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Background Recurrent ventricular tachycardia (VT) can occur after left ventricular assist device (LVAD) implantation. In this case, medical treatment might be insufficient. We report a case of a left-sided thoracoscopic sympathectomy as a feasible treatment escalation in intractable VT. Case report A 72-year-old patient underwent an internal cardioverter defibrillator (ICD) implantation as primary prophylaxis for VTs in the setting of staged heart failure therapy. Afterwards, due to a progressive dilative cardiomyopathy he underwent a minimal-invasive LVAD implantation (HeartWare, Medtronic). After an uneventful minimal-invasive LVAD-implantation the patient was discharged to a rehabilitation program. However, after 7 weeks he developed recurrent VTs which were successfully terminated by ICD shocks deliveries leading to severe discomfort and frequent hospitalizations. Eventually, the patient was admitted with an electrical VT storm. Successful endocardial catheter ablation of all inducible VTs were performed combined with multiple rearrangements of his oral antiarrhythmic medication. However, all these treatments could not suppress further occurrence of VTs. After an interdisciplinary discussion the patient agreed to a left-sided video-assisted thoracoscopic sympathectomy. After a follow up of 150 days the patient was free from VTs apart from one short event. Conclusion We believe video-assisted thoracoscopic sympathectomy might be a surgical treatment option in patients with intractable recurrent VTs after catheter ablation of VT reentrant substrate even after minimal-invasive LVAD implantation.

Simple Summary Peripheral nerve sheath tumors are associated with significant morbidity. Clinical presentation, tumor location, and therapeutic strategies are variable. We aim to provide high-quality data concerning the results of interdisciplinary operative approaches for surgical resection of schwannomas. Understanding the anatomical and functional challenges of surgical interventions in the peripheral nervous system can help to enhance the outcomes of these therapies. We aim to highlight the need for interdisciplinarity and provide evidence for both excellent functional outcomes, as well as improved quality of life for patients undergoing sporadic schwannoma surgery. Abstract Most sporadic peripheral nerve sheath tumors in adults are schwannomas. These tumors usually present with significant pain but can also cause neurological deficits. Symptomatology is diverse, and successful surgical interventions demand interdisciplinarity. We retrospectively reviewed 414 patients treated between 2006 and 2017 for peripheral nerve sheath tumors. We analyzed clinical signs, symptoms, histology, and neurological function in the cohort of adult patients with schwannomas without a neurocutaneous syndrome. In 144 patients, 147 surgical interventions were performed. Mean follow-up was 3.1 years. The indication for surgery was pain (66.0%), neurological deficits (23.8%), significant tumor growth (8.8%), and suspected malignancy (1.4%). Complete tumor resection was achieved on 136/147 occasions (92.5%). The most common location of the tumors was intraspinal (49.0%), within the cervical neurovascular bundles (19.7%), and lower extremities (10.9%). Pain and neurological deficits improved significantly (p ≤ 0.003) after 131/147 interventions (89.1%). One patient had a persistent decrease in motor function after surgery. Complete resection was possible in 67% of recurrent tumors, compared to 94% of primary tumors. There was a significantly lower chance of complete resection for schwannomas of the cervical neurovascular bundle as compared to other locations. The surgical outcome of sporadic schwannoma surgery within the peripheral nervous system is very favorable in experienced peripheral nerve surgery centers. Surgery is safe and effective and needs a multidisciplinary setting. Early surgical resection in adult patients with peripheral nerve sheath tumors with significant growth, pain, neurological deficit, or suspected malignancy is thus recommended.

The aim was to evaluate the incidence of stroke in the setting of cardiac surgery with or without hemodynamically relevant asymptomatic carotid stenosis contralateral to the occlusion. We designed a historical cohorts study, focused on patients with unilateral totally occluded internal carotid arteries who were referred for any cardiac surgery at our center. Isolated unilateral occlusions were assigned to group 1 (n = 60), and those with a contralateral stenosis grade ≥ 60% were included in group 2 (n = 51). A total of 111 patients operated in our center from 1997 to 2016 were included. Patients in group 2 had an asymptomatic contralateral internal carotid artery stenosis with a mean stenosis grade of 71 ± 20%. Simultaneous carotid endarterectomy (CEA) was performed in 22 patients from group 2. The overall mortality was 8/111 (7.2%). Carotid-associated mortality was not observed, whereas an overall stroke incidence of 8/111 (7.2%) was detected. The group-related outcome showed comparable results for mortality (group 1: 4/60 (6.7%) vs. group 2: 4/51 (7.8%); p = 1.0). Regarding stroke incidence, group 2 had a higher incidence of overall strokes (2/60 (3.3%) vs. 6/51 (11.8%); p = 0.14) with more contralateral (0/60 (0%) vs. 2/51 (3.9%); p = 0.209) and ipsilateral strokes (2/60 (3.3%) vs. 4/51 (7.8%); p = 0.411). Stroke rate peaked in patients with simultaneous carotid and cardiac surgery (n = 22; 18.2%; p = 0.048). Performing simultaneous CEA during cardiac surgery in the presence of a contralateral occlusion may promote stroke. Asymptomatic contralateral carotid stenosis is a risk factor for stroke in patients with carotid occlusion prior to cardiac surgery.

We would like to thank G. Rossi et al. for their interest and taking the time to comment on our manuscript "Cryobiopsy increases the EGFR detection rate in non-small cell lung cancer”.

Cotton-based surgical invasive devices with their desired hemostyptic properties have been used for decades in the surgical field. However, in cardiac surgery using the heart-lung machine with direct retransfusion of suction blood, activated blood may re-enter the circulation without filtration and may trigger a cascade reaction leading to systemic inflammation and thrombosis. We therefore set out to evaluate the inflammatory potential of untreated and pyrogen-impregnated cotton-based surgical invasive medical devices. After incubation of the swabs with whole blood or PBMC, the cell-free supernatant was investigated for IL1β and IL6. While the reaction of human whole blood toward cotton swabs could not be influenced by any sterilization technique, dry heat and gamma-irradiation were able to diminish the inflammatory reaction of PBMC toward the material and the used pyrogens. In conclusion, using PBMC in direct contact to cotton we are the first to establish a suitable test method for quantification of the pyrogenic/inflammatory activity of this material. The unaltered reaction of whole blood, however, suggests a crosstalk of cells and plasma proteins in the inflammation activation that is not prevented by sterilization of the swabs. This new in vitro testing methodology may help to better display the clinical situation during development of new materials. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 107B: 1877-1888, 2019.

Background and objectives The role of local surgical procedures in patients with metastatic soft tissue sarcoma is still undefined. Few retrospective studies have reported survival benefits for patients with pulmonary metastases after complete surgical resection. Treatment decisions are therefore mainly based on personal experiences rather than on reproducible knowledge. Method A total of 237 patients with metastatic sarcoma, treated between 1982 and 2015 at the University Hospital Tuebingen, Germany, were eligible for inclusion. Out of the 237 screened patients, 102 patients underwent at least one metastasectomy. Overall survival was defined as the primary endpoint in this study. For association of non-linear relationship to the endpoint, significant prognostic factors were included into a recursive partitioning model. A subgroup analysis for long-term survivors was also performed. Results The median overall survival was 64 months. The 3-, 5-, 10-, and 20-years overall survival rates were 70.7%, 50.3%, 24.7%, and 14.8%, respectively. The number of resections and the progression-free intervals were independent prognostic factors in three statistical models. Conclusion Repeated resections of metastases from different localizations are a strong predictor for prolonged survival. We suggest that the progression-free interval after metastasectomy should be considered as a predictive factor for benefit from further surgery.

Objectives: Detection of activating epidermal growth factor receptor (EGFR) mutation is crucial for individualized treatment of advanced non-small-cell lung cancer (NSCLC). However little is known about how biopsy technique affects the detection rate of EGFR mutations. This retrospective, single center study evaluated the detection rate of EGFR mutations in tissue obtained by bronchoscopic cryobiopsy and compared this to other standard tissue sampling techniques. Materials and methods: We retrospectively analyzed 414 patients with histologically confirmed NSCLC and known EGFR mutation status between 3/2008-7/2014. Tumor specimens obtained by tissue preserving bronchoscopic cryobiopsy were compared to those obtained by other techniques. Results and conclusion: Analysis of bronchoscopic cryobiopsy tissue detected 29 activating EGFR mutations in 27 (21.6 ) out of 125 patients, while analysis of tissue obtained by non-cryobiopsy techniques (bronchoscopic forceps biopsies, fine needle aspiration, imaging guided transthoracical and surgical procedures) detected 42 EGFR mutations in 40 (13.8 ) out of 298 patients (p < 0.05). Cryobiopsy increased detection rate of EGFR mutations in central tumors compared with forceps biopsy (19.6 versus 6.5 , p < 0.05), while an insignificant trend was detected also for peripheral tumors (33.3 versus 26.9 ). Bronchosopic cryobiopsy increases the detection rate of activating EGFR mutations in NSCLC in comparison to other tissue sampling techniques. This will help to optimize individualized treatment of patients with advanced tumors. Because of the retrospective nature of this analysis, a prospective trial is mandatory for final assessment. © 2020 The Author(s)

Purpose Spontaneous pneumothorax (PNTX) is a common disease frequently operated at specialized thoracic surgery units. Videothoracoscopic surgery (VATS) has become the standard for treatment and recurrence prevention. While there is broad consensus regarding indications and techniques of PNTX surgery, postoperative risks and consecutive patient behavioral advice have not been sufficiently elucidated. Methods Single-center cohort analysis of 641 patients operated for primary PNTX by VATS over 10 years. Putatively recurrence-prone lifestyle activities (smoking status, flying habits, and scuba diving) and actual occurrence of recurrences were correlated. Results Follow-up rate was 46% (279/607 patients). Mean time interval between primary operation and follow-up was 61 (range: 5-177) months. In 10 patients (3.6%), a PNTX recurrence was observed. Regarding postoperative risk behavior reported at follow-up, 28% of patients were active smokers (15 ± 7 cigarettes/day), 59% traveled by plane repeatedly, and only two patients did scuba diving (0.7%). Low body-mass-index was associated with an increase in PNTX recurrence, whereas smoking, flying, and scuba diving could not be identified as risk factors. Conclusion In our study, none of the supposed "classic" lifestyle-associated risk factors for PNTX recurrence after VATS proved to be a significant threat. Postoperative patient behavior might not be constrained by overcautious medical advice.

OBJECTIVES: Lung cancer is the leading cause of death in cancer statistics throughout developed countries. While single surgical approach provides best results in early stages, multimodality approaches have been employed in advanced disease and demonstrated superior results in selected patients. With either full-dose chemotherapy and/or radiotherapy, patients usually have a poor general condition when entering surgical therapy and therefore neoadjuvant therapy can lead to a higher morbidity and mortality. Especially in the case of pneumonectomy as the completing procedure, mortality rate can exceed over 40%. Therefore, chest physicians often shy away from recommending pneumonectomy as final step in trimodal protocols. We analysed our experience with pneumonectomy after neoadjuvant chemoradiotherapy in advanced non-small-cell lung cancer (NSCLC) with a focus on feasibility, outcome and survival. METHODS: Retrospective, single-centre study of 146 patients with trimodal neoadjuvant therapy for NSCLC Stage III over 17 years time span. Follow-up was taken from our own outpatient files and with survival check of central registry office in Baden-Wurttemberg, Germany. RESULTS: A total of 118 men and 28 women received 62 lobectomies, 6 bi-lobectomies and 78 pneumonectomies after two different neoadjuvant protocols for Stage III NSCLC. Overall morbidity rate was 53 and 56% after pneumonectomy. Overall hospital mortality rate was 4.8 and 6.4% after pneumonectomy. Overall median survival rate was 31 months with a 5-year survival rate of 38% (Kaplan– Meier). Pneumonectomy, right-sited pneumonectomy and initial T- and N-stages were no risk factors for survival (log-rank test). Significant factors for survival were ypT-stage, ypN-stage, yUICC-stage in univariate testing (log-rank test) and ypUICC-stage in multivariate testing (Cox’s regression). CONCLUSIONS: Pneumonectomy in neoadjuvant trimodal approach for Stage III NSCLC can be done safe with acceptable mortality rate. Patients should not withhold from operation because of necessitating pneumonectomy. Not the procedure but the selection, response rate and R0-resection are crucial for survival after trimodal therapy in experienced centres.

The prognosis of bronchogenic carcinoma in stage III N2 is poor. Five-year survival ranges between 0 and 5%. Lymph-node involvement itself still is the main prognostic factor. Complete lymphadenectomy improves long-term survival in contrast to lymph-node sampling. Recent studies have indicated that the number of involved lymph nodes could be another prognostic factor. It has also been proved that complete lymphadenectomy is necessary for correct staging. This also applies to preoperative staging prior to neoadjuvant treatment. For this reason exact knowledge of lymph-node anatomy and drainage is required. To achieve assessment and comparison of mediastinal staging and of lymphadenectomy, the number of pathologically examined lymph nodes should be documented. Other prognostic factors within N2 stages are age and T stage. Molecular markers are subject to major investigation. A definite clinical relevance, however, could so far not be verified for any of them.

Objectives: Spontaneous pneumothorax (PTX) is a common disease frequently operated at specialized thoracic surgery units. It may arise in adolescents with healthy lung tissue (primary PTX) or in elder patients with preexisting lung disease (secondary PTX). Videothoracoscopic surgery (VATS) has become the surgical standard for treatment and recurrence prevention. While there is broad consensus regarding indications and techniques of PTX surgery, potential postoperative risks and consecutive patient behavioral advice have not been sufficiently elucidated to date. Methods: Single-center cohort analysis of 646 patients operated for primary PTX by VATS over a time period of 10 years. Putatively recurrence prone lifestyle activities (smoking status, flying habits, scuba diving) and actual occurrence of recurrences were correlated. Results: Follow up rate was 43% (279/646 patients). Mean time interval between primary operation and follow up was 61 (range 5–177) months. In 10 patients (3.6%), a PTX recurrence was observed. Regarding postoperative risk behavior reported at follow-up, 28% of patients were active smokers (in average 15 ± 7 cigarettes/day), 59% travelled by plane repeatedly, and only 2 patients did scuba diving (0.7%). Neither smoking nor flying or scuba diving could not be identified as statistically significant risk factors for PTX recurrence. Conclusions: In our study, none of the supposed “classic” lifestyle-associated risk factors for PTX recurrence after VATS proved to be a significant threat. Thus, postoperative patient behavior might not necessarily be constrained by overcautious medical advice.

OBJECTIVES: According to the actual treatment strategies of lung cancer, the current therapeutic regimen is an individualized, multidisciplinary concept. The development of chemoresistance in the last decade represents the most important obstacle to an effective treatment. In our study, we examined a new therapeutic alternative in the treatment of multiresistant lung adenocarcinoma via siRNA-specific transfection of six crucial molecules involved in lung carcinogenesis [serum response factor(SFR), E2F1, Survivin, hypoxia inducible factor1 (HIF1), HIF2 and signal transducer and activator of transcription (STAT3)]. METHODS: Three chemoresistant A549 adenocarcinoma cells were cultured under standard conditions at 37°C and 5% CO2. The chemoresistance against Vinflunine, Vinorelbine and Methotrexate was induced artificially. The A549 cells were transfected for 2 h at 37°C with specific siRNA targeting SRF, E2F1, Survivin, HIF1, HIF2 and STAT3 in a non-viral manner. The efficiency of siRNA silencing was evaluated via quantitative real-time polymerase chain reaction, whereas the surviving cells after siRNA transfection as predictor factor for tumoural growth were analysed with a CASY cell counter 3 days after transfection. RESULTS: The response of the chemotherapeutic resistant adenocarcinoma cells after siRNA transfection was concentration-dependent at both 25 and 100 nM. The CASY analysis showed a very effective suppression of adenocarcinoma cells in Vinorelbine, Vinflunine and Methotrexate groups, with significantly better results in comparison with the control group. CONCLUSIONS: In our study, we emphasized that siRNA interference might represent a productive platform for further research in order to investigate whether a new regimen in the treatment of multiresistant non-small-cell lung cancer could be established in vivo in the context of a multimodal cancer therapy.

e20613Background: Activating mutations in the epidermal growth factor receptor (EGFR) gene are pharmacological targets for EGFR tyrosine kinase inhibitors (TKI) in patients with advanced non-small-...

A 74-year-old man presented with progressive dyspnea after a 10-days latency following a thoracic trauma. CT imaging showed multiple rib fracture and an empyema that was primarily treated by a chest tube. In the course of the hospital stay, a rapidly progressive paraplegia developed and the MR imaging revealed a peridural abscess caused by a pleural empyema. Due to trauma-related barrier damage and the initial delay of the operative therapy a usually less invasive pathogen (streptococcus intermedius) could affect the peridural space. The successful therapy consisted of urgent laminectomy and a subsequent video-assisted thoracoscopy supported by systemic antibiotic therapy.

OBJECTIVES: Persistent mediastinal lymph node metastasis after neoadjuvant therapy is a significant negative indicator for survival. Even though there is still no consensus on the matter, some authors advocate a thorough restaging prior to surgery and deny surgery in cases of persistent N2 because of the poor outcome. We analysed our results after trimodal therapy in pN2/N3 stage III non-smallcell lung cancer (NSCLC) and persistent mediastinal lymph node metastasis after neoadjuvant chemoradiotherapy. METHODS: We conducted a retrospective cohort analysis of 167 patients who received trimodal therapy for stage III NSCLC. Progression-free interval and survival were calculated. T-stage, N-stage, ypT-stage, ypN2/3-stage and surgical procedure were tested as risk factors. RESULTS: Eighty-three patients with potentially resectable initial pN2/3 underwent 44 pneumonectomies and 76% extended resections. Thirty-five patients showed persistent mediastinal lymph node metastasis after trimodal therapy. Treatment-related comorbidity after an operative therapy was 58%. Hospital mortality was 2.4%. The ypT- and ypN2/N3 stages were significant risk factors and, in the case of persistent mediastinal lymph node metastasis, median progression-free period was 17 months and median survival time was 21 months. CONCLUSIONS: Persistent but resectable N2/N3 after chemoradiotherapy in stage III NSCLC is the least favourable subgroup of patients in neoadjuvant approaches. If surgery can be carried out with curative intent and low morbidity, completing trimodal therapy is justified, with an acceptable outcome.

Purpose We started a phase II trial of induction chemotherapy and concurrent hyperfractionated chemoradiotherapy followed by either surgery or boost chemoradiotherapy in patients with advanced, stage III disease. The purpose is to achieve better survival in the surgery group with minimum morbidity and mortality. Patients and Methods Patients treated from 1998 to 2002 with neoadjuvant chemoradiotherapy and surgical resection for stage III NSCLC were analyzed. The treatment consisted of four cycles of induction chemotherapy with carboplatin/paclitaxel followed by chemoradiotherapy with a reduced dose of carboplatin/paclitaxel and accelerated hyperfractionated radiotherapy with 1.5 Gy twice daily up to 45 Gy. After restaging, operable patients underwent thoracotomy. Inoperable patients received chemoradiotherapy up to 63 Gy. Study end points included resectability, pathologic response, and survival. Results One hundred twenty patients were enrolled; 25% patients had stage IIIA, 73% had stage IIIB, and 2% stage IV. After treatment, 47.5% had downstaging, 29.2% had stable disease, and 23.3% had progressive disease. Thirty patients (25%) were not eligible for operation because of progressive disease, stable disease, and/or functional deterioration with one treatment-related death. The 30-day mortality was 5% in patients who underwent operation. The 5-year survival rate for 120 patients was 21.7%, and it was 43.1% in patients with complete resection. In postoperative patients with stage N0 disease, 5-year survival was 53.3%; if stage N2 or N3 disease was still present, 5-year survival was 33.3%. Conclusion Staging and treatment with chemoradiotherapy and complete resection performed in experienced centers achieve acceptable morbidity and mortality.

Objective: In the treatment of advanced stages of lung cancer, increasingly more multimodality approaches applying radiotherapy and/or chemotherapy in a neo-adjuvant setting are being introduced. The impact of induction therapy, especially radiotherapy, on bronchial tissue viabilityhasnotbeeninvestigatedsofar.Methods:In2008,wedeterminedthetissueviabilityofbronchialsegmentsobtainedduringsurgeryin45 consecutivepatients, includingpatientsafter neo-adjuvantradiochemotherapy (RCTX).Bronchialtissue viabilitywas analysed byhistology, life— dead assay and cell proliferation in tissue-specific culture media. Biomedical findings were compared with the clinical course of the patients. Results: Tissue samples of 44 patients were included into this study. Fourteen patients (32%) had undergone neo-adjuvant RCTX. Histology and life—dead assay of the bronchial segments did not show significant differences. While patient age, sex, tumour entity and site of resection had no influence on cell proliferation in vitro, previous RCTX resulted in a 46% decrease of bronchial tissue viability (P = 0.01). However, this effect was not reflected by the clinical course of the operated patients. Conclusions: Neo-adjuvant RCTX reduces bronchial tissue viability substantially. However, this impairment does not necessarily translate into an increased rate of postoperative bronchial insufficiencies. Standard histological work-up is not sensitive enough to characterise changes in bronchial tissue viability following RCTX. # 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Background Surgery alone for stage III non–small cell lung cancer provides a 5-year survival of 20% and competes with multimodal treatments. In 1999, a trimodal protocol was implemented at the Schillerhohe Clinic. The aim of this study was to verify the feasibility and outcome of this trimodal protocol including survival, risk factors for survival, and comorbidity in a single institution. Methods Included were all patients with potentially resectable, previously untreated stage III non–small cell lung cancer operated on between February 1999 and May 2006 in the General Thoracic Surgery Unit of the Schillerhohe Clinic following the same neoadjuvant protocol. Treatment-related morbidity, recurrence, survival after R0 resection, and risk factors for survival (pN0 after trimodal therapy, downstaging of International Union Against Cancer stage, T downstaging, N downstaging, regression rate, and histologic type of tumor) were analyzed. Results From 107 patients with stage III non–small cell lung cancer, 55 patients with mediastinoscopy-positive N2 or N3 were eligible for this study. Forty patients (72%) had the effect of International Union Against Cancer downstaging. Treatment-related comorbidity was 54% with hospital and 120-day mortality of 3.6% and 5.4%, respectively. Overall mean survival (Kaplan-Meier) was 43 months (95% confidence interval, 35 to 52) with an estimated 5-year survival rate of 49%. In multivariate testing, International Union Against Cancer downstaging after trimodal therapy achieved a level of significance ( p = 0.031), and patients with UICC-downstaging after trimodal therapy had a mean survival of 53 months (95% confidence interval, 44 to 63) with an estimated 5-year survival rate of 60%. Conclusions Neoadjuvant trimodal treatment for histologically proven N2 or N3 stage III non–small cell lung cancer is promising and can, like no other approach at present time, considerably improve 5-year survival rates up to 63% in selected patients.

A neonate presented with an interrupted aortic arch type B and VSD with dysplastic aortic valve, subaortic stenosis, and aberrant right subclavian artery. We performed a direct anastomosis between the hypoplastic ascending aorta (0 3 mm), the main pulmonary artery and the descending aorta, mimicking a Norwood-type ventricular outlet. The right-ventricular outflow tract was reconstructed with a 8mm PTFE vascular graft. This combination of a modified Norwood with a Rastelli procedure facilitated establishment of a sufficiently large left-ventricular outflow tract via VSD, at the same time maintaining a biventricular system despite the coexisting anomalies.

International audience; The critical phase during cardiosurgical procedures is weaning the diseased heart from extracorporeal circulation. Postischemic heart failure sometimes requires the administration of inotropic and/or vasconstrictive agents. The natriuretic peptides influence pre- and afterload through their natriuretic, diuretic and vasodilating actions. To date, there are only few informations concerning the therapeutic effect of brain natriuretic peptide administration during cardiosurgical procedures. The goal of this study was to evaluate the effect of brain natriuretic peptide (BNP) administration following extracorporeal circulation in an animal model. Surgery was performed on twenty swine using extracorporeal circulation. A 30-minute ischemic episode was simulated. Following declamping, BNP was administered to the BNP group (n=10) by an IV bolus at 0.3 microgram/kg/min followed by an infusion at a rate of 0.015 microgram/kg/min for 60 minutes. The animals in the control group (n=10) did not receive BNP, but instead a saline solution. Hemodynamic and clinical chemistry parameters as well as the amount of catecholamines that were required were documented. All of the animals in the BNP group had a significantly better cardiac output and cardiac index at the end of the experiment. Seven out of 10 animals from the control group needed catecholamines, whereas only one animal from the BNP group did. Creatine phosphokinase levels were significantly lower in the BNP group. Systemic vascular resistance was markedly lower in the BNP group. Administration of BNP is highly effective in treating post-ischemic heart failure following extracorporeal circulation. Hemodynamics are greatly improved, and there is almost no need for pharmacological support.

Background Thoracoscopic talc pleurodesis is a therapeutic option for recurrent pleural effusion. Methods This retrospective study included 611 patients who underwent thoracoscopic talc pleurodesis between 1994 and 2003. We analyzed the risk factors, efficiency, outcome, follow-up, and survival, while taking into consideration primary disease and general condition. Results The mean follow-up was 319 days (range, 31 to 1994). A total of 105 (17.2%) of 611 patients died within 30 days after treatment. Risk factors for death within 30 days included a Karnofsky index of less than 50%, a body mass index of less than 25 kg/m 2 , malignant disease, and male gender. Treatment was successful in 347 (68.6%) of 506 patients, and 451 (89.1%) reported an improvement in symptoms. Previous thoracic irradiation and a chest tube drainage time exceeding 10 days negatively influenced the outcome of pleurodesis. The survival rate was negatively influenced by a preoperative Karnofsky index of less than 60% and by malignant disease. Conclusions Patients with pleural effusion due to malignant disease gain from early pleurodesis. The most favorable outcome after talc pleurodesis was seen in women whose lungs were fully expandable, in patients whose Karnofsky index exceeded 60%, in patients whose body mass index was greater than 25 kg/m 2 , and in patients with benign disease.

A drug targeting both the inflammatory initiators (lipopolysaccharide; LPS) and mediators [tumor necrosis factor-alpha (TNF-alpha)] should have advantage over a "single-factor targeting strategy" in sepsis prevention trials. We have prepared conjugates of polymyxin B (PMB) and the cytokine binding protein alpha2-macroglobulin (A2M). The conjugate binds TNF-alpha as well as LPS as studied by electrophoresis and phase partitioning. Compared with free PMB, the conjugate is nontoxic to cells and does not affect the viability of human monocytes. The A2M-PMB conjugate binds to the A2M receptor (CD91/low-density lipoprotein receptor-related protein 1) with affinity similar to that of the nonmodified protein. Fluorescein isothiocyanate-labeled LPS in the presence of A2M-PMB is rapidly transported into fibroblasts for degradation via receptor-mediated endocytosis. In vitro, A2M-PMB demonstrated inhibition of LPS-induced secretion of TNF-alpha from isolated monocytes as well as in the whole blood assay. The efficacy of the drug was tested in mice after induction of acute inflammation (LPS model) and after induction of a polymicrobial sepsis by cecal ligation and puncture (CLP) model. Treatment of mice with A2M-PMB up to 250 microg/g body weight was not toxic to the animal. When the drug was administered 30 min before or 30 min after the LPS challenge, a survival rate of 90 and 70%, respectively, was obtained compared with the placebo control group (5%). A2M-PMB also protected mice after induction of polymicrobial sepsis when administered 30 min before CLP. These results support our hypothesis that A2M-PMB acts as a polyvalent drug to target different host mediators as well as sepsis inducer at the same time.

Anamnese und klinischer Befund: Wir berichten uber die Kasuistik eines Patienten unter Peritonealdialyse, der sich mit Dyspnoe, geringem Auslaufvolumen und Gewichtszunahme vorstellte. Untersuchungen: Im Rontgenbild des Thorax zeigte sich ein groser rechtsseitiger Pleuraerguss. Die Punktion erbrachte eine klare eiweisarme Flussigkeit mit einer hoheren Glukosekonzentration als derjenigen im Plasma. Mittels intraperitonealer Toluidinblau-Gabe konnte eine pleuroperitoneale Leckage eindeutig nachgewiesen werden. Diagnose, Therapie und Verlauf: Es erfolgte ein Video-assistierter thoraxchirurgischer Eingriff, bei dem intraoperativ mittels Toluidinblau-Gabe insgesamt vier Durchtrittsstellen im Pars tendinosum des rechten Zwerchfells identifiziert wurden. Durch Aufnahen eines Prolenenetzes auf die Pars tendinosum wurde eine flachige Adhasion des Zwerchfells mit der Lunge induziert. Nach dreimonatiger Uberbruckung mit Hamodialyse erfolgte ein Wiederbeginn der Peritonealdialyse, ohne dass es zu einer weiteren Leckage kam. Folgerung: Im Rahmen der Peritonealdialyse kann es zu einer pleuroperitonealen Leckage mit Ausbildung eines Hydrothorax kommen, was durch einen thoraxchirurgischen Eingriff und Anbringen eines Prolenenetzes auf das Zwerchfell behandelt werden kann.