Search

Bei einem 36-jahrigen Patienten wurde eine allogene Nierentransplantation durchgefuhrt (Match 1‑1‑0, Zytomegalievirus [CMV] Donor [D] +/Empfanger −, hohes Risiko). Elf Jahre zuvor war es zu einer Dialysepflichtigkeit im Rahmen einer bioptisch gesicherten tubulointerstitiellen Nephritis gekommen. Nach Transplantation ereignete sich im Verlauf des initialen stationaren Aufenthalts ein sukzessiver Hamoglobinabfall von 11,4 g/dl auf 7,3 g/dl. Initial war dies erklart durch die stattgehabte Nierentransplantation und einer chronisch fibrosierende Antrumgastritis mit Erosionen. Trotz wiederholter Transfusion von Erythrozytenkonzentraten bestand eine refraktare Anamie, weswegen sich der Patient mehrfach in unserer Klinik zur weiteren Diagnostik und Therapie vorstellte. Bei Darstellung von Riesenproerythroblasten im Knochenmark sowie dem quantitativen Nachweis von Parvovirus B19 (>900 Mio. IU/ml DNA-Replikationen) imponierte das Bild einer virusassoziierten Aplasie der Erythropoese. Eine intravenose Immunglobulinapplikation wurde etabliert und zeigte einen langfristigen therapeutischen Erfolg.

ZusammenfassungEine Verumontanum-Mukosahyperplasie (VMGH) ist eine benigne mikroazinäre proliferative Läsion, die ausschließlich im Verumontanum und in der posterioren Urethra auftritt und die zu den pseudoneoplastischen Imitatoren eines „low risk“ azinären Adenokarzinoms der Prostata zählt. Wir präsentieren den Fall eines 72-jährigen Patienten, bei dem 5 Jahre nach radikaler Prostatektomie wegen Adenokarzinom der Prostata pT2c pN0 cM0 R0, Gleason-Score: 3 + 3 = 6 der bildmorphologische Verdacht eines PSA-negativen Lokalrezidivs 3 × 2 cm im ehemaligen Prostatabett erhoben wurde. Das klinische Bild in Zusammenhang mit der histologischen Diagnostik führten zur Diagnose einer VMGH. Die VMGH ist eine kaum bekannte Differenzialdiagnose zum Lokalrezidiv eines Prostatakarzinoms bei einem PSA im Nullbereich, deren klinisches Bild dargestellt werden soll.

Die hohe Inzidenz parastomaler Hernien (PSH) von bis zu 80 % bei endstandigen Stomatragern und die breite Palette an Beschwerden und Komplikationen mit hohen Raten an Notoperationen aufgrund von Inkarzerationen (ca. 15 %) beweisen die klinische Relevanz der PSH-Pravention bereits bei Stomaanlage bzw. die groszugigere Indikationsstellung zur elektiven Korrektur einer manifesten PSH. Ziel dieser Arbeit ist es, die verfugbare Evidenz zur PSH-Reparation und Pravention zusammenfassend zu bewerten. Eingeschnittene Netzimplantate in unterschiedlichen Schichten der Bauchwand (Sublay, Onlay und Keyhole) weisen in der Korrektur einer manifesten PSH keine guten Ergebnisse auf. Stomalateralisationen mit flachen Netzen (Sandwich und Sugarbaker) oder 3‑D-tunnelformige Implantate zur Abdeckung der Stomarandbereiche liefern bessere Resultate. Die PSH-Pravention mit Netzen lasst sich, basierend auf der verfugbaren Datenlage mit 10 randomisiert kontrollierten Studien, Metaanalysen, einem Cochrane-Review und den Leitlinien der Europaischen Herniengesellschaft (EHS), gesamt gesehen als effektiv bewerten, wobei jedoch auch einzelne Studien ohne Effektivitatsnachweis der PSH-Pravention mit Netz existieren. Die teilweise heterogene Datenlage durfte in der unterschiedlichen operativen Methodenwahl mit verschiedenen Netzimplantaten in verschiedenen Schichten der Bauchwand begrundet sein. Die perioperativen Komplikationen zeigten in allen verfugbaren Arbeiten unabhangig von der Art der Pravention und dem verwendeten Netzmaterial keine Erhohung im Vergleich mit den herkommlichen Stomaanlagen. Trotz der positiven Datenlage spielt die PSH-Pravention in der taglichen Praxis eine untergeordnete Rolle, was mit Unsicherheiten der geeigneten operativen Methodik, dem zeitlichen Mehraufwand am Ende einer anspruchsvollen Operation, der Aversion gegen Fremdmaterialeinbringung in den kontaminierten Situs und der fehlenden Remuneration praventiver operativer Leistungen zu tun hat. Um geeignete Techniken zur PSH-Pravention filtern zu konnen, wird es zielfuhrender sein, in Zukunft differente Methoden der PSH-Pravention komparativ zu untersuchen, als eine bestimmte Form der Pravention mit der herkommlichen Stomaanlage zu vergleichen.

The successful treatment of complex abdominal wall hernias requires individualized and if necessary interdisciplinary treatment concepts. Due to the high potential for abdominal and cardiopulmonary complications, specialized centers with a high level of expertise and experience should undertake the care of patients. Prehabilitation and optimization of hernia-specific risk factors and comorbidities play an essential role in the treatment algorithm. Preoperative conditioning prior to surgery can be crucial for success. Bariatric surgery for weight loss and administration of botulinum toxin A in the lateral abdominal wall for stretching the musculature to provide myofascial advancement and enlargement of the torso diameter are parts of such strategies. The preoperative progressive pneumoperitoneum has its justification in massive evisceration, facilitates repositioning of the viscera and helps the patient to slowly adapt to the postoperatively changed abdominal pressure conditions. From a surgical technical point of view, the following principle should apply: "mesh augmentation comes before defect bridging". This means preference should be given to a morphological functional restoration of the myofascicular abdominal wall compared to procedures that merely bridge abdominal wall defects based on meshing. The retromuscular preperitoneal mesh strengthening in the sense of a sublay technique is the gold standard. This can be extended to anterior or posterior component separation techniques in order to achieve a reduction of tension to the midline and/or to achieve enlargement of the space for mesh placement.

In recent years techniques for ventral hernia repair have undergone a dynamic evolution with the development of minimally invasive and laparoendoscopic techniques. Despite the multitude of methods, five main criteria for setting the target have emerged: 1) functional and morphological reconstruction of the abdominal wall, 2) extraperitoneal mesh augmentation, 3) abandonment of penetrating fixation elements, 4) minimal surgical access trauma of the abdominal wall and 5) minimized intraperitoneal dissection that jeopardizes adherent intestinal structures. The mesh position varies between preperitoneal retromuscular and supraneurotic or preaponeurotic on the anterior rectus sheath. The different approaches can be carried out transhernially or distant from the abdominal wall defect. The latter can be realized by laparoscopic transperitoneal, endoscopic subcutaneous and endoscopic retromuscular/preperitoneal approaches. Some techniques can be extended to anterior or posterior component separation to reduce tension and to enlarge the space for mesh placement. Robot-assisted surgery opens up new perspectives in laparoendoscopic abdominal wall surgery due to additional instrumental degrees of movement. This enables the possibility of preperitoneal ventral hernia operations also behind and lateral to the posterior rectus muscle compartments as was only previously known below the arcuate line from inguinal hernia surgery.

We investigate the effect of key audit matters (KAM) in the auditor’s report as required by the new ISA 701. We consider investment professionals and non-professional investors in our experiments, in which we test the communicative value of a KAM section relating to goodwill impairment. Our main results show that in the condition in which the KAM section suggests that already small changes in the key assumptions could eventually lead to a goodwill impairment (KAM negative condition), investment professionals assess the economic situation of the company to be significantly better as compared to the condition in which the KAM section suggests that only large changes in the key assumptions could eventually lead to a goodwill impairment (KAM positive condition). In the additional analysis with non-professional investors, we find that a KAM section has no communicative value, implying that non-professional investors have difficulties with processing the information conveyed with KAM.

Open anterior release of the external oblique fascia to enable midline closure of large abdominal wall defects is associated with relevant morbidity due to extensive subcutaneous dissection. Using endoscopic techniques, wound complications can be minimized. However, identification of the correct entry point (e.g. for balloon trocar insertion) can be challenging especially in adipose patients. We therefore present a technical modification facilitating the entire procedure. A novel technique for endoscopic anterior component separation using a trocar system allowing blunt and sharp dissection under direct vision is described. This brief communication also contains our initial experience and learning curve with this novel approach. Endoscopic release of the external oblique fascia was successfully performed 29 times in a total of 15 patients. Body mass index accounted for 30.8 kg/m2 (median; range 21.6–42.5). Transverse width of midline defect accounted for 7 cm (median; range 4–12). Subsequent hernia repair was successfully done using sublay mesh reinforcement (n = 13) or a laparoscopic intraperitoneal onlay mesh procedure (n = 2) with midline closure in all cases. One hematoma was seen at site of release managed conservatively. Using a trocar system allowing blunt and sharp dissection under direct vision may be a viable option for the endoscopic anterior component separation.

Hintergrund Knochensarkome sind seltene Erkrankungen mit Haufigkeitsgipfeln im Kindes- und jungen Erwachsenenalter bzw. hoheren Erwachsenenalter.

Die morphologische Diagnose von Knochentumoren stellt oft eine Herausforderung dar. Molekularpathologisch sind bei der Routinediagnostik von Knochentumoren bisher zwei spezifische genetische Veranderungen von Bedeutung: zum einen die Detektion der EWSR1-Translokation bei Ewing-Sarkomen, zum anderen die GNAS1-Mutationsanalyse bei fibroser Dysplasie. Sensitivere und schnellere Techniken ermoglichen jedoch eine bessere Detektion von spezifischen genetischen Veranderungen bei Knochentumoren. So lassen sich bei vielen anderen Knochentumoren spezifische Translokationen und Mutationen feststellen, mit denen sich in Zukunft die Diagnose anhand des morphologischen Bilds durch den molekularpathologischen Nachweis dieser spezifischen genetischen Veranderung unterstutzen lasst. Manche Tumoren, wie z. B. das Osteosarkom, weisen jedoch eine generell hohe genetische Instabilitat mit zahlreichen, nichtspezifischen genetischen Veranderungen auf.

Despite multimodal therapeutic options, esophageal cancer is still among the most deadly malignancies. In the past decade, targeted therapy has shown great potential in other cancers, but data on esophageal carcinoma are still rare. Five potential new molecular targets in esophageal adenocarcinoma (EAC) and esophageal squamous cell carcinoma (ESCC) were investigated for their expression characteristics: vascular endothelial growth factor receptor (VEGFR)-3, human epidermal growth factor receptor-2, stem cell growth factor receptor, tissue inhibitors of metalloproteinase (TIMP)-4 and TIMP-3. One hundred seventy-one EAC and ESCC tissue samples obtained from patients undergoing esophagectomy from 2000 to 2008 were included. Clinical data were evaluated retrospectively. Immunohistochemical staining was performed using tumor tissue with and without neoadjuvant treatment and healthy tissue. For samples without neoadjuvant treatment, expression of all targets was higher in tumor tissue than in healthy tissue except for VEGFR-3 (>98% expression in both tissues). For TIMP-4, TIMP-3 and stem cell growth factor receptor, trends to higher expression in tumor tissue were also found in EAC and ESCC that had received neoadjuvant treatment. Using Matched-pair analysis, we compared target expression in tumor tissue with and without neoadjuvant treatment. Only TIMP-3 had significantly lower expression in neoadjuvant treated tumor tissue (EAC: P = 0.059, ESCC: P = 0.006). TIMP-4, TIMP-3 and VEGFR-3 appear to qualify for targeted therapy in esophageal cancer because of their high expression in neoplastic tissue. TIMP-3 appears to be downregulated in neoadjuvantly treated esophageal cancer, and VEGFR-3 shows high expression in healthy mucosa leading to severe side effects by molecular targeting. Thus, TIMP-4 seems the most promising target.

We investigate the impact of three German audit market characteristics on audit and non-audit fees for the years 2005–2007. We find no relation between audit and non-audit fees, which suggests that audit and non-audit fee determination in Germany does not indicate any particular impairment of auditor independence. Further, we find that fee-cutting for initial audit engagements depends significantly on client size. We find no evidence of network-related fee reporting bias due to the ambiguous phrasing of German fee disclosure requirements, which implies that German fee data are internationally comparable.

Estradiol-17 beta, progesterone, LH and FSH levels in plasma were measured simultaneously by radioimmunoassay and BBT was recorded in order to investigate the effect of a single midcycle oral dose of 0.5 or 2.0 mg dienogest (17 alpha-cyanomethyl-17 beta-hydroxy-estra-4,9-dien-3-one, VEB Jenapharm, Jena/GDR) on pituitary and ovarian function in 18 healthy fertile females. After application of 0.5 mg dienogest in the follicular phase the cycles appeared to be anovulatory. Administration of 2.0 mg two days prior to the expected LH-surge produced a delay of the LH-peak combined with an absence of ovulation as well as the absence of the normal subsequent increase of progesterone. With 0.5 mg the delay of the LH-surge was followed by an ovulation with normal corpus luteum function. The application of 0.5 or 2.0 mg one day before or during the rising LH-peak lowered the LH-surge but ovulation and luteal phase were not altered. Administration of both dosages during the LH-peak could neither prevent ovulation nor disturb corpus luteum function. Postovulatory ingestion of 0.5 or 2.0 mg dienogest during the BBT-rise produced no alteration of the further cycle. These results demonstrate that dienogest in a single-dose-administration in midcycle can alter pituitary and ovarian function depending on the time interval between application and the day of LH-surge.

There are many common features between uterine sarcomas - leiomyosarcoma, endometrial stromal sarcoma, undifferentiated endometrial sarcoma and adenosarcoma -with regards to course, therapy and follow-up, such as post-menopausal bleeding or additional premenopausal bleeding, as well as rapid growth. There is a new staging system according to FIGO and new therapy recommendations according to NCCN. Prior to therapy, imaging staging of the pelvis, abdomen and chest should be carried out due to the frequency with which metastases are found at the time of diagnosis. In the case of disease spread in uterine sarcomas and malignant mixed tumors, good supportive therapy is a possible therapy option instead of chemo- or radiotherapy. The approach - observation, surgery, lymphonodectomy, mono- or polychemotherapy, radiotherapy, hormone therapy - is chosen according to the extent of spread and the resection status. Neoadjuvant therapies are not as yet established.

In contrast to specific shoulder girdle processes tuberculoses of the shoulder joint are observed relatively frequently. From 1955 up to and including 1980, 50 patients with omarthritis tuberculosa were surgically treated at the authors' clinic. Thirty were male, 20 female, 42 were Germans, 8 immigrant workers. Arthrodeses were performed in 28 cases, removal of bone or soft-tissue foci, or a combination of these, in 22. The left joint was affected in 26 cases (52%) and the right in 24 (48%). The youngest patient was 9, the oldest 78 years of age (average age 42.6 years). The time from the onset of complaints to diagnosis was about 1.6 years. Twenty-eight patients (56%) had previously had treatment for tuberculosis and 9 (18%) also had active tuberculosis localized elsewhere. Even though there were clear radiological changes in all cases, abscesses and fistulae or a combination of these in 27 cases (54%), the 1-hour ESR was normal or only slightly elevated (under 20 mm acc. to W.) in 29 patients (58%). The recurrences which occurred immediately after surgery or in the subsequent course of the disease healed without sequelae after secondary interventions. While they prolonged hospitalization they did not influence the result of surgery. Of the 38 (76%) patients who were followed up on average 3 years after the end of inpatient treatment, 30 (79%) had returned to work on average 1.1 year after being discharged from the hospital. Three had meanwhile been retrained for lighter work. In the discussion the etiology and pathogenesis, incidence, side localization, age and sex distribution, complaints, clinical and radiological findings, diagnosis, therapy, prognosis, and differential diagnosis of shoulder joint tuberculosis are reported on with reference to the relevant literature.

Amiodarone-induced bilateral diffuse pulmonary fibrosis developed in a 47-year-old woman with idiopathic hypertrophic subvalvular aortic stenosis who had been treated with amiodarone (Cordarex), 300 mg daily for about 18 months. Although the drug was discontinued and cortisone treatment begun, the pulmonary fibrosis did not regress. When gentamicin (Refobacin) and cefotaxime (Claforan) were administered for suspected fibrosis-induced right-sided bronchopneumonia, gentamicin-induced acute tubular renal damage occurred, requiring dialysis. The patient died soon after of myocardial electro-mechanical dissociation. At necropsy there was, in addition to the idiopathic hypertrophic subvalvular cardiomyopathy, extensive bilateral pulmonary fibrosis, lamellar bodies in foam-cell intraalveolar macrophages, in hepatocytes and in the epithelium of the proximal and distal tubules. Although amiodarone had been discontinued three months previously, high concentrations of the drug were still present, especially in both lungs, fat tissue and the liver.

Patellar foci of any origin are very rare. Form 1955 to the end of 1979, 9 patients underwent patellar surgery in our hospital. 7 of these patients had tuberculosis, whereas in one case the patient had chronic nonspecific osteomyelitis, and in one case we were unable to clarify the underlying cause of the focus, neither from the histological nor from the bacteriological aspect. All tuberculous foci, one of which had penetrated into the knee joint, were situated in the corpus of the patellar. In a 10-year old girl, the entire patellar was infected with tuberculous foci. In the anterior-posterior x-ray film, the processes mainly presented a circular appearance. Their diameter different between 6 and 25 mm. In one of the foci, two sequesters were conspicuous, and one in another patient. 6 of the patients had an active organ tuberculosis at the same time, or reported on a specific disease during anamnesis. The period from the onset of complaints until diagnosis had been established, was on the average 14.4 months with the 7 patients under investigation (average age 29 years, 4 female/3 male). In view of the fact that all the patients reported here were late cases, the results of the combined drug and surgical removal of foci (filling of the surgical cavities with spongiosa) must be classified as good. One knee joint had to be stiffened by operation. There were no reactivations within an average followup period of 3 years.

This paper investigates the potential effect of key audit matters (KAM) in the auditor’s report as required by the new International Standard on Auditing (ISA) 701. Extending prior literature, we do not only consider non-professional investors, but also investment professionals in our experiments, in which we test the communicative value of a KAM section relating to goodwill impairment. Our main results show that in the condition in which the KAM section suggests that already small changes in the key assumptions could eventually lead to a goodwill impairment (referred to as KAM negative), investment professionals assess the economic situation of the company to be significantly better as compared to the condition in which the KAM section suggests that only large changes in the key assumptions could eventually lead to a goodwill impairment (referred to as KAM positive). We interpret our findings in light of a model of trust and conclude that the specific informational content of the KAM section triggers different factors in the model in different ways. However, in the additional analysis with non-professional investors, we find that a KAM section has no communicative value, implying that non-professional investors have difficulties with processing the information conveyed with KAM.

Granular cell tumors are also referred to as granular cell neuromas, Abrikossoffs tumors, or granular cell myoblastomas. These rare and mostly benign neoplasms originate from Schwann cells of peripheral nerves. In 5 -6% of cases, the lesion is located inside the breast where it may mimic the clinical and imaging features of invasive breast cancer. We report on a 52-year-old patient who palpated a firm mass in the sternocostal region of her left breast during breast self-examination. The suspicious area did not reveal any mammographic anomalies. The character of the lesion was not assessable by ultrasonography. Ultrasound-guided core biopsy did not reveal the diagnosis either. Breast MRI was most compatible with breast cancer. Histopathologic analysis after diagnostic excision revealed a granular cell tumor. We discuss pathological and clinical features including diagnostic imaging, management, and prognosis of this rare condition.

Purpose Although benign, radial scar/complex sclerosing adenosis is a lesion which histopathologically resembles tubular carcinoma. On physical examination, it is difficult to distinguish radial scar from a malignant tumour. Mammography cannot differentiate radial scar from malignancy. This clinical study aims to delineate the role of preoperative ultrasonography with emphasis on the question whether ultrasonography could lower the number of false-positive readings and therefore the number of open biopsies required. Materials and methods In this examination, we present the clinical, mammographic, ultrasonographic, and histopathological features of 6 cases of radial scars. Results Although most authors describe radial scars as non-palpable, 2 of 6 lesions were indeed palpable. On mammograms, radial scars have a spiculated appearance, a feature observed in all of our cases. Numerous ultrasonographic characteristics are listed in the literature, but ultrasonography is not reported to have clear-cut advantages. Conclusion Although this study did not elucidate any unique ultrasonographic features to characterise these lesions, the analysis of all ultrasonographic results made us recognise a set of "nearly specific ultrasonographic features" of radial scars. Current B-mode imaging does not appear to lead to the desirable reduction of the rate of unnecessary open biopsies.

Aim: This study aims to evaluate the correlation between ultrasonographic and histologic sizing of benign and malignant breast lesions. Ultrasonography is an important adjunct, because palpatory findings are insufficient to decide about the surgical management, e.g. tissue-sparing resection versus mastectomy. Neither does the physical examination suffice to determine if to proceed with surgery or primary chemotherapy. Method: Over a two-year period, breast ultrasonographic and the corresponding histologic sizing data were prospectively collected. The largest measurement obtained for each lesion was entered into the analysis. Results: Among a total number of 281 lesions, 152 (54.1%) were benign and 129 (45.9%) malignant. Measured by ultrasonography, 74.6% of tumors up to 10 mm are benign. Both ultrasonographic and histologic size data were available in 199 cases. Seven patients had received neoadjuvant chemotherapy, leaving 192 lesions for final analysis. By ultrasonography, lesions measured between 3 and 86 mm (mean 18.1 mm) in size. The average size of benign lesions was 15.3 mm, the average size of malignant lesions 21.4 mm. All lesions larger than 50 mm were malignant. There is a trend toward slight overestimation of the size of malignant and underestimation of the size of benign lesions by ultrasonography. In 33.9% (n = 65) of all 192 cases, ultrasonographic and histologic measurements agreed to within 2 mm. Conclusion: Due to precise lesion sizing, breast ultrasonography possesses a significant potential as a preoperative staging tool.

Maligne Tumoren von Knochen und Weichgewebe machen nicht mehr als 1% der Malignome beim Menschen aus. Aufgrund der morphologischen Ahnlichkeit ist eine Gruppe von klein- und blauzelligen Tumoren abzugrenzen, welche sich in ihrem Vorkommen, Verteilungsmuster und altersmasigem Auftreten unterscheiden und von den zahlenmasig haufiger vorkommenden malignen Lymphomen differenzialdiagnostisch abgrenzen lassen. Die Sicherung der Diagnose dieser seltenen klein- und blauzelligen Tumoren erfolgt nicht nur durch die interdisziplinare Kooperation zwischen Radiologen, behandelnden Klinikern und Pathologen, sondern durch spezielle immunhistochemische und molekularpathologische Untersuchungen. Diese werden in speziellen Zentren und in enger Assoziation zu einer Studienzentrale (z. B. Euro-EWING99-Studie) durchgefuhrt; so kann die in einer spezialisierten Einrichtung entsprechende diagnostische und therapeutische Kompetenz fur die Patienten genutzt werden.

The aim of this study was to verify the efficacy and safety of an herbal medication containing an extract of a mixture of Baptisiae tinctoriae radix, Echinaceae pallidae/purpureae radix and Thujae, occidentalis herba (SB-TOX) in the treatment of upper respiratory tract infections (URIs), and to test whether SB-TOX's clinical efficacy is dose dependent. A total of 91 adults (mean age 42.1 +/- 13.0 years) were randomised to receive 19.2 mg of SB-TOX (n=31), 9.6 mg SB-TOX (n=29) or placebo (n=31) three times daily for 3-12 days. Since a "running nose" is the main symptom of a common cold, the total number of facial tissues used throughout the clinical duration of their cold was the primary efficacy parameter. In the intention-to-treat analysis, this total number of tissues decreased with increasing extract dose. The slope across groups according to the Jonckheere test was significant (p = 0.0259). In the high-dose group, the standardised effect size delta/SD was 0.46 compared with placebo. Time to relevant improvement in cold symptoms (measured as the time until less than 30 tissues per day were used) was 1.1 days (95% CI 0.52; 1.67), 0.76 days (95% CI 0.28; 1.24) and 0.52 days (95% CI 0.22; 0.82) in the placebo, low-dose and high-dose groups, respectively (p(LogRank) = 0.0175). No adverse events were reported. This study demonstrates the efficacy and safety of SB-TOX in the treatment of URIs, and that its efficacy is dose dependent.

This paper shows that due to legal restrictions, audit committee formation in Germany is not only a matter of enhancing monitoring effectiveness, but also a means of increasing Supervisory Board efficiency. This result is linked to some empirical findings derived from a questionnaire developed especially for the survey and sent out to 100 German Supervisory Board/audit committee chairpersons in April 2004. The questionnaire covered the motivation, composition, qualification, organisation, and responsibilities of current German audit committees. The results show that free float, perceived independence of members, and the size of audit committees significantly influence audit committee composition, and that tasks that are mainly auditor-related are treated as supplementary.

We report on a 45-year-old patient who presented with a 7 cm palpable right breast mass which had been classified as a cyst by ultrasonography. Multiple aspiration cytologies revealed no evidence of malignancy. Repeat sonography in our institution showed a lesion at 1 o'clock, 1 cm deep, and 3-8 cm from the nipple. The lesion contained a solitary cystic component measuring 3.9 x 4.1 x 4.4 cm. A 3.1 x 2.6 x 2.5 cm solid, inhomogeneous mass with irregular margins was found at the lateral border of the cyst. This mass raised suspicion of an intracystic carcinoma. Histopathologic analysis of 5 high-speed biopsy tissue cores demonstrated an invasive large-cell ductal carcinoma (G2-3). Final histopathologic assessment subsequent to breast-preserving resection and axillary node dissection confirmed the initial diagnosis: keratinizing intracystic squamous cell carcinoma (G2-3, pT2, pN0 (0/15)). The search for a remote primary squamous cell carcinoma included a chest X-ray, cystoscopy, colposcopy and PAP smear, esophago-gastroscopy, ENT consultation (laryngoscopy), and did not reveal any extramammary cancer. The postoperative management consisted of a total of 6 cycles of chemotherapy (Cisplatinum 75 mg/m (2) BSA and Paclitaxel 175 mg/m (2) BSA every 21 days) and subsequent percutaneous radiotherapy. In accordance with published reports, the diagnostic and therapeutic management was analogous to that of adenocarcinoma of the breast. However, some authors recommend the same chemotherapy as used for squamous cell carcinomas of other organs. It remains difficult to make any statements regarding the adjuvant therapy and prognosis, since this type of tumor is so infrequent, especially as an intracystic lesion.

Objective The investigation of the value of sonographic criteria for the assessment of the character of solid breast lesions. Methods 281 preoperative sonographic studies of breast lesions were analysed and classified according to the following features: characteristics of the contour, echodensity, echo pattern, posterior acoustic properties, mobility, compressibility, axis of the lesion, L/T ratio (longitudinal size divided by transverse size), and architecture of surrounding tissue. We assessed the differential diagnostic value of each feature based on frequency distribution and odds ratio (OR). Results 152 (54.1 %) benign and 129 (45.9 %) malignant breast lesions were evaluated by ultrasound. The following sonographic criteria were the most clear-cut signs for lesions to be malignant: ill-defined borders (OR: 19.8), incompressibility (OR: 9.7), and discontinuity of Cooper's ligaments (OR: 4.8). Benign lesions were characterised by compressibility (OR: 0.12), smooth borders (OR: 0.12), and displacement of Cooper's ligaments (OR: 0.24). Conclusion When distinguishing benign from malignant breast lesions, ultrasound examiners should be primarily guided by the lesion's contour and compressibility and the architecture of the surrounding tissue. Aiming for the widest possible consensus on terminology issues and standardised interpretation of the above criteria would help to advance breast sonography from its current status as a supplementary technique to the status of the modality of choice for the early diagnosis of breast cancer.

Purpose and Methods: Aiming to assess the value of palpation, mammography, and ultrasonography alone, as well as the role of palpation plus mammography and the value of a combination of all three methods, data from 158 female patients with breast lesions diagnosed by physical exam or by imaging studies were entered into this retrospective study. 98 lesions were benign (62%) and 60 were malignant (38%). A 2-by-2 contingency table was used to analyse the data. Unremarkable, benign, and equivocal (probably benign) lesions were included in the benign group; equivocal, but probably malignant, and clearly malignant findings were considered malignant. Out of 60 carcinomas, 51 were palpable and 9 were non-palpable. The preoperative classification was compared with the histological result. Breast ultrasonographers were aware of the physical and mammographic findings. Results: Calculated sensitivities of the various methods were as follows: palpation 71.7%, mammography 53.3%, and ultrasonography 86.7%. By combining palpation with mammography, sensitivity increased to 76.7%. Mammographically, 3 lesions (5%) were diagnosed as malignant, but seemed benign on palpation; two of these lesions were occult on physical examination (4.2%). 14 findings (23.3%) were classified as malignant on palpation, but as benign by mammography; out of these, 5 were mammographically occult (8.3%). When ultrasonographic results were included, sensitivity increased to 91.7%. Two lesions (3.3%) considered malignant on palpation were ultrasonographically benign, one was sonographically occult (1.7%). Ultrasonographically, 11 carcinomas (18.3%) which appeared benign on palpation were classified as malignant, 8 of which were occult on physical examination (13.3 %). One carcinoma (1.7%) seemed ultrasonographically benign (i.e. occult), but was mammographically malignant. With mammography, 21 lesions (35%) were considered benign, but malignant by ultrasonography; 7 of these were mammographically occult. Conclusion: The results of this clinical study suggest that in outpatient mammography, both technical and human quality control issues should be re-evaluated, especially in view of plans for a nation-wide mammographic screening program in Germany. In addition, screening should be supplemented by high-frequency ultrasonography to evaluate if and to what extent sonography increases the sensitivity of screening.

With an incidence of 1-1.6%, lipid-rich breast carcinoma represents a very rare entity among breast cancers. Only 50 cases are reported in the literature, including 1 in a male, 1 in a child and 48 in women. In addition to the clinical, sonographic, and mammographic characteristics of this special type of breast cancer, this case report includes a discussion of the histologic features and therapy options.

Benign tumours in pregnancy are often "lactating adenomas". The differentiation against malignant processes is sometimes difficult. In this case report we demonstrate the diagnostic and therapeutic procedure in an 18-year old woman with multiple nodes in the right and left breast. Pregnancy makes it difficult to examine the breast with the usual methods. Because of suspect clinical and ultrasonic findings we made a core biopsy already during pregnancy. With nodes in the breast during pregnancy, ultrasound is the diagnostic method of choice. Histology by core biopsy must be made. As long as the histology corresponds with the ultrasound findings, controls are sufficient if the findings are benign. Otherwise, diagnostic exstirpation will be necessary even though the patient is pregnant. Ultrasound and biopsy are the only significant examinations in pregnancy and lactation. Mammography is contraindicated because of radiation. Assessment by palpation and NMR is problematic during pregnancy.

Zusammenfassung: Die Wirkung der Einzelwirkstoffe Echinaceae (purpureae et pallidae) radix, Baptisiae tinctoriae radix und Thujae occidentalis herba sowie der Kombination Esberitox®N ist in vitro, in vivo, tierexperimentell und humanpharmakologisch belegt (5). Das Arzneimittel besitzt immunmodulierende und antivirale Eigenschaften, wobei wahrscheinlich das Immunsystem unspezifisch beeinflust wird, insbesondere durch eine Steigerung der Makrophagenaktivitat. Seine Wirksamkeit bei viralen Atemwegsinfekten wurde in jungsten GCP-konformen klinischen Studien erneut nachgewiesen (15, 17). Unter dem Phytotherapeutikum verkurzte sich gegenuber einer Placebobehandlung die Krankheitsdauer, die Responderrate lag signifikant hoher als unter Placebo. Der therapeutische Nutzen zeigt sich um so deutlicher, je fruher das Arzneimittel angewendet wird. Es besitzt eine hohe Arzneimittelsicherheit. Pharmacodynamic Effects and Clinical Efficacy by a Combination of Herbal Active Substances of Cone Flower, Wild Indigo and White Cedar Summary: The effect of the single active ingredients Echinaceae (purpureae et pallidae) radix, Baptisiae tinctoriae radix and Thujae occidentalis herba as well as of the combination Esberitox® N has been verified in vitro, in vivo, in animal experiments and in human pharmacology (5). The pharmaceutical has immunomodulating and antiviral characteristics, whereby the immune system is probably influenced unspecifically, especially by increasing the macrophage activity. The efficacy for viral respiratory tract infections has been proven yet again in recent GCP-compliant, clinical studies (15, 17). Under the influence of the phytotherapeutic the duration of the illness decreased with a responder rate that was significantly higher than under placebo. The therapeutic benefit was even more pronounced, if the pharmaceutical was applied as early as possible. It has a high drug safety.

Breast cancer is the most frequent gynecological tumor. The HER-2/neu oncogene may play a role in the prognosis and management of patients with breast cancer. In a retrospective study on 100 patients, we correlated the expression of this oncogene with the classic clinical and pathological factors. 32 % of patients exhibited overexpression of HER-2/neu. There was no significant correlation with classic parameters. This finding could indicate that HER-2/neu expression is a new independent prognostic factor. Prospective studies correlating HER-2/neu overexpression with prognosis might provide additional data.

We investigated in a large industrial population the antibody response to specific H. pylori antigens (CagA and seven others) in relation to peptic ulcer and nonulcer dyspepsia (NUD). The two groups consisted of 37 and 39 employees, respectively, with endoscopically proven peptic ulcer and NUD. Age- and gender-matched controls were H. pylori seropositive employees without abdominal complaints or history of ulcer disease. IgG antibodies against CagA and other antigens were analyzed by western immunoblot. Relative percentages of CagA-positive individuals were 89 and 76% for ulcer cases and their controls (P = 0.22) and 77% and 74% for NUD cases and their controls. The corresponding percentages of VacA-positive individuals were 87 and 76% for ulcer cases and controls and 64% and 77% for NUD cases and controls, respectively. Analysis of other H. pylori-specific antigens was not particularly helpful in discriminating between symptomatic and asymptomatic seropositive individuals for either disease group. In conclusion, assessment of IgG response against specific H. pylori antigens was not predictive of peptic ulcer or NUD case status in this active employee population and would not appear to be useful in routine clinical practice.

Pseudothrombophlebitis secondary to rupture of a Baker's cyst had been described repeatedly in the literature of rheumatology. If this condition is mistaken for deep venous thrombosis and treated with anticoagulation, serious complication may result, like hematoma of the lower legs or retroperitoneal and gastrointestinal bleeding. The case demonstrated here shows that this condition is not limited to patients with chronic rheumatoid polyarthritis. Qur patient with an endoprosthesis of the knee suffered from marked reaction to metal (= metallosis) in addition to malacia patellae. The resulting severe synovitis was the cause for pseudothrombophlebitis. Therefore, in cases of suspected venous thrombosis in combination with gonarthritis, and arthrogram of the knee joint or a cystogram should be obtained in order to exclude the possibility of pseudothrombophlebitis.

Intravascular lymphoma (IVL) is an uncommon neoplastic disorder characterized by monoclonal intravascular expansion of lymphoid cells. Occlusion of small vessels in various organ systems probably accounts for the broad clinical spectrum of this type of lymphoma, which can closely mimic a variety of diseases, especially vasculitic disorders, and thus lead to delayed clinical diagnosis. This is the first report of a patient who presented with a predominant symptom of symmetric polyarthritis accompanied by fever. While her initial systemic symptoms, such as fever, improved rapidly after initiation of corticosteroid therapy, the response of the polyarthritic joint manifestations was only transient. The patient died of progressive lung involvement and was diagnosed as having IVL by histologic analysis of tissue samples obtained postmortem.

Intravenous leiomyomatosis and leiomyomatosis peritonealis disseminata are extremely rare conditions. Histopathologically they are classed as benign. We report here the case of a 40-year-old woman who presented at our Clinic with hypermenorrhea and dysmenorrhea. As the presenting symptoms were suspicious for myomatous uterus, an abdominal hysterectomy with removal of the adnexa was performed. Histological examination led to the final diagnosis of leiomyomatosis peritonealis disseminata and intravenous leiomyomatosis. The pathology, clinical course, prognosis and therapy are discussed.

The paper gives an overview on safe life and damage tolerance methods applied to railway axles. It describes failure scenarios due to fatigue crack initiation and propagation. Besides common aspects of design, specific features such as corrosion and impact damage from flying ballast are discussed which may reduce the fatigue strength of axles during service. Potential effects of non-metallic inclusions from the steel manufacturing process are addressed in the context of the very high number of loading cycles railway axles are designed for. With respect to damage tolerance general lines of fracture mechanics residual lifetime analyses are introduced. More specific discussion is provided on aspects such as the threshold value of fatigue crack propagation and reliability aspects of non-destructive inspection.

In high risk breast cancer patients who are scheduled to undergo breast reconstruction with a delayed TRAM flap after mastectomy, mini-endoscopic/laparoscopic inferior epigastric vessel occlusion increases and optimizes flap perfusion, and represents a minimal invasive alternative to both the open surgical and the endoscopic approach. We describe and discuss the operative procedure.

We report on a 75-year-old woman with adenoid cystic breast carcinoma (ACC). ACC is very rare: it represents about 0.1% of all breast cancer. On mammography and ultrasonography, ACC appears more like a benign than a malignant lesion. Color and Power-Doppler sonography and MRT should be used to prevent misdiagnosis. ACC is often receptor-negative and not very radiation sensitive. Therefore, simple mastectomy and chemotherapy comprise the treatment of choice.

Purpose According to the S-3 guidelines for the diagnosis and treatment of breast cancer, only palpation and mammography are mandatory follow-up examinations. Ultrasonography is only mentioned as an optional technique. Aiming to elucidate the diagnostic yield for detecting recurrent disease after breast-preserving therapy (BPT) and radiation treatment, we analysed the sensitivity of palpation, mammography, ultrasonography, and combinations of these methods. Materials and methods Over a period of 12 years, 27 suspicious lesions in patients status post BPT and radiation therapy were biopsied (histologic results: 16 benign lesions: 59.3 %, 11 malignant lesions: 40.7 %). Prior to biopsy, the benign or malignant character of each lesion was predicted by palpation, mammography and ultrasonography (BIRADS). Sensitivity, specifity, positive predictive value (ppv), negative predictive value (npv), and efficiency were calculated from a contingency table. Results For lesions status post BPT and radiation treatment, palpation had a sensitivity of 72.7 % and was 25 % specific. For mammography, the respective values were 36.4 % and 87.5 %, and for ultrasonography 90.9 % and 68.8 %. Palpation and mammography combined were 81.8 % sensitive and had a specificity of 6.2 %. The computed sensitivity for the 3 methods applied together was 100 %. Adding ultrasonography to palpation and mammography therefore increases sensitivity by 18.2 %. Conclusion For diagnosing recurrent disease in patients status post BPT and radiation therapy, ultrasonography is superior to palpation and/or mammography and should become an obligatory follow-up tool. The role of mammographic follow-up appears overrated and the role of ultrasonographic assessment underrated. The S-3 guidelines will need to be changed accordingly.