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Aim The German osteoporosis guideline was updated on the basis of a systematic literature review and through a structured consensus process by an interdisciplinary, international (Germany, Austria, Switzerland) expert group representing the 20 member societies of the Joint Osteological Association (DVO) and patient advocacy organizations (BfO). This manuscript summarizes the changes in the German osteoporosis guideline with regard to pharmacological interventions and offers pragmatic pathways for implementation. Method Systematic literature search and structured consensus building according to AWMF regulations. Results The sclerostin antibody romosozumab was adopted into the guideline. In addition, the effectiveness of teriparatide was re-evaluated. For both bone anabolic agents evidence from randomized trials underlined a superiority over oral bisphosphonates with regard to fracture risk reduction. Between the antiresorptive treatments, differences regarding superiority/inferiority could only be shown with respect to surrogate parameters, not with regard to fractures. Data about the duration of treatment of all available drugs is limited. All non-bisphosphonate treatments require follow-up treatment. Conclusion An individualized treatment concept should be developed in a shared decision process, including a bone anabolic-first strategy in high-risk patients. Recommendations on treatment duration, drug holidays and sequential strategies should be considered.

Introduction: Breast tumors such as cystosarcoma phylloides and fibroadenoma may show rapid growth and occur early in thelarche. In adolescents, tumor growth often remains unnoticed due to a lack of breast awareness or a sense of shame in these young girls. The necessity for surgical intervention may interfere with the normal development of the breast, however in certain cases has to be performed due to the threat of deformation of the growing breast or the malignant potential of some tumors like cystosarcoma phylloides. However, visible scars have to be avoided at any price in these young girls, as they are still in their pre-marital and psychologically vulnerable phase. The presumed size of the breast after completion of all Tanner stages of breast development has to be taken into consideration while planning the immediate or deferred reconstruction. Methods: We report on three young girls, 13, 14 and 16 years of age, who presented with a giant cystosarcoma phylloides of 9,6 cm (190 grams), a giant fibroadenoma of 14 cm (287 grams) and a giant PASH-tumor of 16,3 cm (957 grams). All patients were in their thelarche. The extension of the tumor was almost to the whole circumference of the breast with close borders to the skin envelope, resulting in a marked anisomastia due to the giant tumor size. We are proposing here scar-sparing procedures adapted to the form of the breast and the BMI of the patients. For access to the tumor, in two cases, we chose the anterior axillary line to avoid visible scars on the surface of the breast - one with autologous and one with heterologous, implant-based reconstruction. In the third case, the patient had a marked anisomastia with a massively ptotic breast with a huge broadening of the nipple-areolar-complex due to the growth of the tumor. Here we selected a tumor-size adapted, inferior-pedicled reduction mammaplasty according to Ribeiro in the modification of Rezai with a skin reduction and shortening of the diameter of the areola. Patient reported-outcome has been measured by validated Breast-Q-questionnaires. Results: We present three different types of access for the removal of giant tumors and three options for the reconstruction of patients in their thelarche. Two tumors were removed through axillary access to the breast to avoid scars in the developing breast. We achieved free margins at first surgical intervention in all three cases. One reconstruction was performed by autologous tissue through lateral thoracic wall advancement mammaplasty. Another patient had an implant-based reconstruction. The third patient – who presented with a macromastia with marked enlargement of the nipple-areola-complex was treated with a tumor-adapted reduction mammaplasty. All three young patients have reported a high degree of satisfaction in validated Breast QoL questionnaires with the outcome of the procedures.

In the past 50 years, enormous progress has been made in the diagnosis, treatment and control of taeniid cestode infections/diseases and in the scientific understanding thereof. Most interest in this group of parasites stems from the serious diseases that they cause in humans. It is through this lens that we summarize here the most important breakthroughs that have made a difference to the treatment of human diseases caused by these parasites, reduction in transmission of the taeniid species associated with human disease, or understanding of the parasites’ biology likely to impact diagnosis or treatment in the foreseeable future. Key topics discussed are the introduction of anti-cestode drugs, including benzimidazoles and praziquantel, and the development of new imaging modalities that have transformed the diagnosis and post-treatment monitoring of human echinococcoses and neurocysticercosis. The availability of new anti-cestode drugs for use in dogs and a detailed understanding of the transmission dynamics of Echinococcus granulosus sensu lato have underpinned successful programs that have eliminated cystic echinococcosis in some areas of the world and greatly reduced the incidence of infection in others. Despite these successes, cystic and alveolar echinococcosis and neurocysticercosis continue to be prevalent in many parts of the world, requiring new or renewed efforts to prevent the associated taeniid infections. Major advances made in the development of practical vaccines against E. granulosus and Taenia solium will hopefully assist in this endeavour, as might the understanding of the parasites’ biology that have come from an elucidation of the nuclear genomes of each of the most important taeniid species causing human diseases.

Neonatal and infant immune responses are characterized by a limited capability to generate protective Ab titers and memory B cells as seen in adults. Multiple studies support an immature or even impaired character of umbilical cord blood (UCB) B cells themselves. In this study, we provide a comprehensive molecular and functional comparison of B cell subsets from UCB and adult peripheral blood. Most UCB B cells have a mature, naive B cell phenotype as seen in adults. The UCB Ig repertoire is highly variable but interindividually conserved, as BCR clonotypes are frequently shared between neonates. Furthermore, UCB B cells show a distinct transcriptional program that confers accelerated responsiveness to stimulation and facilitated IgA class switching. Stimulation drives extensive differentiation into Ab-secreting cells, presumably limiting memory B cell formation. Humanized mice suggest that the distinctness of UCB versus adult B cells is already reflected by the developmental program of hematopoietic precursors, arguing for a layered B-1/B-2 lineage system as in mice, albeit our findings suggest only partial comparability to murine B-1 cells. Our study shows that UCB B cells are not immature or impaired but differ from their adult mature counterpart in a conserved BCR repertoire, efficient IgA class switching, and accelerated, likely transient response dynamics.

Background: Breast conserving surgery is the standard in T1-T3 primary breast cancer. The cosmetic result is very much depending on the surgeon´s experience, the tumor-size/breast ratio and the technique applied. To improve cosmetic outcome and reduce repeated surgery, we have proposed a nomogram earlier (1) which has been cited by the American Society of Breast Surgeons Consensus Conference (2). In this nomogram, we proposed 5 simple oncoplastic techniques to handle the vast majority of breast cancer cases with a good cosmetic result. However, these techniques used direct access to the mammary gland, leaving scars in the visible skin of the breast. To avoid this, we chose a more natural access to the mammary gland at the natural transitions. Methods: We conducted a prospective open-arm study including all primary invasive and non-invasive breast cancer cases of tumor stages AJCC 0-III A (Version 8.0). Access to the tumor was chosen according to the proximity of the tumor to one of the following natural transitions (Areola, Lateral Insertion of the breast, inframmary fold): Non-palpable tumors and those undergoing neoadjuvant chemotherapy had to be marked by a wireand clippes before. Intraoperative ultrasound was applied before skin incision and after removal of the tumour (ultrasound of the specimen to confirm clear margins). Resection was performed as a segmentectomy and SLN biopsy and axillary clearance was done according to current guidelines.Results: 84 patients with breast conserving NTT-surgery have been enrolled so far. 76 patients had primary surgery with stage distribution as follows: Tis (1), T1a (3), T1b (8), T1c (30), T2 (30), T3 (4) and T4b(1). 8 patients had neoadjuvant chemotherapy with stage distribution as follows: ypT0 (3), ypT1a(2), ypT1c(1) and ypT2 (2). Histopathology was predominantly invasive-ductal breast cancer (70), followed by invasive-lobular (6), ductulo-lobular (5), invasive-ductal and DCIS (1),invasive-ductal and mucinous (1) and mucinous only (1). After first surgery 77 patients had a tumor resection according to the nomogramm of NTT-surgery with free margins and 7 with involved margins, thus 91,6 % tumors were resected with free margins at first surgery. The remaining 8,4 % were margin-free after second surgery. Conclusion: Scars were not visible on the surface of the breast outside of natural transitions and rate of free margins was high at 91,6 % without impairment due to the remote access to the mammary gland. We report a high patient satisfaction. Patient-reported outcome in detail has been evaluated by validated questionnaires and will be presented onsite. References:1. Rezai M., Knispel S., Kellersmann S., Lax H., Kimmig R., Kern P: Systematization of Oncoplastic Surgery: Selection of Surgical Techniques and Patient-Reported Outcome in a Cohort of 1,035 Patients, Ann Surg Oncol (2015) 22:3730-37372. Landercasper J. et al.: Toolbox to Reduce Lumpectomy Reoperations and Improve Cosmetic Outcome in Breast Cancer Patients: The America Society of Breast Surgeons Consensus Conference, Ann Surg Oncol 22, 3174-3183 (2015) Citation Format: Peter Kern, Oliver Hoffmann, Ann-Kathrin Bittner, Rainer Kimmig, Mahdi Rezai, Ines Bücker, Alina Kessel. Natural transition targeted surgery [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS1-11.

Hintergrund: Die Untersuchung des Bewegungsapparats geh��rt zu den Grundfertigkeiten ��rztlichen Personals. Verunsichernd auf Berufsanf��nger wirkt in diesem Bereich jedoch die Vielzahl an Tests. Erfahrungsgem���� reichen f��r die h��ufigsten Pathologien einige wenige Testverfahren [zum vollst��ndigen Text gelangen Sie ��ber die oben angegebene URL]

Taenia species of domestic dogs can cause cysticercosis and coenurosis in a wide range of intermediate hosts including humans. Most taeniids of dogs are globally distributed, but some wildlife-transmitted species can be specific for certain regions. Generally, little information exists on the species composition and frequency in most regions of the world, which impairs risk assessment and control strategies. This study determined the range of taeniid species in dogs in four widely spaced areas of Kenya by genetic identification of eggs in faeces collected from the environment. Individual taeniid eggs were characterised by nested polymerase chain reaction of NADH dehydrogenase subunit 1 and cytochrome C oxidase 1 genes, restriction fragment length polymorphism and partial sequencing. Overall 79/1621 (4.9%) faecal samples contained eggs of Taenia or Hydatigera (8.0% in Turkana, 4.8% in Isiolo, 3.8% in Maasai Mara and 1.3% in Meru). Taenia hydatigena and T. multiceps were the most frequent, found in 36 and 15 samples, respectively. Other eggs found in the faeces belonged to T. serialis (sensu lato), T. madoquae (the first record in domestic dogs), T. ovis, T. saginata and Hydatigera taeniaeformis. Polymorphism of nad1 sequences revealed 22 and 8 haplotypes of T. hydatigena and T. multiceps, respectively. The results show the involvement of dogs in both domestic and sylvatic transmission cycles. In addition to the species range, this study provides data on the intraspecific diversity of T. hydatigena and T. multiceps in Kenya, which will serve as baseline information for further studies into cysticercosis and coenurosis in livestock and humans in the region.

ZUSAMMENFASSUNG Hintergrund: Der indikationsgesteuert durchgeführte direkte Virusnachweis (RT-PCR im Abstrich) unterschätzt wegen der möglichen asymptomatischen Verläufe die Zahl der SARS-CoV-2-Infizierten erheblich. Daher sind populationsbasierte Erhebungen der Antikörperprävalenz zur verlässlichen Einschätzung der gegenwärtigen Pandemie unverzichtbar. Methoden: In einem Klinikum der Maximalversorgung wurden 74,8 % aller Mitarbeiter/innen mit direktem Patientenkontakt (n = 1480) sowie als nicht medizinprofessionelle Kontrollgruppe Mitarbeiter/innen lokaler Supermärkte mit direktem Kundenkontakt (n = 300) auf Antikörper der Klassen IgA und IgG gegen SARS-CoV-2 getestet. Die Gesamtkohorte stellt zugleich 1,5 % der Bevölkerung der Stadtregion Fulda mit 125 000 Einwohnern dar. Ergebnisse: 1,0 % der Testpersonen waren positiv für IgG, 4,4 % für IgA. Bei einer Testspezifität von 99,6 % (IgG) bzw. 92,4 % (IgA) liegt weder im Gesamttestkollektiv noch in einer der Untergruppen eine klinisch signifikante Immunität gegen SARS-CoV-2 vor. Schlussfolgerung: Von einer relevanten Anzahl durchlaufener unerkannter Infektionen kann in dieser Region nicht ausgegangen werden. Die noch spärlichen Daten aus internationalen Regionen lassen Immunitätsraten bis maximal 60 % in stark exponierten Kollektiven vermuten, wobei sich in Deutschland ein dynamisches Mosaik mit aktuellen Werten zwischen null und 15 % abzeichnet. Diese Heterogenität legt eine regionale Planung der Maßnahmen zur Kontrolle der Virusausbreitung nahe. Ein relevanter immunologischer Schutz der Bevölkerung vor SARS- CoV-2 ist bis zur Verfügbarkeit einer Impfung nicht zu erwarten.

Seltene Mammatumoren mit einem Anteil

Background: Ectopic pregnancies occur predominantly in the fallopian tubes or ovaries. Very rarely, the distal part of the greater omentum may have close contact to the fallopian tubes and implantation of the embryo may occur in this part of the greater omentum. In the absence of signs of pregnancy in the uterus or the fallopian tubes, the greater omentum has to be closely examined for ectopic pregnancy. Case Presentation: A 22-year-old woman in her 4th week of pregnancy presents with spotting and severe pain in the right lower abdomen with a history of 2 cesarean sections. The sonographic examination showed a normal uterus with a thin endometrial line. The uterine cavity did not present with any signs of a gestational sac. A great amount of free fluid in the Douglas cavity suspicious of a hemoperitoneum. ßhCG-values in serum was highly elevated up to 16749 mU/ml and confirmed the suspicion of an ectopic pregnancy. A diagnostic laparoscopy was performed, during which a blood clot reaching from the right lower abdomen to the greater omentum was detected. After removing the blood clot, a normal-sized uterus with regular ovaries and no signs of a pregnancy in the fallopian tubes were seen. However, an abdominal adhesion in the right upper part of the omentum close to the liver with bleeding was seen. While examining the abdominal cavity for the cause of bleeding, a small cystic lesion adherent to the greater omentum – close the offspring from the colon – representing an ectopic pregnancy became apparent. A partial omentectomy of 9,5 cm x 5,5 cm x 2,5 cm was performed with the finding of trophoblast and embryoblast implantated in the infrahepatic part of the greater omentum. Conclusion: In cases of ectopic pregnancy with hemoperitoneum, special care has to be taken examining not only the fallopian tubes or ovaries but also the greater omentum, which may harbour an implanted trophoblast and embryoblast – even in the upper part directly beneath the liver – as presented in this case. In cases of ruptured ectopic pregnancy of the greater omentum, the cases may be dealt with laparoscopic partial omentectomy if the case is early detected.

Cystic echinococcosis (CE) is widespread and locally frequent in southern Africa where it affects humans, livestock, and wild mammals. However, most data from the region are old and do not provide information on the causative Echinococcus species. For Namibian livestock only anecdotal records were available prior to this preliminary survey. Our retrospective analysis of slaughterhouse records of CE in cattle from the commercial farming area in central and southern Namibia resulted in 1.65% CE prevalence among 35,143 slaughtered cattle in the period 2015-2016. For comparison, carcasses of ruminant livestock were prospectively examined in the communal farming areas of northern Namibia, resulting in three CE cases among only 12 cattle, and no cases among nine goats. To determine the Echinococcus species affecting Namibian livestock, a total of 53 cysts were collected from all parts of the country and analysed for species and genotype by amplification and sequencing of the nad1 gene. All 50 cattle cysts (isolated from 40 cattle), both from the commercial and communal farming areas, were Echinococcus ortleppi (all fertile, and 42/50 from the lungs), while three opportunistically collected cysts from three sheep in southern Namibia were E. canadensis G7. Our data suggest that E. ortleppi is the only CE agent that is relevant for cattle infection in Namibia, and that low prevalence in the commercial farming areas contrasts with high CE burden in the northern traditional husbandry systems. The present data provide baseline information to stimulate epidemiological studies on the transmission pathways of various CE agents in livestock, wildlife, and humans in Namibia and neighbouring countries.

Fragestellung/Zielsetzung: Geriatrische Patienten nehmen eine besondere Rolle in der medizinischen Ausbildung ein. An der Medizinischen Fakultät Würzburg findet seit 2006 ein verpflichtender Instant Aging-Kurs statt. Die Studierenden lernen mit Hilfe von Selbsterfahrung die Bedeutung [zum vollständigen Text gelangen Sie über die oben angegebene URL]

Cytoreductive surgery (CRS) is an appropriate treatment for selected patients with endometrial cancer (EC)-derived peritoneal metastases (PM). Hyperthermic intraperitoneal chemotherapy (HIPEC) may enhance the therapeutic efficacy of CRS in these patients. We performed a systematic literature search of the databases PubMed and Cochrane Central Register of Controlled Trials to identify clinical trials and case reports reporting on the safety and efficacy of CRS and HIPEC in patients with EC-derived PM. Eight publications reporting on 68 patients were identified. The mean patient age was 57.1 years and the mean time from initial treatment of EC to CRS and HIPEC was 22.3 months. 41/64 patients had adenocarcinomas, type II cancers were present in 23/64 patients. The mean peritoneal carcinomatosis index (PCI) was 16.7. A complete surgical resection CC-0 was achieved in 44/63 (70%) patients. The chemotherapy regimens used for HIPEC were variable, but all included cisplatin, administered either alone (39/68 patients) or combined with doxorubicin or paclitaxel or mitomycin (29/68 patients). The duration of HIPEC was 60 min in 51/68 patients and 90 min in 17/68 patients. Mostly, the closed technique was used (55/68 patients). Adverse events grades 1/2, 3, and 4 were observed in 23/63, 12/63, and 6/63 patients, respectively. Treatment-associated mortality was 1% (1/63). After CRS and HIPEC, most patients received systemic chemotherapy (46/63 patients). Median disease-free and overall survival ranged from 7 to 18 and 12 to 33 months, respectively. In conclusion, CRS and HIPEC in EC with PM is safe and feasible. An additional therapeutic value of HIPEC is suggested, but prospective comparative trials are warranted.

It is well known that certain fractional diffusion equations can be solved by the densities of stable L\'evy motions. In this paper we use the classical semigroup approach for L\'evy processes to define semi-fractional derivatives, which allows us to generalize this statement to semistable L\'evy processes. A Fourier series approach for the periodic part of the corresponding L\'evy exponents enables us to represent semi-fractional derivatives by a Gr\"unwald-Letnikov type formula. We use this formula to calculate semi-fractional derivatives and solutions to semi-fractional diffusion equations numerically. In particular, by means of the Gr\"unwald-Letnikov type formula we provide a numerical algorithm to compute semistable densities., Comment: 32 pages, 5 figures

Almost 60 years ago Zolotarev proved a duality result which relates an α-stable density for α ∈ (1, 2) to the density of a \(\frac 1{\alpha }\)-stable distribution on the positive real line. In recent years Zolotarev duality was the key to show space-time duality for fractional diffusions stating that certain heat-type fractional equations with a negative fractional derivative of order α in space are equivalent to corresponding time-fractional differential equations of order \(\frac 1{\alpha }\). The point source solutions of the former are given by negatively skewed α-stable densities, whereas the latter are solved by densities of corresponding inverse \(\frac 1{\alpha }\)-stable subordinators. We review this space-time duality and take it as a recipe for a previously unknown generalization from the stable to the semistable situation.

We use the theory of Bernstein functions to analyze power law tail behavior with log-periodic perturbations which corresponds to self-similarity of the Bernstein functions. Such tail behavior appears in the context of semistable Lévy processes. The Bernstein approach enables us to solve some open questions concerning semi-fractional derivatives recently introduced in Kern et al. (Fract Calc Appl Anal 22(2):326–357, 2019) by means of the generators of certain semistable Lévy processes. In particular, it is shown that semi-fractional derivatives can be seen as generalized fractional derivatives in the sense of Kochubei (Integr Equ Oper Theory 71:583–600, 2011) and generalized fractional derivatives can be constructed by means of arbitrary Bernstein functions vanishing at the origin.

Primary breast cancer is addressed with multimodal treatment which constitutes surgery, systemic therapy, and radiotherapy.

The two-week block rotation in paediatrics (tenth semester) took place for 62 students purely as online teaching in the summer semester of 2020, at the time of the initial restrictions. As a teaching module, virtual patient presentations including debriefing took place as synchronous teaching. Patients and one parent were broadcast from the wards and outpatient clinics via video conference. Students were able to interact in small groups with 15-22 patients or their parents, respectively, via a doctor and both conduct the case history interview and brief the examination steps. Despite the limitation of not being able to perform the clinical examination themselves, participants rated the block rotation with good marks. They particularly appreciated the ability to interact with the children online as an indispensable compromise in times of suspended classroom teaching during the SARS-CoV-2 pandemic. Das zweiwöchige Blockpraktikum Pädiatrie (10. Semester) fand für 62 Studierende im Sommersemester 2020 zur Zeit der Ausgangsbeschränkung als reiner Online-Unterricht statt. Als ein Unterrichtsbaustein fanden virtuelle Patientenvorstellungen inkl. Nachbesprechung als synchrone Lehre statt. Patientinnen und Patienten sowie ein Elternteil wurden von den Stationen und Ambulanzen per Videokonferenz übertragen. Die Studierenden konnten in Kleingruppen über eine ärztliche Person mit jeweils 15-22 Patienten bzw. deren Eltern interagieren und sowohl das Anamnesegespräch führen, also auch Untersuchungsschritte instruieren. Die Teilnehmenden bewerteten das Blockpraktikum trotz der Limitierung, nicht selbst die klinische Untersuchung durchführen zu können, mit guten Noten und wertschätzten insbesondere die Möglichkeit zur Online-Interaktion mit den Kindern als unverzichtbaren Kompromiss in Zeiten der ausgesetzten Präsenzlehre während der SARS-CoV-2-Pandemie.