[Large Pneumothorax in a Sleep Apnea Patient with CPAP without Previously Known Lung and Thoracic Diseases - a Case Report]. / Großer Pneumothorax unter CPAP-Therapie beim Schlafapnoepatienten ohne vorbekannte Lungen- und Thoraxerkrankungen ­ ein Fallbericht.

CPAP is the most common treatment for obstructive sleep apnea.Serious complications from this treatment are very rare. Pneumothorax following lung barotrauma under CPAP therapy has been described in case reports only in patients with pre-existing lung and thoracic diseases.A 68-year-old sleep apnea patient without pre-existing lung or thoracic diseases and with established CPAP therapy since many years was admitted to the hospital after a severe thoracic pain event with persistent shortness of breath. Chest radiograph and computed tomography showed an extensive right-sided pneumothorax with basal bullous emphysema. After surgical treatment of the secondary spontaneous pneumothorax, on the third postoperative day CPAP with reduced pressure was re-introduced with satisfactory sleep apnea findings and without pneumothorax recurrence.As possible cause of pneumothorax in the patient, alveolar inflammatory changes due to over-distention and increased pressure in the alveoli was assumed, which can occur after years of CPAP treatment with gradual pressure increase.In summary, in sleep apnea patients treated with CPAP for years, after sudden onset of thoracic pain and shortness of breath possible spontaneous pneumothorax should be considered.

[Interventional treatment of tracheoesophageal/bronchoesophageal fistulas]. / Interventionelle Versorgung tracheo-/bronchoösophagealer Fisteln.

A tracheoesophageal fistula is the formation of an abnormal communication between the airway and the esophagus. Acquired tracheoesophageal fistulas can be benign or malignant. The management is either surgical or endoscopic depending on the etiology, size and anatomy of the fistula as well as on the patient's performance status. The interventional treatment of choice is endoscopic stent implantation. In general, tracheoesophageal fistulas in patients with benign conditions are managed surgically. If the patient is unfit for surgery silicone stents should be used because they can be more easily removed after a longer indwelling time compared to metal stents. Malignant fistulas are associated with very limited life expectancy of only a few weeks or months. In this situation fully covered self-expandable metal stents (FC-SEMS) are recommended, whereas surgical treatment approaches can only be considered in individual cases. Depending on the location of the fistula and the presence of an airway stenosis, tracheal stenting, esophageal stenting or parallel stenting of the trachea and the esophagus is carried out. Successful stent placement leads to immediate palliation of symptoms, such as cough or aspiration and results in a higher quality of life. Potential complications are stent migration, bleeding of the upper gastrointestinal tract, arrosion of neighboring organs and vessels with esophageal stents as well as secretion retention and obstruction with displacement of the airway with tracheobronchial stents.

Emergency oesophagectomy for oesophageal perforation after chemoradiotherapy for oesophageal cancer.

INTRODUCTION: Oesophageal perforation following chemoradiotherapy for oesophageal cancer is a devastating condition but there have been no studies investigating the role of emergency oesophagectomy for this life threatening situation. METHODS: This retrospective study comprised all cases of emergency oesophagectomy for oesophageal perforation after chemoradiotherapy for oesophageal carcinoma at a major centre for oesophageal surgery in Germany between 2004 and 2013. RESULTS: A total of 13 patients (mean age: 58.9 years) were identified. During the same time period, 356 elective oesophagectomies were performed. Tumour entities were squamous cell carcinoma (n=12) and adenocarcinoma of the oesophagus (n=1). Alcoholism (odds ratio [OR]: 25.79, 95% confidence interval [CI]: 6.70-121.70, p<0.0001) and chronic pulmonary disease (OR: 3.76, 95% CI: 1.06-14.96, p=0.027) were more common among the emergency cases. Oesophageal rupture was caused by perforation of an oesophageal stent (10 cases) or perforation during implantation of a percutaneous endoscopic gastrostomy tube (3 cases). Emergency oesophagectomy was carried out either as discontinuity resection (10/13) or oesophagectomy with immediate reconstruction (3/13). Compared with the elective cases, patients undergoing emergency oesophagectomy had significantly higher odds for sustaining perioperative sepsis (OR: 4.42, 95% CI: 1.23-16.45, p=0.01), acute renal failure (OR: 6.49, 95% CI: 1.57-24.15, p=0.005) and pneumonia (OR: 24.33, 95% CI: 3.52-1,046.65, p<0.0001). Furthermore, slow respiratory weaning was more common and there was a significantly higher tracheostomy rate (OR: 4.64, 95% CI: 1.14-16.98, p=0.02). Oesophageal discontinuity was eventually reversed in eight patients. Emergency oesophagectomy patients had odds that were three times higher for fatal outcome (OR: 3.59, 95% CI: 0.77-13.64, p=0.05). The overall mortality was 4/13. The remaining nine patients had a mean survival of 25.1 months (range: 5-46 months). The two-year-survival-rate was 38.5% (5/13). CONCLUSIONS: Despite the most unfavourable preconditions, the results of emergency oesophagectomy for oesophageal perforation after chemoradiotherapy are not desperate. The procedure is not only justified but life saving.

[Therapy of bronchiectasis]. / Therapie von Bronchiektasen.

The prevalence of bronchiectasis not due to cystic fibrosis (NCFB) increases with older age. Because of multifaceted etiology of bronchiectasis an extensive diagnostic approach is essential. This includes in-depth anamnesis and a high resolution CT scan of the chest (HRCT). The pathophysiological mechanism with infection, inflammation, secretion retention and destruction determine the therapeutic options. In patients with high rates of exacerbations and severe diseases physicians should think of inhaled antibiotics and macrolids. In case of localized bronchiectasis and failure of conventional therapy surgery of bronchiectasis is an effective treatment option. In some cases surgery is necessary due to haemoptysis, aspergilloma, lung abscess and pleuraempyema. To improve the treatment options of bronchiectasis results of epidemiological, basically and clinical research trials are expected and needed.

Gangrene of the oesophago-gastric junction caused by strangulated hiatal hernia: operative challenge or surgical dead end.

BACKGROUND: Gangrene of the oesophago-gastric junction due to incarcerated hiatal hernia is an extremely uncommon emergency situation which was first recognized in the late nineteenth century. Early symptoms are mainly unspecific and so diagnosis is often considerably delayed. Aim of the study is to share experience in dealing with this devastating condition. MATERIAL: We encountered three male patients with gangrene of the oesophago-gastric junction caused by strangulated hiatal hernia within the last years. Clinical symptoms, surgical procedures and outcomes were retrospectively analyzed. Furthermore, we provide a history outline on the evolving surgical management from the preliminary reports of the nineteenth century up to modern times. RESULTS: Early symptoms were massive vomiting accompanied by retrosternal and epigastric pain. Hiatal hernia was already known in all patients. Nevertheless, clinical presentation was initially misdiagnosed as cardiovascular disorders. Upon emergency laparotomy gangrene of the oesophago-gastric junction was obvious while in one case even necrosis of the whole stomach occurred after considerable delayed diagnosis. Transmediastinal esophagectomy with resection of the proximal stomach and gastric pull up with cervical anastomosis was performed in two cases. Oesophago-gastrectomy with delayed reconstruction by retrosternal colonic interposition was mandatory in the case of complete gastric gangrene. Finally all sufferers recuperated well. CONCLUSIONS: Strangulation of hiatal hernia with subsequent gangrene of the oesophago-gastric junction is a life-threatening condition. Straight diagnosis is mandatory to avoid further necrosis of the proximal gastrointestinal tract as well as severe septic disease. Surgical strategies have considerably varied throughout the last 100 years. In our opinion transmediastinal oesophagectomy with interposition of a gastric tube and cervical anastomosis should be the procedure of choice if the distal stomach is still viable. Otherwise oesophago-gastrectomy is unavoidable. Delayed cervical anastomosis or reconstruction is advisable in instable, septic patients.

Does the Incidence of Adenocarcinoma of the Esophagus and Gastric Cardia Continue to Rise in the Twenty-First Century?-a SEER Database Analysis.

BACKGROUND: The rising incidence and histological change to adenocarcinoma in esophageal cancer over the past four decades has been among the most dramatic changes ever observed in human cancer. Recent reports have suggested that its increasing incidence may have plateaued over the past decade. Our aim was to examine the latest overall and stage-specific trends in the incidence of esophageal adenocarcinoma. PATIENTS AND METHODS: We used the Surveillance Epidemiology and End Results (SEER) database of the National Cancer Institute to identify all patients with adenocarcinoma of the esophagus and gastric cardia between 1973 and 2009. Both overall and stage-specific trends in incidence were analyzed using joinpoint regression analysis. RESULTS: The overall incidence of adenocarcinoma of the esophagus and the gastric cardia increased from 13.4 per million in 1973 to 51.4 per million in 2009, a nearly 400 % increase. Jointpoint analysis demonstrated that the yearly increase in incidence has slowed somewhat from 1.27 per million before 1987 to 0.97 between 1987 and 1997 and 0.65 after 1997. Stage-specific analysis suggests that the incidence of noninvasive cancer has actually declined after 2003 with a yearly decrease of 0.22. The percentage of patients diagnosed with in situ cancer declined after 2000 and remained under 2.5 % through the study period. CONCLUSIONS: The incidence of esophageal adenocarcinoma continues to rise in the USA. The percentage of patients diagnosed with in situ cancer has declined in the twenty-first century.

Time trends and disparities in lymphadenectomy for gastrointestinal cancer in the United States: a population-based analysis of 326,243 patients.

BACKGROUND: The value of lymphadenectomy in most localized gastrointestinal (GI) malignancies is well established. Our objectives were to evaluate the time trends of lymphadenectomy in GI cancer and identify factors associated with inadequate lymphadenectomy in a large population-based sample. METHODS: Using the National Cancer Institute's Surveillance Epidemiology and End Results Database (1998-2009), a total of 326,243 patients with surgically treated GI malignancy (esophagus, 13,165; stomach, 18,858; small bowel, 7,666; colon, 232,345; rectum, 42,338; pancreas, 12,141) were identified. Adequate lymphadenectomy was defined based on the National Cancer Center Network's recommendations as more than 15 esophagus, 15 stomach, 12 small bowel, 12 colon, 12 rectum, and 15 pancreas. The median number of lymph nodes removed and the prevalence of adequate and/or no lymphadenectomy for each cancer type were assessed and trended over the ten study years. Multivariate logistic regression was employed to identify factors predicting adequate lymphadenectomy. RESULTS: The median number of excised nodes improved over the decade of study in all types of cancer: esophagus, from 7 to 13; stomach, 8-12; small bowel, 2-7; colon, 9-16; rectum, 8-13; and pancreas, 7-13. Furthermore, the percentage of patients with an adequate lymphadenectomy (49 % for all types) steadily increased, and those with zero nodes removed (6 % for all types) steadily decreased in all types of cancer, although both remained far from ideal. By 2009, the percentages of patients with adequate lymphadenectomy were 43 % for esophagus, 42 % for stomach, 35 % for small intestine, 77 % for colon, 61 % for rectum, and 42 % for pancreas. Men, patients >65 years old, or those undergoing surgical therapy earlier in the study period and living in areas with high poverty rates were significantly less likely to receive adequate lymphadenectomy (all p < 0.0001). CONCLUSIONS: Lymph node retrieval during surgery for GI cancer remains inadequate in a large proportion of patients in the USA, although the median number of resected nodes increased over the last 10 years. Gender and socioeconomic disparities in receiving adequate lymphadenectomy were observed.

Endoscopic stent insertion for anastomotic leakage following oesophagectomy.

INTRODUCTION: Intrathoracic anastomotic leakage following oesophagectomy is a crushing condition. Until recently, surgical re-exploration was the preferred way of dealing with this life threatening complication. However, mortality remained significant. We therefore adopted endoscopic stent implantation as the primary treatment option. The aim of this study was to investigate the feasibility and results of endoscopic stent implantation as well as potential hazards and pitfalls. METHODS: Between January 2004 and December 2011, 292 consecutive patients who underwent an oesophagectomy at a single high volume centre dedicated to oesophageal surgery were included in this retrospective study. Overall, 38 cases with anastomotic leakage were identified and analysed. RESULTS: A total of 22 patients received endoscopic stent implantation as primary treatment whereas a rethoracotomy was mandatory in 15 cases. There were no significant differences in age, frequency of neoadjuvant therapy or ASA grade between cases with and without a leak. However, patients with a leak were five times more likely to have a fatal outcome (odds ratio: 5.10, 95% confidence interval: 2.06-12.33, p<0.001). Stent migration occurred but endoscopic reintervention was feasible. In 17 patients (77%) definite closure and healing of the leak was achieved, and the stent was removed subsequently. Two patients died owing to severe sepsis despite sufficient stent placement. Moreover, stent related aortic erosion with consecutive fatal haemorrhage occurred in three cases. CONCLUSIONS: Stent implantation for intrathoracic oesophageal anastomotic leaks is feasible and compares favourably with surgical re-exploration. It is an easily available, minimally invasive procedure that may reduce leak related mortality. However, it puts the already well-known risk of stent-related vascular erosion on the spot. Awareness of this life threatening complication is therefore mandatory.

Pulmonary infections imitating lung cancer: clinical presentation and therapeutical approach.

BACKGROUND: Pulmonary infections occasionally present with infectious pseudotumour of the lung not easily distinguishable from true pulmonary neoplasm. In such cases, radiographic findings and clinical manifestation are highly suggestive of lung cancer. These inflammatory lung lesions cause significant diagnostic problems and appropriate therapy is often considerably delayed. We therefore report on our experience with infectious pseudotumour of the lung caused by bacterial, mycobacterial and fungal pulmonary infections. METHODS: In a retrospective case series, patients with lung infections simulating pulmonary carcinoma were identified. Clinical presentation, radiological features, surgical procedures and outcome were analysed. RESULTS: There were seven male and six female patients with a mean age of 53 years. Presumed pulmonary carcinoma and hemoptysis were main reasons for hospital admission. Procedures performed were video-assisted thoracoscopic wedge resection (6), lobectomy (5), video-assisted thoracoscopic lobectomy and open wedge resection each in one case. Pathologic examination of the obtained specimens revealed tuberculoma (5), aspergilloma (3), pulmonary actinomycosis related pseudotumour (3) and coccidioidoma (2). Following definite diagnosis, patients with tuberculosis and fungal infections received antituberculotic and antifungal medications, respectively. Patients suffering from pulmonary actinomycosis received penicillin. There was no in-hospital mortality. One re-thoracotomy was mandatory because of pleural empyema. CONCLUSIONS: Pulmonary infections simulating lung cancer require surgical removal both for establishing definite diagnosis and to manage complications like haemoptysis and ongoing contamination of the airways by infectious agents. Whenever feasible, limited thoracoscopic resections are preferable. Following definite diagnosis antimicrobial drug therapy for a sufficient length of time is mandatory.

Surgical management of pleural empyema in the very elderly.

INTRODUCTION: Parapneumonic pleural empyema is a critical illness. Age is an acknowledged risk factor for both pneumonia and pleural empyema. Furthermore, elderly patients often have severe co-morbidity. In the case of pleural empyema, their clinical condition is likely to deteriorate fast, resulting in life threatening septic disease. To prevent this disastrous situation we adapted early surgical debridement as the primary treatment option even in very elderly patients. This study shows the outcome of surgically managed patients with pleural empyema who are 80 years or older. METHODS: The outcomes of 222 consecutive patients who received surgical therapy for parapneumonic pleural empyema at a German tertiary referral hospital between 2006 and 2010 were reviewed in a retrospective case study. Patients older than 80 years were identified. RESULTS: There were 159 male and 63 female patients. The mean age was 60.5 years and the overall in-hospital mortality rate was 7%. Of the 222 patients, 37 were 80 years or older (range: 80-95 years). The frequencies of predominantly cardiac co-morbidity and high ASA (American Society of Anesthesiologists) grades were significantly higher for very elderly patients (p <0.001). A minimally invasive approach was feasible in 34 cases (92%). Of the 37 patients aged over 80, 36 recovered while one died from severe sepsis (in-hospital mortality 3%). There was no significant difference in mortality between the very elderly and the younger sufferers (p = 0.476). CONCLUSIONS: Early surgical treatment of parapneumonic pleural empyema shows excellent results even in very elderly patients. Despite considerable co-morbidity and often delayed diagnosis, minimally invasive surgery was feasible in 34 patients (92%). The in-hospital mortality of very elderly patients was low. It can therefore be concluded that advanced age is no contraindication for early surgical therapy.

Infected mediastinal bronchogenic cyst in a 12 year old girl.

Bronchogenic cysts are an uncommon congenital malformation deriving from the primitive foregut. They are mainly unilocular, and respiratory distress is the most common presentation in pediatric patients. We describe the case of a 12-year-old girl with a huge infected mediastinal bronchogenic cyst which was resected via an axillary muscle-sparing thoracotomy.

Surgery for inflammatory tumor of the lung caused by pulmonary actinomycosis.

BACKGROUND: Actinomycosis is an uncommon chronic suppurative bacterial infection caused by anaerobic bacteria. Pulmonary actinomycosis is even more infrequent and generally simulates a wide variety of pulmonary disorders including tuberculosis and lung cancer. Therefore delayed diagnosis and misdiagnosis is common. Here, actinomycosis was initially confused with pulmonary carcinoma. METHODS: We report on three cases of inflammatory tumors caused by pulmonary actinomycosis. All three patients were male and had a history of alcoholism and poor oral hygiene associated with dental disease. Clinical symptoms were nonspecific and radiographic imaging showed tumor-like mass lesions not distinguishable from neoplasms. Preoperative bronchoscopy, sputum culture, laboratory tests and bronchoalveolar lavage neither confirmed an infectious disease nor ruled out lung cancer. Hence all patients underwent thoracotomy for both diagnosis and definitive treatment. Intraoperatively we encountered a necrotizing infection forming cavitary as well as tumorous lesions and a lobectomy was performed due to destroyed lung tissue. In one case the tumorous lesion involved the chest wall so that partial resection of the 3rd rib with the adjacent soft tissue was mandatory. RESULTS: Histological examination of the pulmonary specimen established the diagnosis of pulmonary actinomycosis. All patients recovered well and received antibiotic therapy with oral penicillin. CONCLUSIONS: The diagnosis of pulmonary actinomycosis remains challenging. In cases of an inflammatory tumor imitating lung cancer, surgical resection is mandatory, both to confirm the diagnosis and for the definitive treatment in cases with irreversible parenchymal destruction. Here, surgery in combination with medical treatment offered reliably excellent results.

[Early esophageal cancer: pro surgical resection]. / Frühes Ösophaguskarzinom: Pro chirurgische Resektion.

Endoscopic methods are increasingly propagated as oncologically adequate and less invasive treatment modalities for early esophageal cancer compared to surgery. The superiority or equality of endoscopic treatment has, however, so far not been proven by controlled trials. Current guidelines and an analysis of recently published data support surgical resection and lymphadenectomy as the standard of care for early esophageal cancer. This is based on the following arguments: 1) a reliable complete tumor resection with clear margins in all directions (R0 resection) including removal of all precancerous and precursor lesions can currently only be achieved by surgical resection, 2) none of the currently available staging tools allows definitive exclusion of lymphatic spread. A potentially curative surgical lymphadenectomy should thus only be omitted in well-defined subgroups. 3) In experienced hands surgical resection and lymphadenectomy can be performed with low mortality and morbidity, 4) reproducible and reliable data on long-term recurrence-free survival and quality of life are currently only available for surgical series. Thus, endoscopic therapy for early esophageal cancer is an alternative to surgical resection with lymphadenectomy only in patients unfit for surgery and in strictly defined low-risk situations.

Vasospasm in the feet in workers assessed for HAVS.

BACKGROUND: Previous studies have suggested that the presence of the vascular component of hand-arm vibration syndrome (HAVS) in the hands increases the risk of cold-induced vasospasm in the feet. AIMS: To determine if objectively measured cold-induced vasospasm in the hands is a risk factor for objectively measured cold-induced vasospasm in the feet in workers being assessed for HAVS. METHODS: The subjects were 191 male construction workers who had a standardized assessment for HAVS including cold provocation digital photocell plethysmography of the hands and feet to measure cold-induced vasospasm. Bivariate analysis and multinomial logistic regression were used to examine the association between plethysmographic findings in the feet and predictor variables including years worked in construction, occupation, current smoking, cold intolerance in the feet, the Stockholm vascular stage and plethysmographic findings in the hands. RESULTS: Sixty-one (32%) subjects had non-severe vasospasm and 59 (31%) had severe vasospasm in the right foot with the corresponding values being 57(30%) and 62 (32%) in the left foot. Multinomial logistic regression indicated that the only statistically significant predictor of severe vasospasm in the feet was the presence of severe vasospasm in the hands (OR: 4.11, 95% CI: 1.60-10.6, P < 0.01 on the right side and OR: 4.97, 95% CI: 1.82-13.53, P < 0.01 on the left side). Multinomial logistic regression analysis did not indicate any statistically significant predictors of non-severe vasospasm in the feet. CONCLUSIONS: Workers assessed for HAVS frequently have cold-induced vasospasm of their feet. The main predictor of severe vasospastic foot abnormalities is severe cold-induced vasospasm in the hands.

A prospective observational study of anaemia management in cancer patients - results from the German Cancer Anaemia Registry.

The use of erythropoiesis-stimulating agents (ESA) in cancer patients is still under debate. However, little is known about rationales, strategies, objectives, and effectiveness of anaemia treatments in common practice. The Cancer Anaemia Registry prospectively surveyed about 2000 cancer patients with anaemia throughout Germany. The main objectives of anaemia treatment regardless of modality were to improve quality of life (QOL) and to correct haemoglobin (Hb) levels. The Hb threshold for any anaemia treatment (means ± SD: 9.4 ± 1.2 g/dL) but not for blood transfusions (8.7 ± 1.0 g/dL) depended on cancer type and treatment strategy. Physicians preferred ESA as first-line treatment to prevent transfusions in patients with solid tumours, if they thought that chemotherapy caused the anaemia. If they suspected other causes or patients had lymphoproliferative malignancies, physicians preferred transfusions or attempted to correct underlying disorders; both mainly to improve QOL or prognosis. Effectiveness of all strategies was comparable. However, ESA most effectively prevented transfusions; primary transfusions appeared less suitable for correcting Hb or improving QOL. Using supportive treatments for QOL improvement was common whereas diagnostic measures and intravenous iron therapy were underused. Prospective clinical trials using QOL as end point and evaluating diagnostics in cancer-associated anaemia are warranted.

No easy solution for the fractionation of faecal nitrogen in captive wild herbivores: results of a pilot study.

Faecal nitrogen (FN) concentration is used as a marker for habitat quality and digestive efficiency in free-ranging herbivores. In herbivores, FN can be separated into undigested plant N (analysed as the N concentration of the neutral detergent residue) and metabolic faecal N (MFN). It has been suggested that by differential analysis of the faecal fibre-bound N, the MFN fraction can be further split into a bacterial N and an endogenous N fraction [Hesta et al., Br. J. Nutr. 90 (2003) 1007]. We applied these methods to 96 faecal samples of 48 mammalian herbivore species from zoos. Species were grouped into coprophageous and non-coprophageous hindgut fermenters and ruminating and non-ruminating foregut fermenters. Diet was not controlled. The FN decreased with body mass, possibly reflecting higher proportions of concentrates in diets of smaller animals. The proportion of MFN increased with FN, indicating that higher quality food might enhance the gastrointestinal bacterial flora. The only outlier to this pattern was the lesser panda (Ailurus fulgens), confirming the low relevance of fermentative digestion in this herbivorous 'carnivore'. No relevant differences between the four digestion types were noted. The proportion of endogenous faecal N (32-80% of FN) was always higher than that of bacterial faecal N (7-30%), which contradicts basal understanding of herbivore digestive physiology. Thus, the method of Hesta et al. (2003) does not appear applicable to herbivores. While the results do not exclude the possibility that detailed differences might occur between digestion types, they indicate a high degree of similarity between herbivores that rely on bacterial fermentation, regardless of their digestion type, with respect to metabolic faecal losses.

Hemoglobin levels that trigger erythropoiesis-stimulating agent treatment decisions for cancer-associated anemia--examination of practice in Germany.

OBJECTIVE: Given the safety concerns regarding off-label use of erythropoiesis-stimulating agents (ESAs) in the treatment of cancer-associated anemia, data from the German Cancer Anemia Registry (CAR) were analyzed to examine whether current practice in Germany adheres to treatment guidelines. RESEARCH DESIGN AND METHODS: CAR was a web-based registry gathering patient data for 12 weeks following anemia diagnosis or until the primary treatment objective was achieved. RESULTS: Of over 2000 patients surveyed, 783 were treated with ESAs. Treatment was primarily aimed at improvement of quality of life (37.3%), hemoglobin correction (32.7%), and prevention of transfusions (24.4%). The average hemoglobin level triggering ESA treatment was 9.7 g/dL (6.0 mmol/L), however, starting levels varied with cancer type. For 67.8% of patients, transfusions could be avoided. ESA treatment was stopped at 11.2 g/dL (7.0 mmol/L) and maximum hemoglobin levels during the study averaged 11.8 g/dL (7.3 mmol/L). In 4.8% of the women and 6.0% of the men, maximum hemoglobin levels were >14 g/dL (8.7 mmol/L); in 15.6% and 9.1%, respectively, levels were between 13 and 14 g/dL. The median hemoglobin level triggering transfusion was 8.3 g/dL (5.2 mmol/L), irrespective of the malignant disease. CONCLUSION: Current use of ESAs for the treatment of cancer-associated anemia in Germany appears to be in good compliance with treatment guidelines. Similar results obtained from other studies in Europe and the US indicate this to be true beyond Germany.

Treating physicians' perceptions of barriers to return to work of their patients in Southern Ontario.

AIMS: The aim of this paper is to understand the treating physician's perspective with respect to the barriers that their patients face returning to work from injury and illness. METHODS: The methodology used was focus groups conducted in Southern Ontario with treating physicians. RESULTS: The main barrier identified by the treating physicians in the return to work process was the lack of accommodated work. The main areas identified for the use of additional resources was facilitated investigations, assessments and treatments for their patients and education and training for treating physicians. With respect to communication, physicians indicated that they wanted to know more about the work to which their patients were returning. CONCLUSIONS: Treating physicians believe that the most significant barriers for the timely return to work for their patients exist in the workplace, specifically related to lack of knowledge about appropriate modified work. The treating physicians' role in the return to work process is demanding due to insufficient time to deal with return to work issues, lack of training, not enough of the appropriate information and the treating physicians' role ambiguity.

A phase I clinical and pharmacokinetic study of the camptothecin glycoconjugate, BAY 38-3441, as a daily infusion in patients with advanced solid tumors.

BACKGROUND: The aim of this study was to define the maximum tolerated dose (MTD), dose-limiting toxicity (DLT) and pharmacokinetics of the camptothecin glycoconjugate BAY 38-3441, administered as an infusion for 30 min on two separate schedules every 3 weeks. PATIENTS AND METHODS: A total of 81 patients with advanced solid tumors were treated with BAY 38-3441 either at doses of 20, 40, 67, 100, 140, 210, 315, 470 and 600 mg/m2/day for 1 day every 3 weeks (single-dose schedule), or at doses of 126, 189, 246, 320 and 416 mg/m2/day once daily for three consecutive days every 3 weeks (3-day schedule). Plasma sampling was performed to characterize the pharmacokinetics of BAY 38-3441 and camptothecin with these schedules. RESULTS: DLTs included renal toxicity, granulocytopenia and thrombocytopenia on the single-day schedule at doses > or = 470 mg/m2/day, and diarrhea and thrombocytopenia on the 3-day schedule at doses > or = 320 mg/m2/day. Other non-DLTs were gastrointestinal, dermatological and hematological. Pharmacokinetics of BAY 38-3441 and camptothecin appear to be dose-dependent, but not linear. CONCLUSIONS: Renal toxicity was dose-limiting for BAY 38-3441 using 30-min infusions on the single-dose schedule. Dose escalation to 470 mg/m2/day is feasible using a 2-h infusion. However, because of the superior safety profile, we recommend the 3-day schedule for BAY 38-3441 at a dose of 320 mg/m2/day as 30-min infusions for further phase II studies.

Differentiation of a pancreatic metastasis of a renal cell carcinoma from a primary pancreatic carcinoma by echo-enhanced power Doppler sonography.

In a 70-year-old patient who had been treated for a renal cell carcinoma, a pancreatic mass was detected on CT scan. To differentiate a pancreatic metastasis of the renal cell carcinoma from a pancreatic carcinoma, an echo-enhanced power Doppler sonography was performed. The pancreatic mass demonstrated a strong echo enhancement, proving its hypervascularization. This behaviour favoured the diagnosis of a pancreatic metastasis of the renal cell carcinoma which was confirmed by histology. The principles and the role of echo-enhanced power Doppler sonography in the differential diagnosis between a primary pancreatic carcinoma and a metastasis of a renal carcinoma in the pancreas are discussed. We conclude that this technique can provide an important contribution to the diagnosis in this special instance. However, histology is the standard in the differential diagnosis of pancreatic tumours.