[S3 guidelines on treatment of polymyalgia rheumatica : Evidence-based guidelines of the German Society of Rheumatology (DGRh), the Austrian Society of Rheumatology and Rehabilitation (ÖGR) and the Swiss Society of Rheumatology (SGT) and participating medical scientific specialist societies and other organizations]. / S3-Leitlinie zur Behandlung der Polymyalgia rheumatica : Evidenzbasierte Leitlinie der Deutschen Gesellschaft für Rheumatologie (DGRh), der Österreichischen Gesellschaft für Rheumatologie und Rehabilitation (ÖGR) und der Schweizerischen Gesellschaft für Rheumatologie (SGR) und der beteiligten medizinisch-wissenschaftlichen Fachgesellschaften und weiterer Organisationen.

Polymyalgia rheumatica (PMR) occurs almost exclusively in persons aged 50 years or older and it is the second most common inflammatory rheumatic disease in older people after rheumatoid arthritis. Since there are no specific tests for PMR, the exclusion of clinically similar differential diagnoses is essential to ascertain the diagnosis. These recommendations for the management of PMR assume an already established diagnosis of PMR. It is recommended to initiate treatment with glucocorticoids immediately after diagnosis and to provide appropriate patient information and education about the impact of the disease and its treatment. Methotrexate should be considered in patients at high risk for relapse and/or glucocorticoid-related adverse events. These guidelines have been elaborated because there is significant heterogeneity in the management of PMR in clinical practice in Germany (but also Europe and worldwide), despite the large number of patients with this disease. These guidelines are primarily based on the 2015 EULAR-ACR recommendations for the management of PMR, which were updated by the guideline committee and adapted to the German speaking countries.

[The regional network ADAPTHERA : Rheumatology care through coordinated cooperation: comprehensive, trans-sectoral, covering all health insurance. Initial results]. / Das landesweite Netzwerk ADAPTHERA : Erste Ergebnisse einer flächendeckenden, krankenkassenübergreifenden und transsektoralen rheumatologischen Versorgung.

The aim of the rheumatology network ADAPTHERA ("risk-adapted rheumatology therapy") is to achieve a comprehensive improvement in rheumatology care by coordinating treatment in a regional, trans-sectoral network. Accompanying biomedical research projects, training concepts, and the construction of a rheumatology register (gathering data and biomaterials) should furthermore ensure the stable and sustainable optimisation of care. In the pilot phase (2012-2015) the focus of the ADAPTHERA network, required as a "regional key project" within the framework of the Initiative on Health Economy of Rheinland-Palatinate (RL-P), Germany, was placed on the optimisation of the early diagnosis of rheumatoid arthritis, where it is well-known that there is a significant care deficit.Through the intensive, stable, and coordinated cooperation of all health care partners in the field of rheumatology (registered general practitioners and orthopaedic specialists, registered core rheumatologists as well as the Association of Rheumatology of RL-P) a unique regional, comprehensive offer with verifiable care optimisation has been established in RL-P. The network is supported by outstanding collaboration with the Association of Statutory Health Insurance Physicians and the self-help organisation Rheumatology League.The aims that were established at the start of the project will be achieved by the end of the pilot phase:- significant improvement in the early diagnosis of rheumatoid arthritis (an average of 23.7 days until diagnosis by rheumatologists)- access covering all health insurance (regardless of the particular scheme the patients belong to)- comprehensive (verifiable participation of general practitioners from all over RL-P)- data and biomaterials collection, established as a basis for biomarker research, and a rheumatology register for RL-P.

Practice of HER-2 immunohistochemistry in breast carcinoma in Austria.

Practice and accuracy of immunohistochemistry is known to vary highly. Reliability of HER-2 immunohistochemistry is critical because of its role in patient selection for therapeutical options in breast cancer. Therefore reliability of HER-2 immunohistochemistry in pathology laboratories in Austria was assessed. Ten tissue specimens of invasive ductal breast carcinomas and three cell line samples were tested. Presence/absence of gene amplification was determined by FISH to be used as a gold standard. Laboratories were asked to stain and assess slides using their routine immunohistochemical staining protocol. Overall the study consisted of 311 tests on tissue specimens and 142 on cell lines. In all cases manual scoring was performed. Participation was voluntary and was 94%. Overall sensitivity was 90.5% and specificity 99.2%. Overscoring including true false positive results were found in 6.7% and 6.3% in tissue specimens and cell lines, respectively. False negative determinations were obtained in 1.9% and 2.8% of tissue specimens and cell lines, respectively. HercepTest showed slightly higher reliability in comparison with individualized staining methods. By manual scoring inaccurate scoring affected 12.3% of test results and 62% of the laboratories. In conclusion participation rate and accuracy of HER-immunohistochemistry was high all over the country. Manually performed scoring demonstrated some limitations.

[Operative differential therapy of rheumatic wrists]. / Operative Differenzialtherapie des rheumatischen Handgelenks.

The wrists are affected in the long-term in 90% of people with rheumatism and are often (42%) the first manifestation of a destructive disease. The functionality of the wrist and the whole hand is of great importance because in many cases loss of function of the wrists leads to severe limitations. Local and operative treatment of the wrist in rheumatoid arthritis (RA) is one of the main duties in rheuma-orthopaedics. For operative treatment there is a finely tuned differential therapeutic spectrum available. The diagnostic indications take the local and total pattern of affection, the current systemic therapy as well as patient wishes and patient compliance into consideration. In the early stages according to LDE (Larsen, Dale, Eek), soft tissues operations such as articulo-tenosynovectomy (ATS) are most commonly carried out. In further advanced stages osseus stabilisation must often be performed. At this point a smooth transition from partial arthrodesis to complete fixation is possible. After initial euphoria, arthroplasty of the wrist is being increasingly less used for operative treatment due to the unconvincing long-term results and high complication rate. With reference to the good long-term results of all operative procedures, in particular early ATS with respect to pain, function and protection of tendons, after failure of medicinal treatment and persistence of inflammatory activity in the wrist, patients should be transferred to an experienced rheuma-orthopaedic surgeon.

[Reevaluation of cytological smears in patients with cervical cancer. Regional quality assurance program with the cooperation of the Austrian Society for Cytology, the Carinthian Medical Association and the Carinthian Ministry of Health]. / Reevaluation von Zervixabstrichen bei Zervixkarzinompatientinnen. Regionales Qualitätssicherungsprogramm unter Mitwirkung der Osterreichischen Gesellschaft für Zytologie, der Kärntner Arztekammer und der Landessanitätsdirektion Kärntens.

BACKGROUND AND METHODS: To evaluate the reasons for the occurrence of invasive cervical cancer in Carinthia despite cytological screening, all 132 patients diagnosed with cervical cancer in the years 2000-2002 were recorded and all gynecological cytological smears made within the 5 years prior to the diagnosis of cancer were reevaluated. RESULTS: Within the 5 years prior to diagnosis, no gynaecological cytological smear was found for 50% of the patients diagnosed with cervical cancer in the years 2000-2002. In the year 2002, a total of 53 patients were reported to have cervical cancer and 78 smears were reevaluated. Of all the smears primarily diagnosed as negative, 49% were found to be positive (> or =Pap III) after reevaluation and 92% of all smears "correctly" diagnosed as negative showed quality deficiencies. The interobserver variability (kappa-statistics) showed a moderate value when the primary screening results were compared with the reevaluation. The interobserver variability within the group of reevaluators was also moderate.

[Sonography of the rheumatoid hand]. / Sonographie der rheumatischen Hand.

In the long-term course of rheumatoid arthritis, the hand is afflicted in more than 90% of the cases, but even at first manifestation of the disease the hand is affected at a frequency of almost 40%. It is necessary to reach the diagnosis as quickly as possible to initiate timely therapy. Since early manifestations appear predominantly in damaged soft tissue, plain film radiology usually provides no definitive results. In contrast, sonography not only facilitates detection of soft tissue damage, but also makes it possible to follow the spontaneous course and treatment outcome. The advantages of sonography include feasibility of dynamic examination, lack of side effects, reproducibility, low costs, and almost ubiquitous availability. The disadvantages are the considerable dependence on the examiner and as yet the limited differentiation between effusion and synovitis as well as visualization of the infiltration into the tendon to assess an impending or extant rupture. Based on experience with sonography gathered to date for diagnostic evaluation of inflammatory rheumatic diseases particularly of the hand, it can be stated that especially in the early phases it already provides evidence for inflammatory substrate. Using suitably high-resolution probes (> or =7.5 MHz), it is frequently possible to detect superficial usures and erosions before plain film X-rays which corresponds to the direct arthritic signs in the roentgenogram.

Cytopathology in Austria.

Cervical cancer screening developed rapidly during the 1970s. Today, approximately 1.5 million smears are taken annually, so 50% of the target population are screened every year, 30% are cytologically underserved (24% never had a smears, 6% only once). This figure correlates with the fact that there are still 30% deaths from cervical cancer compared with 1960. Since 1998 a voluntary quality assurance programme was introduced by the Austrian Society of Cytology, based on comparison of results reported from participating laboratories.

Results of preoperative ultrasound guided fine needle aspiration biopsy of solitary thyroid nodules as compared with the histology. A retrospective analysis of 538 patients.

AIM: The goal of this study was to assess the accuracy and limitations of ultrasound guided fine-needle aspiration biopsy (ug-FNAB) of solitary thyroid nodules. METHODS: The ug-FNAB results of 538 patients with solitary thyroid nodules, who afterwards underwent thyroid surgery, were compared retrospectively with the histology. Patients with multinodular goiter were excluded from the study. Ug-FNAB was performed on growing and/or hypoechoic and/or hypofunctional nodules. The ug-FNAB results were grouped as follows: group 1: malignant (n = 44); group 2: malignancy cannot be ruled out (n = 173); group 3: non-malignant (n = 296), group 4: inadequate (n = 25). RESULTS: When the cytological results of group 1 and group 2 were interpreted as being malignant and those of group 3 as being benign, sensitivity, specificity and accuracy of ug-FNAB were 96.7%, 65.8% and 69.5% respectively. The 62 thyroid carcinomas (TC) biopsied presented in 59 cases a suspicious or malignant cytology (95.2%). The smallest TC diagnosed by ug-FNAB had a diameter of 0.5 cm and 36.4% of all papillary TC < or = 1 cm displayed stage pT4. The histology verified a TC in 18 cases out of the 173 ug-FNABs in group 2. Non-malignant ug-FNABs were confirmed by histology in 294 patients (99.3%) in group 3. In 4.65% of the ug-FNABs inadequate material was aspirated. CONCLUSION: Nodules with non-suspicious ug-FNAB results can be safely followed-up by sonography, as the cytological diagnoses were verified in more than 99% by histology. Papillary TC can be diagnosed with ug-FNAB very accurately. As stage pT4 was present in more than one third of patients with papillary TC < or = 1 cm, ug-FNAB is also recommended for thyroid nodules 0.5-1 cm in diameter located adjacent to the thyroid capsule. However, microfollicular proliferations remain the limitation of ug-FNAB, as the cytology cannot distinguish between benign adenoma and follicular TC.

Value of ultrasound-guided fine-needle aspiration biopsy of thyroid nodules in an endemic goitre area.

The aim of this study was to determine the value, advantages and limitations of ultrasound-guided fine-needle aspiration biopsy (US-FNAB) in an endemic goitre area. US-FNAB was performed on all outpatients who presented with hypoechoic and/or hypofunctional and/or growing nodules. A total of 4518 US-FNABs were performed and 718 patients from this series underwent surgery. Cytological results of the primarily performed US-FNAB of these patients were compared retrospectively with the histological results. US-FNAB results were grouped as (1) non-malignant (n = 303), (2) non-malignant follicular proliferation (n = 177), (3) malignancy cannot be ruled out (n = 133), (4) malignant (n = 61), (5) inadequate (n = 34), and (6) sampling error; biopsy of a non-malignant nodule (n = 10). Nodules as small as 5 mm in diameter could be biopsied, gaining representative material. US-FNAB found a malignant or suspicious cytology in 65 out of 87 cases with malignant histology (74.71%). Diagnosis of early tumour stages was often possible: 12 of 18 thyroid carcinomas biopsied and smaller than 10 mm in diameter had malignant or suspicious cytology (groups 3 and 4). US-FNAB was performed incorrectly within non-malignant nodules in ten patients (1.39%) with multinodular goitre (ten papillary carcinomas, nine smaller than 10 mm). Regarding the cytology of groups 1 and 2 as benign and those of groups 3 and 4 as malignant, US-FNAB performance was as follows: sensitivity 87.84%, specificity 78.50%, negative predictive values 98.13%, positive predictive values 33.51% and accuracy 79.53%. Biopsies with inadequate material were obtained in 4.73% of all biopsies. No major adverse effects occurred. Re-biopsies in 61 cases did not alter the cytological outcome in those cases where adequate material was obtained. US-FNAB is a valuable method in the pre-operative assessment of thyroid nodules in order to select patients for surgery, as malignancy can often be detected even in early tumour stages. However, even with ultrasonographic guidance, the minimal tumour size detectable by US-FNAB is around 5 mm. The cytological interpretation in cases with regression and microfollicular proliferation also sets limits on the method. However, patients with non-malignant cytologies can be followed up safely by sonography due to the high NPV of US-FNAB as long as thyroid nodules do not become larger. Re-biopsies seem to be of limited value as long as adequate material was obtained by US-FNAB.

Comparison of different tracers in the follow up of differentiated thyroid carcinoma.

In the follow up of differentiated thyroid carcinoma (DTC) several scintigraphic methods are used in addition to the serum thyroglobulin and ultrasonography of the neck. Iodine-131 whole body scintigraphy (WBS), which is performed since many years, is able to detect iodine positive recurrence, lymph node metastases and distant metastases in a very specific way. However, the problem of I-131 WBS is the fact that only 67% of metastases from DTC accumulate iodine. Therefore non specific radionuclides like TI-201 or tracers such as Tc-99m Sestamibi or Tc-99m Tetrofosmin and new metabolic tracers like F-18 FDG were introduced in the diagnostic work up to detect iodine negative metastases as well. This study describes the comparison of different tracers in 35 patients with elevated thyroglobulin and suspicion of metastatic disease or already known metastases from DTC.

Thallium-201 uptake with negative iodine-131 scintigraphy and serum thyroglobulin in metastatic oxyphilic papillary thyroid carcinoma.

We report a case of a 48-yr-old woman who underwent surgery because of papillary oxyphilic thyroid carcinoma pT3. After total thyroidectomy, we administered 2960 MBq (131)I for ablation of the residual tissue. initial follow-up visits showed no clinical, radiological or scintigraphic evidence of residual or metastatic thyroid tissue. Serum thyroglobulin levels (Tg) and (131)I whole-body scintigraphy were negative. Three years after thyroidectomy, the patient experienced seizures, and as a consequence a brain tumor was removed. It was an undetected metastasis of the primary thyroid carcinoma. Histological examinations showed that neither the primary tumor nor the metastasis produced any Tg. With this fact in mind and the knowledge of negative (131)I whole-body scans we had to concentrate on radiological (CT and MRI scans) and nonspecific scintigraphic methods such as 201TI whole-body scintigraphy in our management of the patient. Further follow-up demonstrated multiple metastasis by 201TI whole-body scan (mediastinum, bones and soft tissue), and most of them have been removed by surgery. This case report demonstrates that, in addition to (131)I whole-body scans and measurement of serum Tg, the use of nonspecific tracers like 201TI is important to detect (131)I and/or Tg negative metastases.

Technetium-99m-tetrofosmin uptake in sarcoidosis stage I.

The uptake of 99mTc-tetrofosmin in enlarged lymph nodes, of the lung hilus, in the case of sarcoidosis Stage I (histopathologically confirmed by mediastinoscopic biopsy) is demonstrated. On a routine chest radiograph of a 78-yr-old woman, hilar lymphadenopathy was first detected. In the following mammography, disseminated micro calcifications were found in the left breast and a 99mTc-tetrofosmin study was performed for detection of breast cancer. Scintigraphy using 99mTc-tetrofosmin showed clear uptake in the hilar lymph nodes, but not in the left breast. The 99mTc-tetrofosmin uptake in the hilar lymph nodes was due to sarcoidosis confirmed by histology. Therefore, 99mTc-tetrofosmin scintigraphy may be useful in patients with suspected sarcoidosis, especially in Stage I.

Radioimmunoscintigraphy with Tc-99m labeled monoclonal antibody 170H.82 in suspected primary, recurrent, or metastatic breast cancer.

Radioimmunoscintigraphy (RIS) with Tc-99m labeled 170H.82, an intact murine monoclonal antibody (MAb) was performed in 27 patients with suspected primary, recurrent, or metastatic breast cancer. For radioimmunoimaging the authors used a double-headed, high-resolution gamma camera. The lesions detected by RIS were evaluated by histopathology, and for metastatic disease by CT, MRI, and bone scan. If the evaluation was made lesion by lesion, RIS with Tc-99m MAb 170H.82 showed 23 true-positive results, 3 false-negative results, 9 true-negative results, 3 false-positive results for primary and recurrent disease; sensitivity was 88% and specificity was 75%. In patients with distant metastases, detection rate was 67% (12 true-positive results and 6 false-negative results). All patients had normal baseline values for human anti-mouse antibodies (HAMA) and 6 weeks after RIS with 2 mg MAb, only 2 of 23 patients had developed a HAMA response (9%). No adverse effects were observed. The authors' clinical experience shows that RIS with MAb 170H.82 is a valuable additional method for detecting breast cancer, especially in patients with uncertain primaries or scar tissue after breast conserving treatment in which differential diagnosis is very difficult.

Cytomorphology of anaplastic ependymoma in a pleural effusion. A case report.

In a 42-year-old women a recurrent anaplastic ependymoma of the frontal lobe developed intracerebral metastases and, after implantation of an atrioventricular shunt, also metastasized to the lung, pleural cavity and mediastinal lymph nodes. In routinely stained smear preparations of the pleural effusion sediment, the typical cytologic features of an anaplastic ependymoma were found--papilliform cell clusters with acellular axes ("pseudorosettes"), incomplete true ependymal rosettes, and epithelioid and tanycytoid tumor cells with signs of anaplasia. A peculiar matrix material was a characteristic feature of this case and, to our knowledge, was not reported previously. It consisted of refringent, fibrillar strands composed of tightly packed, roundish to rodshaped granules. This matrix seemed to be associated with the cytoplasmic processes of the tumor cells.

[Squamous cell carcinoma of the thyroid originating from a thyroglossal duct cyst]. / Plattenepithelkarzinom der Schilddrüse ausgehend von einer Ductus thyreoglossus Zyste.

A 73 y old female was found to suffer from a squamous cell carcinoma with a focal thymus-like differentiation in a thyroglossal duct cyst. A neoplasma of this type in a goitre with Graves' disease is extremely rare. Sonographic, radiological, scintigraphic and microscopic findings are discussed.

[Abdominal wall implantation metastasis 2 years after apparently uneventful laparoscopic cholecystectomy]. / Bauchdeckenimplantationsmetastase zwei Jahre nach scheinbar unauffälliger laparoskopischer Cholecystektomie.

An extraordinary rare case of implant metastasis at the laparoscopic working port, two years after an apparent uncomplicated laparoscopic cholecystectomy is presented. The histological reexamination of the gallbladder with the detection of a minimal carcinomatous lymphangiosis in newly prepared sections, the exclusion of other primary tumors and also the tumor-free interval of six months until now, after radical excision of the abdominal wall, are strongly suggestive for an intraoperative tumor cell dissemination into the abdominal wall by a histologically unrecognized carcinoma of the gallbladder.

Immunostaining of human autopsy aortas with antibodies to modified apolipoprotein B and apoprotein(a).

A systematic immunohistochemical study of different stages of atherosclerosis in human aortas was performed using several antibodies. Because oxidation of lipoproteins could be a key event in atherogenesis, an antibody against apolipoprotein B (apoB) from low-density lipoprotein (LDL) modified with the lipid peroxidation-specific aldehyde, 4-hydroxynonenal (4-HNE) (anti-4-HNE-apoB), was raised in rabbits. This antibody recognizing 4-HNE protein adducts was used in concert with an antibody to apo(a) from lipoprotein(a), considered also potentially atherogenic, as well as with an antibody and a monoclonal antibody (mAb) to apoB. Autopsy material from 12 corpses was investigated. The immunohistochemical investigation by the alkaline-phosphatase technique included control specimens regarding postmortem artifacts by autolysis and oxidation. The results from six specimens from five corpses are presented. A positive staining with the antibody to apoB but not with anti-4-HNE-apoB was seen in the normal intima. The thickened intima of early, transitional, and advanced atherosclerotic lesions and atheromata showed a predominantly extracellular staining with all antibodies and the applied mAb. To test the specificity of the staining, antibodies preadsorbed by the appropriate antigens and nonimmune sera were used, giving negative results. These findings indicated a colocalization of epitopes derived from lipid peroxidation of polyunsaturated fatty acids and epitopes specific for apoB and apo(a) during atherogenesis in humans.

A combined biopsy-plugging device based on the Menghini- or Trucut needle for percutaneous liver biopsy: clinical experience.

Impaired blood clotting precludes percutaneous liver biopsy for histologic examination of liver tissue. The transjugular or laparoscopic approach are ways to reduce the risk of bleeding. These techniques, however, are laborious and confined to specialized centers. Methods of plugging the needle track with sealant presented so far are hampered by the need to leave either the cannula in situ or the need for a second percutaneous approach for the application of the sealant. We have tested a combined plugging-biopsy device allowing to perform the biopsy as a one-step procedure in patients with impaired clotting under laparoscopic vision control. In 37 patients either a modified Trucut or Menghini needle was tested. Handling of the Trucut needle proved easier. Tissue yield was satisfactory with both needles. Only one episode of bleeding was observed with a prototype Menghini needle. We conclude, that the combined plugging-biopsy device is a safe and reliable tool for obtaining liver tissue in patients with impaired blood coagulation.