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Undifferentiated carcinoma of the biliary tract is rare and more frequently occurs in the gall bladder than in the extrahepatic bile ducts. We report on an extremely rare case of a spindle and giant cell type undifferentiated carcinoma of the distal bile duct. In the presented tumor, atypical glands and single-cell clusters arising from the bile duct epithelium gradually transitioned into a predominantly sarcomatoid architecture, which constituted more than 98 % of the whole tumor volume. Focally, osteoclast-like giant cells were intermixed with the spindle cells. The tumor showed a high proliferation activity (Ki-67) and was demonstrated to harbor mutations in the genes for cyclin D3Undifferenzierte Karzinome der Gallenwege sind eine Rarität und manifestieren sich häufiger in der Gallenblase als in den extrahepatischen Gallenwegen. Wir berichten hier von einem äußerst seltenen undifferenzierten Karzinom des distalen Gallengangs vom Spindel- und Riesenzelltyp. Der Tumor ging in Form atypischer Drüsen und Einzelzellkomplexe aus dem biliären Epithel hervor und graduell in eine vorwiegend spindelzellige Architektur über, die mehr als 98 % des Tumorvolumens ausmachte. Fokal gelangten osteoklastäre, multinukleäre Riesenzellen zur Darstellung. Die immunhistochemischen Untersuchungen zeigten in den besser differenzierten, drüsigen Tumoranteilen eine kräftige Expression epithelialer Marker, die in den spindelzelligen Arealen bei Hinzutreten einer Positivität für Vimentin nur noch einzelzellig erhalten blieb. Der Tumor wies eine hohe Ki-67-Proliferationsaktivität auf und zeigte Mutationen in den Genen Cyclin D3

Putting into practice legal prescriptions of both children's rights and the personal freedom guaranteed by the German basic constitutional law requires a reflected and sensitive use of freedom-restricting coercive measures. Such measures imply uncertainties and burdens for staff and patients in child and adolescent psychiatry. Using guidelines of psychiatric associations and instructions from three institutions, basic attitudes and quality characteristics of indication, performance, and participation with regard to freedom-restricting coercive measures are described.

Service utilization and total direct cost of care was assessed in 270 patients suffering from depressive disorder. Patients were recruited from primary care physicians or family doctors (n = 43) or psychiatrists (n = 23) in office practice, from three different regions in Germany (county of Düren and city of Aachen, Lörrach-county, city of Munich). A detailed catalogue of unit costs (including inpatient, outpatient and rehabilitative services) was used for calculating total cost of care on an individual basis. Service utilization and costs referred to 2001. Mean cost of total medical care of the study patients was euro 3849 (excluding cost of drugs for physical illness). The cost for treating depressive disorders and additional psychiatric co-morbidity (which is included into the total cost of care) was euro 2073 per patient and year. When cross-checking with ICD-10 criteria for depressive disorders, the original diagnosis by family doctors or psychiatrists could be confirmed in 186 patients of the total sample (n = 270), suggesting that there is a high amount of falsely diagnosed patients in primary and specialized care of depressive patients in Germany. Direct cost of the 186 confirmed patients was higher (total care cost: euro 4715, cost for treatment of depression and psychiatric co-morbidity: euro 2541) than in the total group and should be considered as reference cost, when discussing cost of care in depressive patients in Germany. Results suggest to analyse cost of care in depressive patients further and to discuss a more efficient allocation of health budgets in the field.