Search

This paper discusses a research launched by the European Aviation Safety Agency (EASA) to enhance helicopter safety performance through advanced reliability assessment of Type A helicopter main gearbox (MGB) lubricating systems. Oil starvation within a helicopter MGB will lead to increased friction between components, and an escalation in component surface temperatures that can result in subsequent thermal expansion and failure of the gearbox components. This is a concern for the industry as increasing numbers of helicopter accidents are witnessed that have been caused due to such loss of lubrication. This paper reports on a new method for assessing reliability of pressurized MGB lubrication systems. Safety risk modeling which included fault tree analysis (FTA) of MGB oil system related accidents and incidents was conducted. This led to the identification of prevailing failure modes for MGB lubrication systems and key contributing components. Reliability of the MGB lubrication systems at component level was accordingly investigated using The influence diagram (ID) approach. Random failure probabilities of MGB components were integrally used within the ID to map the infinite possible combinations of failures causes and modes. The theory is applicable to other pressurized lubrication systems. Results are discussed.

Background: Official guideline “indications and methods of hysterectomy” to assign indications for the different methods published and coordinated by the German Society of Gynecology and Obstetrics (DGGG), the Austrian Society of Gynecology and Obstetrics (OEGGG) and the Swiss Society of Gynecology and Obstetrics (SGGG). Besides vaginal and abdominal hysterectomy, three additional techniques have been implemented due to the introduction of laparoscopy. Organ-sparing alternatives were also integrated. Methods: The guideline group consisted of 26 experts from Germany, Austria and Switzerland. Recommendations were developed using a structured consensus process and independent moderation. A systematic literature search and quality appraisal of benefits and harms of the therapeutic alternatives for symptomatic fibroids, dysfunctional bleeding and adenomyosis was done through MEDLINE up to 6/2014 focusing on systematic reviews and meta-analysis. Results: All types of hysterectomy led in studies to high rates of patient satisfaction. If possible, vaginal instead of abdominal hysterectomy should preferably be done. If a vaginal hysterectomy is not feasible, the possibility of a laparoscopic hysterectomy should be considered. An abdominal hysterectomy should only be done with a special indication. Organ-sparing interventions also led to high patient satisfaction rates, but contain the risk of symptom recurrence. Conclusion: As an aim, patients should be enabled to choose that therapeutic intervention for their benign disease of the uterus that convenes best to them and their personal life situation.

The purpose of this study was to determine the value of dynamic pelvic floor MRI relative to standard clinical examinations in treatment decisions made by an interdisciplinary team of specialists in a center for pelvic floor dysfunction. 60 women were referred for dynamic pelvic floor MRI by an interdisciplinary team of specialists of a pelvic floor center. All patients were clinically examined by an urologist, gynecologist, a proctological, and colorectal surgeon. The specialists assessed individually and in consensus, whether (1) MRI provides important additional information not evident by physical examination and in consensus whether (2) MRI influenced the treatment strategy and/or (3) changed management or the surgical procedure. MRI was rated essential to the treatment decision in 22/50 cases, leading to a treatment change in 13 cases. In 12 cases, an enterocele was diagnosed by MRI but was not detected on physical exam. In 4 cases an enterocele and in 2 cases a rectocele were suspected clinically but not confirmed by MRI. In 4 cases, MRI proved critical in assessment of rectocele size. Vaginal intussusception detected on MRI was likewise missed by gynecologic exam in 1 case. MRI allows diagnosis of clinically occult enteroceles, by comprehensively evaluating the interaction between the pelvic floor and viscera. In nearly half of cases, MRI changed management or the surgical approach relative to the clinical evaluation of an interdisciplinary team. Thus, dynamic pelvic floor MRI represents an essential component of the evaluation for pelvic floor disorders.

Zusammenfassung Ziel: In einer doppelblinden, randomisierten, plazebokontrollierten, multizentrischen klinischen Studie wurden Wirksamkeit und Verträglichkeit einer systemischen Enzymtherapie bei Patienten mit akuter Thrombophlebitis superficialis im Beinbereich untersucht. Methode: 159 Patienten wurden aufgenommen; in der Verumgruppe wurden 79, in der Plazebogruppe 77 Patienten einer maximal 14 ± 2-tägigen Behandlung unterzogen. Die eingesetzte Dosis des Enzympräparats (Wobenzym® N, Mucos Pharma) betrug 3 × 4 magensaftresistente Dragees täglich. Alle Patienten erhielten zusätzlich einen Kompressionsstrumpf. Das Hauptzielkriterium war die Abnahme des Spontanschmerzes bis Tag 7, der bei Studienbeginn wenigstens 4 Scorepunkte auf einer Visual Rating Analogue Scale (VRAS) betragen musste. Ergebnisse: Unter der Behandlung kam es am Tag 7 zu einer signifikant stärkeren Schmerzreduktion unter Verum verglichen mit Plazebo (p = 0,0071). Das sekundäre Zielkriterium, die Responderraten (Abnahme des Schmerzscores auf 0 oder 1), betrug bei Abschluss der Behandlung unter Verum 77,0% und unter Plazebo 58,1% (p = 0,011). 8 Nebenzielparameter wurden untersucht. Diese Parameter und auch die Abschlussurteile zur Wirksamkeit ergaben signifikante Gruppenunterschiede zugunsten der Enzymtherapie. Schlussfolgerung: Diese Studie konnte die klinische Wirksamkeit und die gute Verträglichkeit der systemischen Enzymtherapie bei der Behandlung der akuten Thrombophlebitis superficialis beweisen, was für die antiphlogistische, antiödematöse und analgetische Wirkung dieser Therapie spricht.

James L. Kinneavy, who was until this year the Blumberg Centennial Profes sor of English at the University of Texas, has been one of the major influences on the development of composition for more than 25 years. His bestknown book, A Theory of Discourse, published in 1971, is credited by many in our field with promoting the revival of rhetoric in university English departments. That book was followed in 1976 by Aims and Audiences in Writing and Writing-Basic Modes of Organization (Both written with John Cope and J.W. Campbell). Kinneavy's theory of discourse relies on his definition of discourse as any utterance having a beginning, middle and end, and a purpose. He explained his theory graphically by means of his well-known "communications triangle." In this interview, conducted in May 1996 in Austin, Texas, he offers some ways that the triangle can be used in teaching writing. He also uses the trianglewith its acknowledged debt to Jakobson-to generate his theory of the major aims of discourse. Using this taxonomy, Kinneavy attempts to explain the basic organizational pattern of each aim of discourse. But Kinneavy does not wish to be known solely or even principally as a taxonomer, for, as he says, "taxonomy is only a part of theory," and he has extended much of his influence as a theorist and historian of rhetoric. His 1987 book, Greek Rhetorical Origins of Christian Faith, explains how the new testament idea of faith grew out of the use of the term pisteis by Isocrates and Aristotle. Kairos is another term frequently associated with Kinneavy because of his lucid explanation of the term in his work. Kinneavy is credited with demonstrating the moral aspect of kairos, establishing a link between it and justice by arguing that to be moral and just means to observe the proper measure in action and words. At the end of the interview, with typical Kinneavian modesty in response to a question about how he looks back on his career as a scholar and teacher, he concedes that "In the discipline of rhetoric, I tried to recognize the importance of history and the importance of theory and the importance of the empirical." Finally, with a touch of pride, he closes with this admission: "I think one of the most important contributions I gave to rhetoric as a discipline was as one of the people-Corbett comes to mind; a lot of other people come to mind-who gave rhetoric a respectable name as a scholarly discipline in English departments." Few, if any, of the many members of our profession whose minds have been touched by Kinneavy would disagree.

Oral enzymes are known as therapy of herpes zoster for more than 30 years. Nevertheless, today's standard treatment of herpes zoster in immunocompetent patients is oral acyclovir. Other therapies are no longer customary because of their insufficient efficacy and frequent side effects. The positive results obtained in earlier studies with an orally administered enzyme combination preparation has led to the assumption that this might definitely represent an alternative therapy. The purpose of this study was to determine whether the enzyme combination differs from acyclovir with regard to efficacy and tolerance in the treatment of acute herpes zoster. In this double-blind, controlled, multicenter trial, immunocompetent patients with herpes zoster were randomly assigned to receive one of the two test drugs for 7 days. The parameters of pain and skin lesions were measured over 14-21 days. Forty-four patients were enrolled in the enzyme therapy (ET) group and 46 in the acyclovir therapie (AT) group. Following entry into the study, patients demonstrated no significant differences with respect to anamnestic or clinical data. Significant differences regarding the statistically evaluated parameters of efficacy were not seen either. Paracetamol use and total pain over 14 days also failed to reveal any notable differences between the two groups. Side effects were observed in four patients of the ET group and in three of the AT group. Results suggest that the therapy of herpes zoster with an orally applied enzyme combination preparation is a valid and even cheaper alternative to therapy with acyclovir.

Background Today's standard treatment of zoster in immunocompetent patients is oral acyclovir. Other therapies are no longer customary because of their insufficient efficacy and frequent side effects. The positive results obtained with an orally administered enzyme combination led to the assumption that this might represent an alternative therapy. The purpose of our study was therefore to determine whether the enzyme combination differs from acyclovir with regard to efficacy and tolerance. Patients and Methods In a double-blind, controlled multicenter trial immunocompetent patients with zoster were randomly assigned to receive one of the two test drugs for 7 days. Parameters of pain and skin lesions were measured over 14–21 days. Forty-four patients were enrolled in the enzyme group (ET) and 46 in the acyclovir group (AT). Results There were no significant differences with respect to anamnestic and clinical data at entry into the study. Neither were there significant differences regarding the statistically evaluated parameters of efficacy: “segmental pain on day 7” (P= 0.496) and “vesicle duration” (P= 0.803). Paracetamol use and total pain over 14 days also failed to show any notable differences between the two groups. The beginning of crust formation and the duration of skin lesions showed a very similar frequency distribution. Side effects occurred in four patients in the ET group and in three in the AT group. Conclusions Our trial suggests that the therapy of zoster with an orally applied enzyme combination is a valid alternative to the therapy using acyclovir.

OBJECTIVE: To assess the effect of ranitidine on ethanol absorption after ethanol 0.5 g/kg is given in three single doses of 0.167 g/kg to simulate normal social drinking. DESIGN: A double-blind, placebo-controlled, crossover trial was performed in 16 healthy men. Ethanol serum concentrations were measured on day 6 of each of the three treatment periods (placebo, ranitidine 150 mg bid, or ranitidine 300 mg bid). METHODS: Ethanol 0.167 g/kg was administered followed by a standard meal at 1700. The last tablet of the test medication was given 15 minutes later. Thirty and 60 minutes after the first intake, the same amount of ethanol was given again. Serum ethanol concentrations were measured multiple times during the four-hour period following oral ingestion of the first dose. RESULTS: Comparison of median serum ethanol concentrations, the areas under the curve, peak and time to peak serum ethanol concentrations showed no significant differences during medication with placebo, ranitidine 150 mg bid, or ranitidine 300 mg bid. Peak ethanol concentrations (median values) were 153, 140, and 155 mg/L, respectively. CONCLUSIONS: This study shows that treatment with ranitidine, in a dose up to 300 mg bid, has no significant effect on serum ethanol concentrations, even when ethanol was given in divided doses to simulate normal patterns of social drinking. This implies that concomitant dosing with ranitidine will not increase the adverse effects of moderate doses of ethanol on concentration and psychomotor function.

PURPOSE We report two randomized trials of adjuvant systemic therapy in 747 patients < or = 65 years of age with histologically proven node-positive breast cancer. PATIENTS AND METHODS Patients were selected for the two trials on the basis of lymph node and hormone receptor status. The only stratification was based on the treating institution. In patients with a lower probability of recurrence (n = 276), a comparison between endocrine therapy (tamoxifen [Tam] 30 mg/d for 2 years) and chemotherapy (cyclophosphamide, methotrexate, and fluorouracil [CMF] intravenously [IV], six cycles every 4 weeks) was performed. In patients with a higher risk of recurrence (n = 471), a comparison between chemotherapy alone (doxorubicin plus cyclophosphamide [AC] i.v., eight cycles every 3 weeks) and the same chemotherapy plus Tam was made. RESULTS Overall, we found that CMF and Tam are equally effective in a subgroup of patients with a relatively good prognosis (low-risk patients). However, in the subset of women < or = 49 years old, a significantly greater disease-free survival (DFS) rate (P = .01) and overall survival (OS) rate (P = .002) was observed following therapy with CMF compared with Tam. In patients > or = 50 years old, the opposite was found, and Tam appeared to be superior to CMF (DFS, P = .003; OSm P = .5). These results must be interpreted cautiously, since a post-hoc stratification of patients by age (< or = 49, > or = 50) was performed, and significantly more younger, low-risk patients were randomized to receive chemotherapy alone and more older patients to receive Tam alone. Among patients with a relatively poor prognosis (high-risk patients), a combination of AC plus Tam was equivalent to AC and, when women were analyzed by age, this was found to be true of patients < or = 49 years as well. However, the addition of Tam to AC in women age > or 50 years resulted in a statistically significantly higher DFS (P = .01) and a trend toward better OS compared with women who received AC alone. CONCLUSION Further trials are required to analyze the role of combined simultaneous or sequential chemoendocrine adjuvant treatment or each single therapy alone in defined risk-adapted subsets of node-negative and node-positive patients.

Fifty patients with advanced (stage III or IV) ovarian carcinoma were followed-up until the date of their death or their fifth year of survival. Prognostic factors, including those currently in use, as well as ploidy and proliferation, chemoresistance testing and hormone receptor levels of the tumours were analysed for predictive value and independence from each other. In the univariate analysis, only stage, residual tumour, second-look status, chemoresistance, ploidy and proliferation were significantly correlated with survival. After being tested in a multivariate Cox regression model, however, only the results of chemoresistance testing at initiation of therapy, and second-look status at a later point, retained prognostic significance. Within the group of patients with a positive second-look, i.e., with the worst prognosis, the chemoresistance test was still able to discriminate between two subgroups with significantly different survival.

The managing of the pregnant patient with immune thrombocytopenic purpura (ITP) is complicated by the unavailability of the foetal platelet count and the risk of bleeding. We report on our experiences of 17 pregnancies in 15 patients, who delivered in the Department of Gynaecology of Freiburg University from 1969 to 1989 (frequency: 0.5 per 1,000). ITP was established prior to pregnancy in 9 of 15 patients, and developed in 6 cases during pregnancy. The a patients received steroid therapy ante partum. However, maternal platelet count did not relate to infant platelet count. Eleven infants were born vaginally, six by caesarean section. One of the 17 live births died immediately post partum at the 28th week of gestation. Six infants were temporarily thrombocytopenic at delivery without further morbidity. Based on our experience and the literature, an individual management of delivery for parturient patients with ITP is recommended.

Indication for fertility preserving surgery results from the patient's age, the histologic tumor type and the stage of the ovarian malignancy. Approximately 80-85 % of these lesions are ovarian cancers. 10-15 % tumors with low malignant potential (LMP) and approx. 5 % germ cell tumors. Of the ovarian cancers approx. 15 % of LMP tumors 50 %, and of germ cell tumors more than 90 % occur in patients below 40 years of age, in which fertility preserving surgery might be considered. An adequate operative staging permits a conservative procedure for ovarian cancers stage Ia. Due to the good prognosis of LMP-tumors (10 year survival, all stages, approx. 90 %) and the low rate of recurrences after conservative surgery of 6.8 % (10/147), a fertility preserving operation is feasible in select cases also in more advanced stages than Ia. In cases of germ cell tumors, which in the majority of cases are unilateral, even if the tumor extends beyond the ovaries, an adnexectomy will suffice. A successful chemotherapy, e.g. with bleomycin, etoposid, and cisplatin leads to remission rates of90 %. The reduced number of patients treated according to the above criteria in 90 % had a normal menstrual cycle after surgery and chemotherapy. Besides numerous case reports on successful pregnancies, there are also reports in literature on results in larger patients groups. Thus it has been reported that of 99 patients with an ovarian cancer stage I. 56 underwent conservative surgery. Child-bearing desire, present in 17 of these women, could be fulfilled in all cases (Colombo et al. 1995). Bianci and coworkers also described successful pregnancies (14/48) after conservative treatment of tumors of LMP. Numerous case reports have been published showing that after fertility preserving surgery of germ cell tumors pregnancies may also be successful. Since especially in ovarian cancers recurrences may occur at a later time, a hysterectomy with removal of the contralateral adnexa is suggested after complete family planning or when the patient enters the menopause. The possibilities offered by in vitro-fertilization have theoretically enlarged the spectrum of fertility preserving surgery. Thus, individual authors propose the conservation of the uterus after bilateral ovarectomy-keeping the option of a pregnancy by oocyte donation open for the patient. As further alternative conservation of a restovary after removal of the uterus and one adnexa is discussed. In these cases the patient's oocytes are preserved for feasible in vitro-fertilization in a "substitute" mother. Results of such fertility preserving procedures have not yet been published.

Both nuclear DNA content and S-phase fraction (SPF) can be helpful in predicting prognosis in certain malignancies. We investigated in a retrospective study the prognostic significance of nuclear DNA content and SPF as measured by flow cytometry of tumor specimens from 162 women with nonpretreated surgically staged FIGO stage I endometrial cancer using clearly defined inclusion criteria. A total of 139 (86%) cases were found to be diploid, whereas 23 (14%) were aneuploid. Ploidy showed a correlation with histologic grade, estrogen as well as progesterone receptor levels, and depth of myometrial infiltration. Univariate analysis of follow-up data showed an increased relative risk (RR) for recurrence-free survival (RFS) for grade 3 tumors (RR = 2.11, ns), for age (RR = 1.04, P = 0.023) as a continuous variable, and for SPF in diploid tumors (RR = 3.10, P = 0.035). In addition, univariate analysis of overall survival revealed similar results with a slightly increased relative risk for ploidy (RR = 1.52, ns). Multivariate analysis of RFS showed age as the only independent prognostic factor. Multivariate analysis of RFS for diploid tumors showed no independently significant factor; however, age as a continuous variable with a relative risk of 1.04 and SPF with a relative risk of 2.94 were of borderline significance. Our results suggest that abnormalities of the nuclear DNA content and SPF in this homogeneous group of patients are associated with clinical and morphological prognosticators; however, ploidy is no independent prognostic factor for RFS. For diploid tumors, SPF might be a possible independent prognostic factor.

Weitgehende Veranderungen auf den Bankenmarkten bewirkten bereits in den vergangenen Jahren erhebliche Akzentverschiebungen bei der Geschaftsausrichtung vieler Kreditinstitute. Die anhaltende Umweltdynamik wird auch in der Zukunft einen starken Anpassungsdruck auf die Wettbewerber ausuben. Dabei sind die Anpassungszwange durch unterschiedliche Einflusfaktoren bedingt.

Die vorzeitige Plazentalosung gehort zu den akuten Ereignissen in der Geburts hilfe. Sie ist definiert als partielle oder vollstandige Losung der regelrecht lokalisierten Plazenta vor der Geburt des Kindes. Dies fuhrt abhangig von der Grose der gelosten Plazentahaftflache zur akuten intrauterinen Asphyxie des Feten bis hin zum intrauterinen Fruchttod. Die klassischen Symptome wie Blutung und schmerzhafter Uterustonus treten stets akut auf, wahrend Hinweiszeichen, die sich aus dem Verlauf der Schwangerschaft ableiten lassen, fehlen. Assoziationen zur Gestose/Praeklampsie und zum vorzeitigen Blasensprung sind bekannt; im Einzelfall last sich das Risiko allerdings nicht vorhersagen [1, 3, 6, 9, 10, 20]. Neben der akuten Gefahrdung des Kindes ist stets auch eine Gefahrdung der Mutter gegeben. Durch das sich bildende retroplazentare Hamatom kann es zur Aktivierung des mutterlichen Gerinnungssystems kommen, so das sich eine disseminierte intravasale Koagulopathie (DIC) entwickelt [5, 14, 22]. Dies kann einerseits uber eine Verbrauchskoagulopathie zu unstillbaren Blutungen, andererseits zu Organnekrosen, z.B. zum Nierenversagen, fuhren.

Adenocarcinoma of the endometrium is the most common malignancy of the female genital tract. The majority of women with endometrial carcinomas are diagnosed and treated at an early clinical stage. Several prognostic factors have been suggested in this disease, including increasing patient age [1] , histologic type and grade [2], depth of myometrial invasion [3], metatases to adnexa, [4] pelvic or para-aortic lymph nodes [5], malignant cells in peritoneal washing [6], and the lack of steroi hormone receptors in the neoplasm [7].

Die kontrollierten Studien der Gynecologic Oncology Group (GOG) haben gezeigt, das die Ausbreitung des Endometriumkarzinoms durch die praoperative Stadienein- tieilung nicht ausreichend erfasst wird (1). Zu den entscheidenden Prognosefaktoren des Endometriumkarzinoms zahlen neben dem histologischen Typ und Differenzie- rungsgradvor allem die Infiltrationstiefe ins Myometrium und die Ausbreitung auserhalb des Uterus. Das operative Vorgehen hat sich deshalb in den letzten Jahren trotz des zum Teil recht hohen Alters der Patientinnen allgemein durchgesetzt, so das seit 1988 auf Empfehlung der FIGO die Stadieneinteilung nicht mehr klinisch (praoperativ) sondern chirurgisch (pathologisch) erfolgen soll. Die Unterteilung im Stadium I richtet sich nicht mehr nach der Sondenlange bei der Abrasio sondern nach der Infiltrationstiefe ins Myometrium. Der wesentliche Unterschied ergibt sich im Stadium III, da jetzt alle primar okkulten Lymphknoten extrauterinen Ausbreitungen im kleinen Becken, den retroperitonealen Lymphknoten und in der Peritonealzytologie zum Stadium III gezahlt werden. Die Bestimmung der exakten Ausbreitung wird mit der Forderung nach einer ausgedehnteren Operation verknupft und fand nicht allgemeine Zustimmung (2). Die vorliegende Untersuchung soll die Unterschiede zwischen klinischem und postoperativem Stadium am Kollektiv einer Klinik dargestellt und die Schwierigkeiten aufzeigen, die sich bei einem Vergleich der Therapieergebnisse zwischen alter und neuer Klassifikation ergeben.

Das Auftreten eines Rezidivs verschlechtert die Prognose einer Patientin mit dem allgemein eher als gunstig eingeschatzten Endometriumkarzinom erheblich. Das Rezidiv kann entweder aufgrund unzureichender Therapie oder aufgrund besonderer Aggressivitat des Karzinom bei vermeintlich adaquater Therapie entstehen (1). In einer retrospektiven Analyse soll gezeigt werden, welche Parameter des Primatumors die Rezidivhaufigkeit beeinflussen und so den Grad der Malignitat widerspiegeln. Weiterhin soll der Einflus der adjuvanten Strahlentherapie auf die Rezidivhaufigkeit und die Lokalisation analysiert werden.

Die idiopathische thrombozytopenische Purpura (ITP, Morbus Werlhof) ist eine chronische, zum Teil in Schuben verlaufende erworbene Thrombozytopenie, die durch Autoantikorper (7SIgG-Globuline) verursacht wird. Das klinische Bild der durch den Thrombozytenmangel verursachten hamorrhagischen Diathese ist sehr variabel. Der Altersgipfel der haemorrhagischen Diathese ist sehr variabel. Der Altersgipfel dieser Erkrankung liegt im fuhren Erwachsenenalter, wobei Frauen dreifach haufiger betroffen sind als Manner [17]. Die Bevorzugung des weiblichen Geschlechts fuhrt dazu, das der Geburtshelfer gelegentlich mit einer Patientin konfrontiert werden kann, die in der Anamnese eine ITP aufweist oder bei der sich diese Erkrankung in der Schwangerschaft zum erstenmal manifestiert hat. Das klinische Bild ist gepragt von plotzlich auftretenden Petechien und Schleimhautblutungen vor allem an den distalen Extremitaten. Auch Nasenbluten wird haufig beobachtet, wahrend Blutungen in die Gelenke, Retinablutungen und intrakranielle Blutungen selten sind. Eine Splenomegalie findet sich in 10% und spricht fur eine chronische, symptomatische Form der Thrombozytopenie.

Seit etwa 15 Jahren werden humane Papillomviren (HPV) als mogliche Cofakto-ren bei der Entstehung des menschlichen Zervixkarzinoms diskutiert. In bis zu 90% der primaren invasiven Zervixkarzinome kann HPV-DNA verschiedener Typen nachgewiesen werden. Die Ergebnisse zahlreicher zell- und molekularbiologischer Untersuchungen aus den letzten Jahren deuten auf eine kausale Bedeutung dieser Viren bei der Karzinogenese an der Zervix hin (zur Hausen 1989).

In der UFK Freiburg wurden von 1973–1989 1404 Patientinnen wegen eines Mammakarzinoms behandelt. Die 5-J-ULZ aller Patientinnen lag bei 67%, die 10-J-ULZ bei 41,6%. Die mediane Beobachtungsdauer betragt derzeit 76 Monate.

Die unvollstandige oder vollstandige Losung der Plazenta von der Uteruswand vor der Geburt des Kindes kann sich nicht nur fur das Kind intrauterin, sondern auch fur die Mutter zu einem vital bedrohlichen Krankheitsbild entwickeln. Als mogliche Ursachen dieser Erkrankung, die uber die Bildung eines retroplazen-taren Hamatoms zur Gerinnungsstorung der Mutter fuhren kann, gelten die Gestose und Veranderungen an den Arteriolen des Endometriums. Doch sind hier noch viele Fragen offen. Die Diagnostik stutzte sich fruher allein auf die klinische Symptomatik: den schmerzhaften Uterus, die Blutung und die Veranderung der kindlichen Herztone. Darauf basierte die Einteilung dieses Krankheitsbildes in vier Schweregrade nach Page et al. 1954. Die Sonographie hat hier die diagnostischen Moglichkeiten entscheidend verbessert. Auch die Therapie hat sich in den vergangenen Jahren gewandelt: einerseits konnte die Perinatologie die Prognose der Fruhgeburten entscheidend verbessern, andererseits haben der Einsatz von Prostaglandinen und die gezielte Substitution von Gerinnungsfaktoren die moglichen mutterlichen Komplikationen reduziert. Um diese Vermutung zu uberprufen, wurden die an der UFK Freiburg in den Jahren 1968–1987 beobachteten Falle einer vorzeitigen Plazentalosung retrospektiv analysiert und die zwei Dezennien einander gegenubergestellt.

Spezifische Steroidhormonrezeptoren vermitteln die Wirkung von Ostrogenen und Progesteron am Endometrium im physiologischen Zyklus der geschlechtsreifen Frau. Seit mehr als 15 Jahren konnen Ostrogen- und Progesteronrezeptoren im Zytoplasma und in der Kemfraktion von Endometriumzellen nachgewiesen werden [6,16,22]. Innerhalb des menstruellen Zyklus gibt es quantitative Unterschiede mit einem Gipfel von Ostrogenrezeptoren zur Zyklusmitte, dem sich die maximale Konzentration der Progesteronrezeptoren unmittelbar anschliest. In Gewebsproben von pramalignen und malignen Veranderungen des Endometriums lassen sich ebenfalls Steroidhormonrezeptoren nachweisen - allerdings in geringerer Konzentration [5]. Es ergaben sich recht fruh Hinweise auf eine Beziehung zwischen dem Steroidhormonrezeptorgehalt und der histologischen Differenzierung: je mehr das histologische Bild dem Ursprungsgewebe glich, desto haufiger liesen sich Steroidhormonrezeptoren nachweisen; entdifferenzierte Karzinome waren eher rezeptornegativ [13]. Die Steroidhormonrezeptoren beim Endometriumkarzinom scheinen auch mit anderen klinisch bekannten Prognosefaktoren wie beispielsweise dem Stadium oder der Infiltrationstiefe zu korrelieren. Schlieslich ist es eine offene Frage, ob den Ostrogen- oder den Progesteronrezeptoren eine eigene prognostische Bedeutung zuzurechnen ist.

The managing of the pregnant patient with immune thrombocytopenic purpura (ITP) is complicated by the unavailability of the foetal platelet count and the risk of bleeding. We report on our experiences of 17 pregnancies in 15 patients, who delivered in the Department of Gynaecology of Freiburg University from 1969 to 1989 (frequency: 0.5 per 1,000). ITP was established prior to pregnancy in 9 of 15 patients, and developed in 6 cases during pregnancy. The a patients received steroid therapy ante partum. However, maternal platelet count did not relate to infant platelet count. Eleven infants were born vaginally, six by caesarean section. One of the 17 live births died immediately post partum at the 28th week of gestation. Six infants were temporarily thrombocytopenic at delivery without further morbidity. Based on our experience and the literature, an individual management of delivery for parturient patients with ITP is recommended.

Das Endometriumkarzinom zahlt zusammen mit dem Karzinom der Cervix uteri zu den zweithaufigsten bosartigen Erkrankungen der Frau. Eine Zunahme der Haufigkeit des Endometriumkarzinoms, dessen Altersgipfel zwischen dem 60. und 70. Lebensjahr liegt, ist vor allem auf eine hohere Lebenserwartung der weiblichen Bevolkerung und z.T. auf sozialkulturelle Faktoren zuruckzufuhren. So gelten Adipositas, Diabetes mellitus und Hypertonie als typische Risikofaktoren dieser Erkrankung. Das Endometriumkarzinom wird allgemein fur eine maligne Erkrankung mit relativ gunstiger Prognose gehalten. Denn mehr als Dreiviertel der Patientinnen erkranken im Stadium I, das eine 5-Jahresuberlebensrate von mehr als 70% aufweist. Dies ist in Anbetracht des hohen Durchschnittsalters der Patientinnen ein relativ gunstiges Ergebnis. Demgegenuber stellen Patientinnen in sehr ungunstigen Stadium IV mit 2,8% eine Seltenheit dar (Tabelle 1).

Das Adenokarzinom der Cervix uteri entwickelt sich histogenetisch aus dem endozervikalen Drusenepithel oder aus den sogenannten Reservezellen der Grenzzone zwischen Platten- und Drusenepithel. Es stellt etwa 5% aller Zervixkarzinome dar. Zahlreiche Autoren berichten in den letzten Jahren uber eine Zunahme des Anteils der Adenokarzinome auf bis zu 10% und mehr (Tasker u. Collins 1974; Tamimi u. Figge 1982). Bei 3043 Patientinnen, die wegen eines Zervixkarzinoms an der Universitatsfrauenklinik Freiburg in den Jahren 1964–1985 zur Behandlung kamen, wurden 192 Adenokarzinome (6,3%) beobachtet. Ihr prozentualer Anteil stieg im Verlauf dieser Jahre von 5,3% auf 8,3%, die absolute Zahl der Adenokarzinome pro Jahr ist jedoch konstant geblieben bzw. eher rucklaufig. Dieser Effekt last sich vor allem durch einen starkeren Ruckgang der Plattenepithelkarzinome der Cervix uteri erklaren.

Die Indikation zur Radikaloperation war in den letzten beiden Jahrzehnten in unserer Klinik, wie auch in anderen grosen onkologischen Zentren, einem standigen Wandel unterworfen. Zu Beginn der 70er Jahre wurde die Indikation zur Radikaloperation in den FIGO-Stadien I b, II a und selten auch bei zervixnaher Induration des Parametriums, also im Stadium II b, vor allem dann gestellt, wenn eine Kontraindikation fur eine Strahlentherapie vorlag. Solche Kontraindikationen wurden bei gleichzeitig bestehenden Adnextumoren, grosen Myomen, einer Schwangerschaft, grosen exophytischen Zervixkarzinomen, vorausgegangenen ausgedehnten Konisationen und auch bei Adenokarzinomen wegen ihrer vermuteten geringeren Strahlensensibilitat gesehen [23].

The different prognoses for patients with adenocarcinomas and squamous cell carcinomas of the cervix uteri were proved by matched-pair analysis. One hundred forty-four patients with adenocarcinoma treated in 1964-1985 were compared in a ratio of 1:2 with 268 patients with squamous cell carcinoma comparable in age, stage, and treatment modality. In both groups 45% of patients were in stage I, 38% in stage II, 15% in stage III, and 2% in stage IV. Five- and 10-year survivals of patients with adenocarcinoma were significantly lower than for those with squamous cell carcinoma (53% resp. 42% vs 68% vs 58%, P = 0.006). In an analyses of patients' prognosis according to clinical stage there was no significant difference between both groups in stages III and IV treated exclusively by radiotherapy. No significant differences were found in stage I and II patients treated by radical surgery. However, the most significant difference in prognosis was seen in stage I and II patients treated by radiotherapy. Five-year survival was 58.6% in stage I adenocarcinomas compared with 85.0% in squamous cell carcinomas. It can be concluded from these results that a discussion of the problem of FIGO staging is more necessary than a discussion of the different radiosensitivities of these two histological types. Surgical treatment must have the same priority as radical surgery or staging laparotomy for exact histologic staging in adenocarcinomas of the cervix uteri.

Summary Fatal GVHD developed in two male newborn babies, who had been treated by repeated intrauterine (only case 2) and exchange blood transfusions because of severe Rhesus incompatibility. The clinical manifestations of the disease were fever, enlargement of liver and spleen, diarrhea, exanthema, anemia, and blood eosinophilia. Both babies died at the age of three weeks. In case 2 identical HL-A antigens were found in the blood of the last donor and in the lymphocytes of the baby obtained shortly after death. Autopsy and histologic examinations disclosed a marked atrophy of the lymphatic organs with depletion of lymphocytes, together with an hypoplastic bone marrow. Around blood vessels in the systemic connective tissue and in many organs infiltrates of eosinophilic granulocytes, histiocytes, lymphocytes and lympho-monocytoid blasts were found. The gastro-intestinal tract, the liver and the skin were predominantly affected. In addition we observed hemorrhagic necroses of lymph nodes with extreme dilatation of lymph vessels, which were occupied by mature and immature erythroid and monocytoid cells. Ringshaped fibrinoid and hemorrhagic necroses were also found in the spleen around the Malpighian corpuscles. These inflammatory and necrotizing tissue damages are attributed to local immune reactions between proliferating T-lymphocytes of the donor and tissue antigens of the host. No primary defect of the immune system of the babies could be verified. It is therefore postulated that intrauterine transfusions (or an accidental materno-fetal transfusion via the placenta) induced a state of nonspecific immune tolerance by exhaustion of the immature cellular immune defence mechanisms of the fetus, thus allowing subsequent implants of immune competent cells not to be rejected but to proliferate and inhabit the lymphatic organs of the host. This hypothesis is supported by two facts: 1. Intrauterine and subsequent exchange transfusions are usually required to induce GVHD in primary immunologically normal babies (with Hassal's corpuscles and immune globulines shown to be present). 2. Only lymphocytes of the exchange transfusion donors and non of the intrauterine donors were found in the blood of the GVHD babies. Both these requirements were also met in the cases of Naiman et al. (1969) and Parkman et al. (1974). Our case 1 may have been caused by a slightly different mechanism in that instead of intrauterine transfusions, maternal blood cells had crossed the placenta and had induced a state of nonspecific fetal immune tolerance. This, however, could not be directly proven because no immunological and cytogenetic studies were performed in this case.

Die Diskussion und das Vorlegen von Erfahrungsberichten im Arbeitskreis hat ergeben, das eine Fruherkennung des Endometriumcarcinoms mit geeigneten morphologischen Methoden grundsatzlich moglich ist.

Prognostic significance of DNA content and of distribution of cell cycle phases in ovarian carcinomas (stage III and IV) were investigated using flow cytometry. From 37 tumors 15 had DNA indices less than 2.5 and 22 had DNA indices greater than or equal to 2.5 (diploid = 2). Patients with diploid or near diploid tumors had significantly longer survival times than those with aneuploid tumors (DNA indices greater than 2.5) (log-rank test, p = 0.009, rank-sum test, p = 0.011). Patients whose tumors showed a high proportion of S/G2/M-phase cells (greater than 17%) had shorter survival times than those with tumors with a lower proportion of S/G2/M-phase cells (log-rank test p = 0.009, rank-sum test p = 0.022). The median length of follow-up of the patients was 4 years. Thus, our experiments have shown that measurements of DNA ploidy and proliferative activity using flow cytometry are important prognostic indicators for patients with ovarian carcinomas. In the future these factors might play an important role for the prognosis of patients with ovarian carcinomas. In addition, there exists a tendency for patients with in vitro resistant tumors to die earlier than those with sensitive tumors, but these results were not significant (log-rank test, p = 0.16; rank-sum test, p = 0.059).

Estrogen receptors (ER) and progesterone receptors (PR) were evaluated in 173 primary ovarian cancers and in 6 ovarian metastases. In epithelial ovarian carcinomas 63% had ER and 46% PR. Almost all granulosa cell tumours were receptor-positive, while sarcomas, dysgerminomas, and teratomas lacked ER and PR. Both receptors were found less often in tumours of the histological grade I than in those of grade II and III. During the development of metastases and during chemotherapy there was a loss of PR in 27% and 53% of the cases, respectively, while the amount of ER remained more or less constant. In addition to ovarian cancers ER and PR were present in carcinomas of the fallopian tube as well. ER-negative and especially PR-negative tumours seemed to respond better to chemotherapy than receptor-positive carcinomas. The possible significance of ER and PR with regard to the success of an endocrine treatment is discussed.

In 49 carcinomas of the endometrium of varying clinical stages the estrogen and progesterone receptors were studied by charcoal absorption methods. The cases were studied between 1979 and 1981. 64% of the investigated cases were receptor positive, 35% were receptor negative. Estrogen receptors were detected in 61% and progesterone receptors in 49% of the cases. Both estrogen and progesterone receptors were detected in 45% of the cases. The receptor status was correlated with the clinical stage, the microscopic differentiation and the age of the patient. In 30 cases with a follow-up of more than 3 months it was attempted to determine the prognostic value of the steroid receptor status in endometrial carcinoma. The treatment possibilities with progestational agents and antiestrogens and with tamoxifen were discussed in view of the receptor status.

Human ovarian carcinomas ( n = 215) were xenotransplanted into thymus-aplastic female nunu mice (NMRI). Growth of transplants was defined as take-off rate, growth rapidity, and feasibility of passages. In 204 cases these growth characteristics could be correlated with survival time of the individual tumor-donor patients. It could be shown that median survival time of patients without take-off was longer than with take-off. In the same way there was a significant difference between slow- and fast-growing transplants as well as in tumors with only one animal passage and with more than three passages. A life table analysis similarly shows that a good growth of a xenotransplanted human ovarian carcinoma into nude mice is correlated with a poor prognosis of individual patients. It could be demonstrated that at least in ovarian cancer growth of xenotransplants in nude mice indicates a prognostic significance.