fungoides wird eine seltene Variante des CD4-positiven, kutanen T-Zell-Lymphoms Mycosis fungoides beschrieben, die durch eine besondere Epitheliotropie (Adnexotropie) gekennzeichnet ist. Das bedeutet, dass die Hautadnexe, vor allem die Haarfollikel, durch das Einwandern von Infiltratzellen besonders betroffen sind. Unser Patient litt seit 20 Jahren an juckenden Hautveranderungen, die unter der Diagnose atopische Dermatitis eingeordnet wurden. Die Diagnose konnte durch die Entnahme einer Probebiopsie gesichert werden. Im vorliegenden Fall konnten wir mit alleinigen topischen Masnahmen keine Beschwerdebesserung erreichen, sodass eine Systemtherapie zugig eingeleitet worden ist. Unter der systemischen Therapie mit Peginterferon-α-2b 25 µg/Woche konnte eine deutliche Besserung des Hautbefundes erreicht werden. Aufgrund der polymorphen klinischen Prasentation wird die follikulotrope Mycosis fungoides erst mit Verzogerung und daher oft in einem spateren Stadium als die klassische Mycosis fungoides erkannt. Wir empfehlen daher eine fruhzeitige Biopsieentnahme bei Auftreten von hier beschriebenen therapieresistenten Hautlasionen.

A 87-year-old woman presented with a three-year history of partially erosive, partially bullous skin and mucosal lesions, symblepharon of both eyelids as well as dysphagia. To date, multiple excisions of the skin lesions, which had been described as "skin tumors" by surgeons, had been performed. The synopsis of histology, direct and indirect immunofluorescence established the diagnosis of anti-p200/anti-laminin γ1 pemphigoid and BP180 NC16A/4575- positive mucous membrane pemphigoid with an unusual "epitope-spreading" phenomenon. Due to the late initiation of therapy, the disease-related loss of vision unfortunately was irreversible.

We report the case of a 79 year old woman presenting with progressive confusion and drowsiness. Renal insufficiency with hyperkalemia as well as hypercalcemia and severe hyperphosphatemia were diagnosed. Renal insufficiency improved with treatment. However, hyperphosphatemia persisted without apparent explanation. We discuss possible causes of hyper- and pseudohyperphosphatemia. Specifically, phosphate analysis may be disturbed by the paraproteins in patients with multiple myeloma, resulting in pseudohyperphosphatemia. We review the standard laboratory phosphate measurement and the mechanisms of interference with paraproteins.Wir berichten über eine 79-jährige Patientin mit zunehmender Verwirrung und Somnolenz. Neben einer Hyperkalzämie und Hyperkaliämie wurde eine schwere Hyperphosphatämie festgestellt. Trotz Behandlung und Verbesserung der gleichzeitig bestehenden Niereninsuffizienz blieb eine ungewöhnlich hohe Serumphosphatkonzentration nachweisbar, die klinisch und anamnestisch nicht erklärbar war. Wir diskutieren mögliche Ursachen einer Hyper- bzw. Pseudohyperphosphatämie. Bei Patienten mit multiplem Myelom und einer Hyperphosphatämie kann die laborchemische Phosphatmessung durch die Paraproteinämie gestört werden, was zu einer Pseudohyperphosphatämie führt. Wir diskutieren die Standard-Phosphatbestimmung sowie die möglichen Gründe einer Interferenz durch Paraproteine.

A 67-year-old man presented with a maculopapular exanthem which started over the major joints. Within a few days, it spread to the entire skin surface and was accompanied by blisters as well as changes of the oral mucosa. The histological examination revealed subepidermal blistering. Targeted laboratory examinations detected serum antibodies against the epidermal basement membrane and autoantibodies against type VII collagen. The findings supported the diagnosis of a generalized inflammatory epidermolysis bullosa acquisita with mucosal involvement.

Autoimmune pancreatitis (AIP) was first classified as a defined disease entity in 1995. It accounts for approximately 2 % of cases of chronic pancreatitis (western world prevalence 36-41/100,000 inhabitants) and AIP is diagnosed in 2.4 % of pancreas resection specimens.Presentation of strategies for diagnosis and treatment with focus on differentiation of AIP and pancreatic carcinoma.Selective literature research in PubMed regarding pathogenesis, diagnosis and treatment of AIP.Key characteristics of AIP are recurrent jaundice due to obstructed bile ducts, histological evidence of fibrosis, a lymphoplasmocytic or granulocytic infiltrate and the response to steroid therapy. There are two distinctive forms of AIP: type I or lymphoplasmocytic sclerosing pancreatitis and type II or idiopathic duct centric pancreatitis. The IgG4 positive AIP type I belongs to the group of IgG4-related systemic diseases. Diagnosis of AIP is established according to the international consensus diagnostic criteria (ICDC) or HISORt (mnemonic standing for histology, imaging, serology, other organ involvement and response to therapy) criteria. Differentiation from pancreatic adenocarcinoma can be challenging. The standard treatment consists of corticosteroids and in some cases azathioprine can be added. In refractory disease rituximab is a further option. Treatment is indicated in patients with jaundice, systemic manifestation or persistent pain.Although AIP is increasingly being identified, the differentiation from pancreatic adenocarcinoma still remains difficult and in cases of a suspicion of neoplasia, resection should be favored. It can successfully be treated conservatively with steroids and rituximab.

The patient reported outcome in interventional studies is often measured with questionnaires at baseline and after the intervention. A person whose difference in outcome exceeds a critical threshold (the minimal important difference, MID) is classified as a responder, otherwise as a non-responder. The generally low reliability of differences causes misclassifications. False positives and false negatives usually do not cancel out: an MID above the average difference results in an overestimated proportion of responders, while an MID below the average difference results in an underestimated proportion of responders. Such misclassifications can be substantial. We introduce a new and simple method for estimating the true proportion of responders which is based on the assumptions of classical test theory. The consequences of the method are demonstrated with empirical data. It is recommended to report the estimates of true responders. This applies to settings with one study group as well as to settings with an additional control group.

Unambiguous identification of the recurrent laryngeal nerve with detection of nerve dysfunction giving rise to postoperative vocal cord palsy (VCP) is the principal objective of intraoperative neuromonitoring (IONM) in thyroid surgery. Because intraoperative loss of the electromyographic (EMG) signal (LOS) does not result in VCP in one third of patients, controversy surrounds the issue of whether a change in strategy is needed in planned total thyroidectomy after LOS on the first side of resection.This was a retrospective institutional study of 1,049 consecutive patients (2,086 nerves at risk) with intended bilateral thyroid surgery who were operated on between April 2010 and July 2012 with the use of IONM. The rates of temporary and permanent VCP were analyzed on the basis of the IONM results of the first side of resection and the extent of contralateral resection for completion: resection without LOS (group 1); resection with LOS and contralateral thyroidectomy (group 2); resection with LOS and contralateral subtotal resection (group 3); resection with LOS without any contralateral resection (group 4).LOS on the first side of resection was noted in 27 patients (2.6 %). All VCPs were unilateral. The rates of temporary and permanent VCP were 2.5 and 0.4 %, respectively, overall; specifically: group 1: 0.5 and 0 %; group 2: 64 and 9.1 %; group 3: 100 and 50 %; group 4: 83 and 8.3 %, respectively.Because an abnormal intraoperative electromyogram carries an 80 % risk for early postoperative VCP, the initial plan of bilateral surgery needs to be critically reviewed after LOS has occurred on the first side of resection, taking into account the underlying thyroid disease of the patient and surgeon expertise. Since more than 80 % of affected nerves will fully recover after the operation, staged completion thyroidectomy is recommended.

Aneurysmatic bone cysts are usually diagnosed by the combination of x-ray imaging and magnetic resonance imaging (MRI) with a sensitivity of 77.8% and specificity of 66.7%. We present an unusual case of an aneurysmatic bone cyst which initially mimicked an osteosarcoma on imaging and later developed the characteristic features of an aneurysmatic bone cyst which was confirmed by histology.

A 73-year-old man with a mechanical aortic valve and a history of congestive heart failure was admitted to our hospital with an unspecifically reduced general condition. Physical examination was normal according to age apart from mechanic valve closure tones and a 2/6 sytolic murmur at Erb's point.Inflammation markers were elevated (leukocytosis 22 100/μl, CRP 22 mg/dl ), there was mild anemia (hemoglobin 9.7 mg/dl) and digitoxin blood level was increased to 56 μg/l (therapeutic range 10-30 μg/l). Because NT-proBNP was highly elevated, further diagnostics focused on cardiac causes of BNP elevation despite missing clinical symptoms. Transesophageal echocardiography was inconspicuous and blood cultures were negative. Therefore an infection of unknown origin or an emerging endocarditis were presumed.Pragmatic treatment with antibiotics and diuretics as well as discontinuation of digitoxin led to normalization of leukocytes, CRP and digitoxin levels. But the patient's general condition deteriorated further, NT-proBNP rose to 37731 pg/ml and the patient became disoriented. On thorough questioning the patient's relatives stated that he had fallen 6 weeks previously. Computed tomography then revealed a large chronic subdural hematoma which had caused the NT-proBNP elevation. The patient was operated successful.In patients with elevated BNP and atypical symptoms neurological causes should be considered.

For cosmetic reasons, a 24-year-old man performed subcutaneous autoinjections with a preparation having alpha-MSH-like effects (melanotan II) purchased via the internet. The changes of patient's nevi were documented by sequential videodermoscopy before and during treatment. The observed dermoscopic changes made it difficult to differentiate a nevus from a melanoma.

A lack of correlation of cytological diagnoses with subsequent histological tissue diagnoses in cervical pathology is caused by either sampling or by interpretation errors. The term sampling error refers to both obtaining cytological material by a cervical smear as well as obtaining tissue samples by surgical procedures such as biopsy or conization. The term interpretation error refers to a lack of correlation as a consequence of the subjective variability in the diagnostic evaluation of cytological, histological or colposcopic findings. This so-called interobserver variability is well known and of considerable significance. Cytological-histological correlation is an important and mandatory method of quality assurance in the cytology laboratory. Lack of correlation can be crucial for the patient because of possible over treatment or under treatment. It can also undermine the relationship between cytopathologists and clinicians. It is therefore crucial to recognize the sources of error presented in this review and to make an effort to resolve discordances by communication and second review.

Hereditary corneal disorders can show a unilateral corneal erosion for several days due to different morphological etiologies which may result in the misdiagnosis of bacterial or viral keratitis. In such a situation it is very important to examine the contralateral eye with regard to a possible corneal opacity. The slit lamp examination has to be performed with dilated pupil in direct and indirect illumination. Patient history including familial ocular problems and recurrent alternating ocular pain can be a hint for the correct diagnosis. Masquerade keratitis of hereditary corneal disorders can be distinguished in 3 main groups: (i) recurrent corneal erosion due to systemic hereditary disorders with corneal involvement; (ii) recurrent corneal erosion due to corneal dystrophies with dystrophy-specific corneal opacities; (iii) recurrent corneal erosion in childhood without dystrophy-specific corneal opacities (occurrence of dystrophy-specific corneal opacities in adults). The ocular pain which may last several days with third group of patients often occurs in the second half of night. The children's suffering is enormous and has a negative impact on the whole family. The wearing of therapeutic contact lenses during the night may considerably reduce the ocular pain.

Until now German language tests have been rarely evaluated for their diagnostic accuracy. The goal of the study was to determine whether frequently used German language instruments are valid measures for identifying developmental language disorders in 3-year-old children.The language test SETK 3-5 (including the short version SSV) and the parent questionnaire SBE-3-KT were administered to 88 children with and without language impairment. The procedure of the selection of children enabled an extrapolation to general population. A language sample rating was used as a gold standard.Depending on case definition 6-22% of children were classified as language impaired by SETK 3-5, 9% by SSV and 15% by SBE-3-KT. Sensitivity, specificity and positive predictive values of SETK 3-5 for specified cut-offs were 35-93%, 86-97% and 41-58%, respectively. The corresponding values of SSV were 49%, 96%, 56% and of SBE-3-KT 92%, 93%, 59%.3-year-old children with developmental language disorders can been identified with sufficient accuracy by means of SETK 3-5, an individual language test, as well as by SBE-3-KT, a parent questionnaire. However, the number of false positive classifications is relatively high. The hit rate of SSV, an individual short test, was too low for clinical use.

The objective of the present study was the measurement of the pregnancy associated hormones progesterone (P4) and pregnanediol-glucuronide (PdG) in saliva, milk and urine of alpacas and their potential use in pregnancy diagnosis. Sample of blood, saliva, milk and urine were obtained from 36 female alpacas before mating and throughout the pregnancy. Concentrations of P4 and PdG were determined using an enzyme immunoassay (EIA). Pregnancy was checked by ultrasonography at any sampling time. The milk samples were also tested using a commercial on-farm progesterone kit which was designed for dairy cattle. EIA-Concentrations of P4 in blood, milk and urine and urine PdG concentrations were significantly higher in pregnant than in not pregnant alpacas. There was no difference in concentrations of P4 or PdG in saliva. The accuracy of the progesterone kit was 90% for diagnosis of pregnancy and 69% for non-pregnancy. However, 70% of the false positive results also showed relatively high P4 milk concentrations in the EIA. Values of P4 in blood and PdG in urine are comparable to previous reports in alpacas and therefore can be confirmed as an indicator for pregnancy. Saliva seems unsuitable in pregnancy diagnosis in alpacas, whereas milk seems to be an adequate alternative. The use of milk and urine would simplify the pregnancy diagnosis in alpacas since in contrast to the current methods (e. g. blood progesterone) the owners can take the samples. The avoidance of blood sampling results in a considerable stress reduction for the animals. P4 measurement in milk and PdG measurement in urine are good alternatives in pregnancy diagnosis during the first month of pregnancy, when a trans-abdominal ultrasonographic examination is not yet reliable. However, since high values of P4 and PdG only show the presence of active luteal tissue and therefore are indirect markers of pregnancy the diagnosis should be confirmed using ultrasound later in pregnancy.

The goal of this work was to answer the question of whether or not there are significant differences between cows with abnormal vaginal discharge and cows with the diagnosis of puerperal or chronic endometritis, using blood and urine parameters. In addition, cows with and without vaginal discharge were examined for significant bacteriological differences in uterine mucous samples. The question of false positive and false negatives from the diagnosis of endometritis was also investigated. A total of 35 matched-pairs (+/-vaginal discharge) from 27 stables was examined 21 to 63 days post partum. The examination consisted of a rectal and vaginal exam, urine and blood samples as well as vaginal swab from the corpus uteri using a Folmer-Nielsen-Catheter. Based on the history vaginal discharge occurred more frequently in dystocia and retentio secundinarium. Cows with a history of distocia and retentio secundinarium showed significantly more vaginal discharge. Gammaglutamyltransferase (GGT; p=0.01) and cholesterine (p=0.04) were different in cows with endometritis. The bacteriology results showed a statistically significant difference (p0.01) only for Escherichia coli and Arcanobacterium pyogenes. The Folmer-Nielsen smears/endometritis showed a significant difference between the two groups (p0.01). In a multivariate analysis with final step-back procedure regarding endometritis Gammaglutamyltransferase (GGT) and Betahydroxybutteracid (BHB) were significant different (p=0.02). The hypothesis vaginal discharge alike endometritis showed that 34 % of the clinical suspicious cases were recorded as false negatives. In the non-suspicious cases 20 % were diagnosed as false negative.

For good reasons, newly detected prostate cancer must not necessarily be treated with curative -intent: Prostate-specific antigen screening leads to overdiagnosis in 54 %. Current international guidelines on the treatment of prostate cancer take this development into account by recommending "active surveillance" (AS) as an equitable treatment option for low-risk prostate cancer. Data on the natural history of prostate cancer indicates that only few men with localised prostate cancer profit from active therapy. Currently, there are 6 series on AS with more than 2000 patients documented in the literature, 200 of them having a follow-up of ten years or more. Disease-specific survival is 99-100 %, and there is no hint at that progression was detected too late for effective treatment. The rates of biochemical recurrence and pathohistological findings of deferred treatment compare well with those of immediate intervention. Thus AS is a safe treatment option for a well-defined patient cohort that has only a small chance of benefit but a high risk of harm from curative treatment.

Apart from misdiagnosis, the Lazarus phenomenon, a spontaneous return of circulation after cardiac arrest, is a potential cause for false positive death certification. Because of medicolegal consequences and thus a negative publication bias, the incidence of false positive death certification is unknown. As a false positive death certification results in criminal prosecution and thus media interest, numerous media archives in Germany, Austria and Switzerland were searched for such reports. A total of nine cases of false positive death certification in these three countries were identified since the early 1990s of which eight occurred in an emergency medical service system setting. Apart from a lack of diligence of emergency physicians, a Lazarus phenomenon could be the reason for such incidents. As definite signs of death will not have developed only a few minutes after stopping CPR it might be difficult for an emergency physician to definitely certify a patient's death in an out-of-hospital setting with 100% safety. Thus, prehospital death certification poses a risk of error and subsequent legal prosecution of the emergency physician, as a Lazarus phenomenon may still occur in this phase. Delegation of death certification from emergency physicians to qualified physicians in a follow-up examination might increase both legal safety for emergency physicians in the field and patient safety.

To monitor time trends of obesity in children, data from the school-entry screening programs (SEU) are widely used. By using data from the SEU in North Rhine-Westphalia (NRW), Germany, from 1996 to 2008, it was investigated, if age distribution is changing over time and if changes influence the overall proportion of obese children in NRW. In addition, the time trend of obesity in three age groups of children before school entry is shown. Children who were examined during SEU are becoming younger (1996: 75.3 months; 2008: 71.3 months, on average). The observed stagnation of obesity in NRW in recent years also persists when the influence of different age patterns are taken into account. Younger children are less obese than older ones. A sustained increase in the proportion of younger children during SEU might influence the overall proportion of obese children in the future. Thus, it should be discussed which procedures should be used to increase the quality of the indicator that is used for public health reporting and is generated by data from SEU.

EGFR mutations and EGFR gene copy number are considered as predictive markers for response to EGFR tyrosine kinase inhibitors in non-small cell lung cancer (NSCLC).NSCLC are often diagnosed by cytology alone. The isolation or selection of a pure tumour cell population is critical for mutation analysis by PCR and sequencing in order to avoid an admixture of tumour DNA with normal DNA of adjacent benign cells. The collection of tumour cells is easily possible by laser microdissection (LMD).EGFR FISH analysis on cytological specimens with a high proportion of benign respiratory cells should be performed after automated relocation of carcinoma cells. The only hitherto established EGFR-FISH criteria were developed using histological specimens and cannot be applied to cytological specimens as such. The cell nuclei in cytological specimens are intact, while they are often truncated in histological specimens. Therefore, when applying the Colorado criteria, the rate of FISH positive results is higher in cytological than in histological specimens and in fact represents false positive results in cytology.Cytological specimens are equally well suited for EGFR gene analyses and FISH analysis as histological specimens. At present, the value of EGFR-FISH analysis is limited by the lack of validated criteria for FISH positivity.

Sampling inspections are an approved instrument for assuring and promoting the quality of healthcare. Individual documentations of medical services are requested from physicians and randomly selected for quality rating by experienced peer reviewers. For example, sampling inspections are stipulated by law for certain ambulatory services (e.g., colonoscopies) delivered by SHI-authorised physicians in order to maintain professional performance standards of colonoscopists.On behalf of the regional Association of Statutory Health Insurance Physicians (ASHIP) experienced colonoscopists regularly rate selected visual documentations (videotapes, photographs) of colonoscopies performed by SHI-authorised physicians in the ambulatory care sector. For anatomical reasons, however, a certain proportion of colonoscopies of inadequate quality will generally be tolerated. Whenever this value is exceeded, ASHIP may impose sanctions against the physician. The question is how sampling inspections have to be performed and dimensioned in order to ensure that the tests be sufficiently meaningful in terms of sensitivity and specificity.Relevant sampling test parameters such as the false-positive rate (physicians are wrongly accused of inadequate quality) and the false-negative rate (existing deficiencies are not identified) are calculated. The calculations are performed analytically or, in the case of complex sampling test scenarios, numerically by means of computer simulations.The calculations show that single-stage sampling tests usually do not result in acceptable values for the false-positive and the false-negative rates. For example, a sampling test which requires the documentation of 20 colonoscopies will -- assuming some reasonable tolerance of inadequately performed colonoscopies -- result in a false-positive rate of 6% and a false-negative rate of 47%. The false-positive-rate, which is particularly relevant from a legal point of view, can be reduced by providing a two-stage sampling test. A significant reduction of the false-negative-rate may be achieved by (multiple) repetition of the single-stage sampling test and consideration of cumulative probabilities.In principle, sampling inspections permit statements in terms of probabilities only. In sampling inspections of healthcare quality false-negative rates are usually considered, i.e., the probability that the test is unable to identify existing quality deficiencies. However, false-positive rates also need to be considered in cases where sanctions may be imposed against the physician on the basis of a positive sampling test. Numerical calculations of false-positive and false-negative rates for simple and complex sampling test scenarios should be performed in order to choose the optimum procedure and dimension of a sampling test.

The authors report on two cases of suspected Munchausen by proxy syndrome. In a 3-year-old boy, clinical toxicological analyses produced suspicious clues that an antidepressant had been administered, which could not be verified by forensic toxicological investigations. In a 13-month-old boy, the mother was also suspected of having poisoned the child. Initial clinical toxicological examinations failed to explain the observed symptoms (unclear unconsciousness, narrowed pupils). While in the first case, the incorrect interpretation of findings by a laboratory without forensic experience resulted in suspicions against the mother, the cause for the observed symptoms in the second case could be proved by complex analyses not performed before and the suspicion that the clinical picture had been intentionally brought about could be cleared up (use of an antitussive containing clobutinol). The two reports show that especially in cases with a potential forensic background, adequately qualified forensic laboratories with a broad spectrum of analytical methods should be involved.

Many hypertensive patients still have elevated blood pressure values despite antihypertensive treatment. However, which patients really do not respond to antihypertensive treatment? 41 primary care patients with treated essential arterial hypertension with office blood pressure140/90 mmHg received 24-hour ambulatory blood pressure measurement. The patients were categorized into a group with elevated blood pressure both in office (or = 140/90 mmHg) and daytime ambulatory blood pressure measurement (135/85 mmHg) and into a group with False Non-Response to treatment (office blood pressureor = 140/90 mmHg but normal daytime mean ambulatory blood pressure135/85 mmHg). Patients in the group with False NonResponse were significantly more likely to be female compared to patients with both office and ambulatory hypertension (67% vs. 23%, p = 0.009), whereas diabetes mellitus was a significant predictor of elevated blood pressure both in office and ambulatory measurement (7% vs. 39%, p = 0.033). False-Non-Response is common in primary care patients treated for hypertension. These patients have normal ambulatory BP values despite elevated office BP values. Female gender and absence of diabetes mellitus are significant predictors of False Non-response to antihypertensive treatment.

Prehospital treatment of acute coronary syndrome (ACS) by anaesthetists acting in physician staffed emergency medical service (EMS) was compared with that of the gold standard of cardiologists.Prospectively 599 patients with assumed ACS were traced. Prehospital diagnosis and therapy were compared with re-evaluation of ECGs and diagnosis on hospital discharge.In the case of ST-segment elevating myocardial infarction (STEMI) anaesthetists diagnosed 84% of cases correctly and cardiologists in 94% (p=0.048). False positive diagnoses were given in 11% by anaesthetists versus 5% by cardiologists (p=0.31). Anaesthetists accompanied all patients with instable angina versus 94% by cardiologists (p=0.06). Anaesthetists achieved 82% of patients to be pain-free versus 73% of cardiologists (p=0.01). Mortality until discharge was identical for the two groups (8.2%).In prehospital management of ACS cardiologists showed higher diagnostic competence, whereas anaesthetists revealed a greater degree of therapeutic caution. Patient mortality was not influenced.

Diseases that can clinically simulate an uveitis are summarised under the name Masquerade syndromes. They constitute a heterogenous group of malignant and non-malignant entities that must be excluded in the differential diagnosis. Of the malignant diseases lymphomas are only rarely observed as the cause of a pseudo-uveitis, whereas especially leukaemic diseases and, in childhood, retinoblastomas and the extremely rare intraocular medulloepithelioma must be excluded. Of the non-malignant diseases in childhood, besides Coats' disease, a juvenile xanthogranuloma as well as persisting hyperplastic primary vitreous body should also be considered as the cause of an atypical uveitis. Systemic diseases such as tuberous sclerosis or neurofibromatosis are usually diagnosed in good time by means of the accompanying symptoms. In case of doubt in childhood, an examination under anaesthesia and, if necessary, further imaging diagnostics should be performed in order to avoid with certainty a false diagnosis having possibly serious consequences.