Thyroblastoma in a rhesus macaque (Macaca mulatta): A case report.

In this report, we describe the gross, histopathology, and immunohistochemical findings of a thyroblastoma that arose in the right lobe of the thyroid gland in a 2-month-old rhesus macaque (Macaca mulatta).

Toxoplasmosis in ring-tailed lemurs (Lemur catta) and a peahen (Pavo cristatus) in a zoological collection caused by the common toxoplasma genotype in wild animals in the US.

Toxoplasmosis is caused by the ubiquitous Apicomplexan protozoan Toxoplasma gondii. This pathogen affects domestic and wildlife species, but prosimians including ring-tailed lemurs (Lemur catta) are highly susceptible to infection with high mortality rates. Avian species are considered resistant to infection and are often used in surveillance efforts to determine genotypes of T. gondii present in geographical areas. This study describes the gross and histologic lesions of an outbreak of toxoplasmosis in a university-run zoological collection involving three ring-tailed lemurs and a peahen (Pavo cristatus). DNA was extracted from the liver of the lemurs and peahen to determine the genotype of T. gondii by polymerase chain reaction restriction fragment length polymorphism (PCR-RFLP), which revealed that all samples were ToxoDB PCR-RFLP genotype #5 (haplogroup 12) that is common in wildlife in North America.

Retrospective Analysis of Aetiological Agents Associated with Pulmonary Mycosis Secondary to Enteric Salmonellosis in Six Horses by Panfungal Polymerase Chain Reaction.

Pulmonary mycosis secondary to enterocolitis is an uncommon diagnosis in equine medicine, but is thought to result from mucosal compromise and translocation of enteric fungi. The aetiological agent associated with translocation is often identified based on fungal culture or hyphal features in histological sections. In order to understand better the aetiological agents involved, six horses diagnosed with Salmonella enteritis and concurrent pulmonary mycosis were identified retrospectively through a database search of veterinary teaching hospital records. Samples from these cases were subjected to polymerase chain reaction and sequencing of the internal transcribed spacer 2 (ITS-2) located between the 5.8S and 28S rRNA genes to identify the aetiological agent involved. Sequencing identified Aspergillus fumigatus, Aspergillus flavus, Fusarium spp., Cladosporium spp. and Curvularia spp. A single case had a dual infection with Fusarium spp. and A. fumigatus.

Phylogenetic analysis of Histoplasma capsulatum var duboisii in baboons from archived formalin-fixed, paraffin embedded tissues.

Histoplasma capsulatum var. duboisii (Hcd) infections have been well documented to cause chronic granulomatous disease, mainly involving the skin of baboons and humans in African countries primarily. This retrospective study classified the subspecies of Histoplasma and developed a phylogenetic tree utilizing DNA sequences extracted from formalin-fixed, paraffin embedded (FFPE) tissues from 9 baboons from a research colony in Texas histologically diagnosed with Hcd. Based on sequence analysis of ITS-2, Tub-1, and ARF, Hcd isolated from the archived samples closely aligns with the African clade and has 88% sequence homology with a sample isolated from an individual in Senegal.

Digital palpation of the pilot balloon vs. continuous manometry for controlling the intracuff pressure in laryngeal mask airways.

This study compared two methods of controlling the intracuff pressure in laryngeal mask airways. One hundred and eighty patients were randomly assigned into two groups. In the first group (n = 90), after training, the intracuff pressure was controlled using digital palpation of the pilot balloon. In the second group (n = 90), continuous manometry was used to control the intracuff pressure. An upper pressure limit of 60 cmH2 O was set. The median (IQR [range]) intracuff pressure in the palpation group was 130 (125-130 [120-130]) cmH2 O compared with 29 (20-39 [5-60]) cmH2 O in the manometry group (p < 0.001). In the palpation group, 37% of patients experienced pharyngolaryngeal complications vs. 12% in the manometry group (p < 0.001). We conclude that the digital palpation technique is not a suitable alternative to manometry in controlling the intracuff pressure in laryngeal mask airways.

[Continuous cuff pressure measurement during laryngeal mask anesthesia : An obligatory measure to avoid postoperative complications]. / Kontinuierliche Cuff-Druck-Messung bei Larynxmaskennarkosen : Eine obligatorische Maßnahme zur Vermeidung postoperativer Komplikationen.

BACKGROUND: Inflation of laryngeal masks is often performed only with regard to the clinical impression and without any objective measurement of cuff pressure. As a result the use of laryngeal masks frequently leads to postoperative complications, such as sore throat, dysphonia, dysphagia and nerve palsy. In this study the influence of continuous measurement of cuff pressure on the incidence of postoperative sore throat was investigated in patients who underwent laryngeal mask anesthesia. PATIENTS/MATERIAL AND METHODS: In the context of a retrospective audit all patients who underwent laryngeal mask anesthesia were asked to complete a questionnaire on anesthesia. The primary endpoint of the study was the postoperative occurrence of a sore throat. For analysis the patients were divided into two groups. In the first group the cuff pressure was controlled only by clinical means and in the second group the cuff pressure was controlled using continuous manometry. The study covered a 10-month period of observation for each group. RESULTS: During the observation period laryngeal mask anesthesia was performed in 4169 patients. Of these 917 patients (manometry group n = 433 and control group n = 484) voluntarily completed the questionnaire. In the group without cuff pressure measurement 36 % of patients complained of sore throat postoperatively but only 12 % of the patients in the group with cuff pressure measurement (p < 0.001). Postoperative nausea and vomiting occurred in 16 % of the patients and 13 % complained of severe pain in the area of the operation. No differences between the two groups were found. While 97 % of patients in the group with continuous measurement of cuff pressure were satisfied with the anesthesia, this applied to only 79 % of patients in the control group (p = 0.006). CONCLUSION: In terms of the results of this study and with respect to data from the literature, measurement of cuff pressure should be compulsory during laryngeal mask anesthesia.

Overinflation of the cuff and pressure on the neck reduce the preventive effect of supraglottic airways on pulmonary aspiration: an experimental study in human cadavers.

BACKGROUND: The oesophageal leak pressure is defined as the pressure which breaks the seal between the cuff of a supraglottic airway and the peri-cuff mucosa, allowing penetration of fluid into the pharynx and the oral cavity. As a consequence, a decrease in this variable increases the risk of reflux and can lead to pulmonary aspiration. The aim of this study was to analyse the effects of cuff overinflation and pressure on the neck on the oesophageal leak pressure of seven supraglottic airways. METHODS: Three laryngeal masks, two laryngeal tubes, and two oesophageal-tracheal tubes were tested in an experimental setting. In five human cadavers, we simulated a sudden increase in oesophageal pressure. To measure baseline values (control), we used an intracuff pressure as recommended by the manufacturer. The first intervention included overinflation of the cuff by applying twice the amount of pressure recommended. A second intervention was defined as external pressure on the neck. RESULTS: The oesophageal leak pressure was decreased for laryngeal masks (control, 28 cm H2O; overinflation, 9 cm H2O; pressure on the neck, 8 cm H2O; P<0.01) and for laryngeal tubes (control, 68 cm H2O; overinflation, 37 cm H2O; pressure on the neck, 39 cm H2O; P<0.01) and was unaffected for oesophageal-tracheal tubes (control, 126 cm H2O; overinflation/pressure on the neck, 130 cm H2O; n.s.). CONCLUSION: Cuff overinflation and pressure on the neck can enhance the risk of gastro-oesophageal reflux when using supraglottic airways. Therefore, both manoeuvres should be avoided in clinical practice.

Hodgkin lymphoma is as common as non-Hodgkin lymphoma in HIV-positive patients with sustained viral suppression and limited immune deficiency: a prospective cohort study.

OBJECTIVES: The incidence of HIV-related non-Hodgkin lymphoma (NHL) but not that of Hodgkin lymphoma (HL) has been declining. The aim of the study was to compare HIV-infected patients with NHL and HL with respect to antiretroviral therapy (ART) exposure at the time of lymphoma diagnosis. METHODS: HIV-infected patients with NHL and HL included in a prospective multicentre cohort study since January 2005 were compared with respect to ART exposure and viral load at the time of lymphoma diagnosis. RESULTS: As of 31 December 2012, data for 329 patients with NHL and 86 patients with HL from 31 participating centres were available. Patients with HL were more likely to be on ART (73.5% vs. 39.1%, respectively; P < 0.001) and more frequently had a viral load below the detection limit (57.3% vs. 27.9%, respectively; P < 0.001) than patients with NHL. The proportion of patients with HL was 8.0% in ART-naïve patients, 34.8% in patients with current HIV RNA < 50 HIV-1 RNA copies/mL, and 50.0% in patients with both HIV RNA < 50 copies/mL for > 12 months and a CD4 cell count of > 200 cells/µL. Of note, 45.8% of all patients with NHL were not currently on ART and had a CD4 count of < 350 cells/µL. CONCLUSIONS: This prospective cohort study shows that HL was as common as NHL in patients with sustained viral suppression and limited immune deficiency. In contrast to NHL, the majority of patients with HL were on effective ART, suggesting that ART provides insufficient protection from developing HL. The high proportion of untreated patients with NHL suggests missed opportunities for earlier initiation of ART.

[Assessment of quality of life and gynaecological follow-up after transvaginal cholecystectomy]. / Untersuchungen zur Lebensqualität und gynäkologisches Follow-up nach transvaginaler Cholezystektomie.

BACKGROUND: It has been reported recently that transvaginal cholecystectomy (TV­ChE) has advantages over 'classic' laparoscopic cholecystectomy (LAP­ChE) because of its minimal invasiveness. TV­ChE seems to be associated with a lesser need for analgesics and faster reconvalescence of patients. However, substantial doubts about the transvaginal access and possibly associated complaints and complications of the procedure have been raised. PATIENT/MATERIAL AND METHODS: In this prospective case-control study 30 female patients undergoing transvaginal cholecystectomy (TV­ChE group) have been compared with 30 women undergoing conventional laparoscopic cholecystectomy (LAP­ChE group). Female patients were evaluated with special regard to health-related quality of life, outcome data such as surgical complications and gynaecological complaints and changes in sexual behaviour after surgery. Additional attention was given to the extent of postoperative pain, the analgesic consumption and the rate of postoperative nausea and vomiting (PONV). RESULTS: The demographic data of both groups were comparable to a great extent. Compared to the LAP­ChE group women of the TV­ChE group reported less postoperative pain, less PONV and a lower analgesic consumption (p < 0.001). There were no serious complications in the LAP­ChE group and also none in the TV­ChE group. In comparison with the preoperative status, the results regarding health-related quality of life and feeling of well-being were significantly better for both groups after a follow-up of 12 months (p < 0.01). However, this effect was especially pronounced in the TV­ChE group (p < 0.05). No infections of the surgical wound, wound healing problems or other complications were seen in the gynaecological follow-up examination 3 weeks after the TV­ChE. Two women reported slight and temporary colpotomy-related complaints without any consequences for their sexual behaviour. CONCLUSIONS: The transvaginal cholecystectomy is a safe and less invasive surgical technique providing for an excellent patient comfort and a fast reconvalescence. TV­ChE has a positive longterm effect on health-related quality of life. Doubts about transvaginal approach of this surgical technique with regard to an increased risk of infection or late gynaecological complications appear to be unfounded.

The impact of allogeneic stem cell transplantation on the natural course of poor-risk chronic lymphocytic leukemia as defined by the EBMT consensus criteria: a retrospective donor versus no donor comparison.

BACKGROUND: In a single-center retrospective donor versus no-donor comparison, we investigated if allogeneic stem cell transplantation (alloSCT) can improve the dismal course of poor-risk chronic lymphocytic leukemia (CLL). PATIENTS AND METHODS: All patients with CLL who were referred for evaluation of alloSCT within a 7-year time frame and had a donor search indication according to the EBMT criteria or because of Richter's transformation were included. Patients for whom a matched donor could be found within 3 months (matches) were compared with patients without such a donor (controls). Primary end point was overall survival measured from the 3-month landmark after search initiation. RESULTS: Of 105 patients with donor search, 97 (matches 83; controls 14) were assessable at the 3-month landmark. Matches and controls were comparable for age, gender, time from diagnosis, number of previous regimens, and remission status. Disregarding if alloSCT was actually carried out or not, survival from the 3-month landmark was significantly better in matches versus controls [hazard ratio 0.38, 95% confidence interval (CI) 0.17-0.85; P = 0.014]. The survival benefit of matches remained significant on multivariate analysis. CONCLUSION: This study provides first comparative evidence that alloSCT may have the potential to improve the natural course of poor-risk CLL as defined by the EBMT criteria.

[Postoperative pain management after minimally invasive hysterectomy: thoracic epidural analgesia versus intravenous patient-controlled analgesia]. / Postoperative Schmerztherapie nach minimalinvasiver Hysterektomie : Thorakale Periduralanalgesie vs. intravenöse patientenkontrollierte Analgesie.

BACKGROUND: In view of the development of innovative and non-traumatic surgical techniques, postoperative pain management should be carried out depending on the invasiveness of the intervention. In the present study two analgesic strategies were compared in patients undergoing minimally invasive hysterectomy: epidural analgesia (EDA) and intravenous patient-controlled analgesia (iv-PCA). MATERIAL AND METHODS: For this prospective case controlled study 60 women with benign uterine diseases undergoing vaginal hysterectomy (VH) or laparoscopically assisted vaginal hysterectomy (LAVH) were enrolled. Patients were divided for analysis into two groups (n=30 each) according to the postoperative analgesic strategy (EDA group versus iv-PCA group). A matched-pair analysis was applied (matching criteria: risk assessment, surgeon and age of patient) to minimize the differences between both groups. Patients were evaluated with respect to the extent of pain determined by a numeric rating scale (NRS 0-10 scale), analgesic consumption, rate of postoperative nausea and vomiting (PONV), mobilization from bed, oral intake of nutrition, complications, duration of stay in the recovery room as well as hospital stay and health-related quality of life (SF-36 Health Survey; collected before and 6 weeks after surgery). RESULTS: Laparoscopically assisted removal of the uterus was carried out in 22 women and by vaginal hysterectomy in 38 women. No significant differences between the study groups were seen in the duration of surgery (iv-PCA 58 ± 25 min versus EDA 60 ± 26 min). Demographic data of both groups as well as intraoperative hemodynamic and respiratory parameters were comparable to a great extent. Compared to the iv-PCA group, women in the EDA group showed lower NRS values (p<0.01): recovery room admission 4.7 ± 2.5 iv-PCA vs. 0.9 ± 1.3 EDA, recovery room discharge 3.8 ± 1.8 iv-PCA vs. 1.0 ± 1.2 EDA, day of surgery at 8 p.m. 5.0 ± 2.1 iv-PCA vs. 1.8 ± 2.3 EDA and first postoperative day at 8 a.m. 3.5 ± 1.7 iv-PCA vs. 1.9 ± 2.2 EDA. In addition, less PONV (iv-PCA 9/30 vs. EDA 1/30, p<0.01), less shivering (iv-PCA 8/30 vs. EDA 2/30, p<0.05), reduced fatigue (iv-PCA 26/30 vs. EDA 9/30, p<0.05) and a lower consumption of analgesics were found. Average postoperative requirement for piritramide in the iv-PCA group was 7 mg (range 0-24 mg) on the day of surgery and 5 mg (0-39 mg) on the first postoperative day. In the EDA group no opiate medication was given postoperatively (p<0.01). Duration of stay in the recovery room was shorter in the EDA group (71 ± 32 min vs. 50 ± 13 min, p<0.05). Hospital stay was 5 days on average in both groups. There were no surgical complications or epidural catheter-related complications. Because of urinary retention catheterization of the bladder had to be made in 3 patients of the iv-PCA group and 13 patients of the EDA group (p<0.05). Furthermore, the possibility to take a shower postoperatively was restricted in the EDA group because the epidural catheter was in place and thereby hygiene concerns. Regarding the early oral nutritional intake as well as postoperative mobilization, no significant differences between groups were found. In comparison with the preoperative status, the results regarding health-related quality of life were significantly better for both groups after a follow-up of 6 weeks (p<0.01); however, this effect was especially pronounced in the EDA group (p<0.05). CONCLUSIONS: To reduce the number of patients suffering from postoperative pain a procedure-specific pain management should be developed. The results of this study have shown that even in minimally invasive surgery, such as vaginal hysterectomy and laparoscopically assisted vaginal hysterectomy there are some advantages for epidural analgesia compared to intravenous patient-controlled analgesia. In particular reduced pain intensity, lower need for analgesics and reduced occurrence of PONV can lead to excellent patient comfort, fast recovery as well as positive effects on health-related quality of life. However, there are also some disadvantages such as an increased rate of urinary retention and restriction of mobility.

[Fatal outcome of multiorgan tuberculosis with peritoneal involvement after abdominal surgery]. / Deletärer Verlauf einer Multiorgantuberkulose mit peritonealer Beteiligung nach abdominalchirurgischem Eingriff.

Severe cases of tuberculosis can cause vital functional disturbances depending on the stage of the disease and the organ manifestation. There is a particularly high mortality rate in intensive care patients with tuberculosis. Extrapulmonary organ manifestations of this disease in particular can be associated with misdiagnosis and fatal outcome. In this article the intensive care treatment of a patient who suffered from abdominal as well as pulmonary tuberculosis is reported.

Excellent long-term survival of 170 patients with Waldenström's macroglobulinemia treated in private oncology practices and a university hospital.

The purpose of this study was to compare treatment and outcome of patients with Waldenström's macroglobulinemia (WM) in four private oncology practices (PP) and a university hospital (UH) in southwest Germany. We retrospectively reviewed the charts of all patients with WM of the last two decades of four PP in Mannheim, Heidelberg, Karlsruhe, and Speyer and the Department of Hematology of the University of Heidelberg. One hundred seventy patients could be identified, 74 from PP, 96 from the UH. Median age was 63.3 years. Patients from PP were older (median 65.3 vs. 62.5 years, p = 0.01). Only 54 % of patients from PP have received treatment during the observation time, as compared to 78.1 % of the UH (p < 0.001). In PP, 35 % of treated patients have received rituximab, as compared to 62.6 % of the patients of the UH (p < 0.001). Sixty percent of treated patients of PP have received bendamustine, as compared to only 8 % of the patients of the UH (p < 0.001). Time to first treatment was significantly shorter in patients from the UH compared to PP (median 13.7 vs. 52.9 months, p = 0.05). A trend towards a better overall survival was observed for patients treated with a rituximab-containing first-line regimen. The International Prognostic Scoring System for WM had significant prognostic value. Median overall survival was 25.0 years and did not differ between PP and UH. Despite different treatment strategies between PP and UH today overall survival of patients with WM is excellent, and better than previously reported.

Selective neurogenic blockade and perioperative immune reactivity in patients undergoing lung resection.

OBJECTIVE: This double-blind, prospective, randomized, controlled trial examined the effects of thoracic epidural block and intravenous clonidine and opioid treatment on the postoperative Th1/Th2 cytokine ratio after lung surgery. The primary endpoint was the interferon γ (IFN-γ; Th1 cytokine)/interleukin 4 (IL-4; Th2 cytokine) ratio. Secondary endpoints were reductions in pain and incidence of pneumonia. METHODS: Sixty patients were randomized into three groups to receive remifentanil intravenously (remifentanil group, n=20), remifentanil and clonidine intravenously (clonidine group, n=20), or ropivacaine epidurally (ropivacaine group, n=20). Pain was assessed using a numerical rating scale (NRS). Cytokines were measured using a cytometric bead array. RESULTS: Patients in the ropivacaine group (thoracic epidural block) had a significantly lower IFN-γ/IL-4 ratio at the end of surgery than those in the remifentanil group and clonidine group. There were no significant between-group differences in the IFN-γ/IL-4 ratio at other time-points. There were no differences in NRS scores at any time-point. No patient developed pneumonia. CONCLUSION: Intraoperative thoracic epidural block decreased the IFN-γ/IL-4 ratio immediately after lung surgery, indicating less inflammatory stimulation during surgery.

[Immunoglobulins in PID, SID and neurological autoimmune disease]. / Anwendung von Immunglobulinen bei primären und sekundären Immundefekten und neurologischen Autoimmunerkrankungen.

Human immunoglobulins (IG, mostly IgG) are used as replacement therapy in patients with inherited primary immunodeficiencies, and in patients with secondary immuno-deficiencies often observed in multiple myeloma or chronic lymphocytic leukemia. Ig are also approved as immunomodulatory therapy in neurological autoimmune diseases (NAID) such as Guillain-Barré syndrome, chronic inflammatory demyelinating polyneuropathy (CIDP) and multifocal motor neuropathy (MMN). 16 different Ig preparations for intravenous and subcutaneous use are at the moment available in Germany. The SIGNS study (Assessment of immunoglobulins in a long-term non-interventional study) investigates the clinical use of these drugs under clinical practice conditions. In this non-interventional prospective open-label cohort study, 550 patients with new or maintenance Ig therapy are observed with respect to drug utilization, effectiveness, (i. e. number of infections in PID and SID, functionality in NAID), tolerability, quality of life and costs in approximately 50 sites throughout Germany (neurologists, pediatricians, oncologists, other) for at least two years. This largest study of its kind is expected to contribute to optimization of Ig therapy in the postmarketing setting.

[Comparison between transvaginal and laparoscopic cholecystectomy - a retrospective case-control study]. / Vergleich zwischen transvaginaler und laparoskopischer Cholezystektomie - eine retrospektive Fall-Kontroll-Studie.

BACKGROUND: Natural orifice transluminal endoscopic surgery (NOTES) appears to be established in specialised surgical centres. Potential advantages of these operating techniques include surgery without scars as well as faster and more comfortable recovery. However, to date there are no controlled studies evaluating the assumed advantages of NOTES compared with both minimally invasive and open surgery. PATIENT / MATERIAL AND METHODS: In this retrospective case-controlled study 47  women undergoing transvaginal cholecystectomy (TV-ChE) have been compared with 46 women undergoing conventional laparoscopic cholecystectomy (LAP-ChE). Both groups were evaluated with regard to intraoperative respiratory and oxygenation parameters, pain intensity and need for analgesics postoperatively, rate of postoperative nausea and vomiting (PONV), duration of stay in recovery room as well as hospital stay. RESULTS: Demographic data of both groups were comparable to a great extent. However, in comparison with the women of TV-ChE group those of the LAP-ChE group were 5  years older on average (49 ±â€Š15 vs. 54 ±â€Š16  years). Even so, there were no differences in preoperative risk assessment (ASA classification) as well as intraoperative respiratory and haemodynamic parameters. Compared to the LAP-ChE group, women of TV-ChE group reported less postoperative pain (p < 0.001), less nausea or vomiting (p < 0.001) and a lower analgesic consumption in both opiates (p < 0.001) and non-opiates (p < 0.001). Furthermore, the duration of stay in recovery room was shorter in the TV-ChE group (40  minutes vs. 60  minutes, p < 0.001). Hospital stay in the TV-ChE group was 3  days on average compared to 4  days for the LAP-ChE group. The rate of general and surgical complications was lower in TV-ChE group (1 / 47) compared to the LAP-ChE group (4 / 46). In 9  women undergoing transvaginal cholecystectomy negligible vaginal bleeding was seen which stopped spontaneously in each case. CONCLUSION: The transvaginal cholecystectomy is a safe and less invasive surgical technique. Compared to laparoscopic cholecystectomy, there seem to be some advantages such as better cosmetic results, lower need for analgesics, faster mobilisation, more comfortable recovery and shorter hospital stay. These effects should be confirmed in prospective controled studies.

Addition of rituximab to fludarabine and cyclophosphamide in patients with chronic lymphocytic leukaemia: a randomised, open-label, phase 3 trial.

BACKGROUND: On the basis of promising results that were reported in several phase 2 trials, we investigated whether the addition of the monoclonal antibody rituximab to first-line chemotherapy with fludarabine and cyclophosphamide would improve the outcome of patients with chronic lymphocytic leukaemia. METHODS: Treatment-naive, physically fit patients (aged 30-81 years) with CD20-positive chronic lymphocytic leukaemia were randomly assigned in a one-to-one ratio to receive six courses of intravenous fludarabine (25 mg/m(2) per day) and cyclophosphamide (250 mg/m(2) per day) for the first 3 days of each 28-day treatment course with or without rituximab (375 mg/m(2) on day 0 of first course, and 500 mg/m(2) on day 1 of second to sixth courses) in 190 centres in 11 countries. Investigators and patients were not masked to the computer-generated treatment assignment. The primary endpoint was progression-free survival (PFS). Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00281918. FINDINGS: 408 patients were assigned to fludarabine, cyclophosphamide, and rituximab (chemoimmunotherapy group) and 409 to fludarabine and cyclophosphamide (chemotherapy group); all patients were analysed. At 3 years after randomisation, 65% of patients in the chemoimmunotherapy group were free of progression compared with 45% in the chemotherapy group (hazard ratio 0·56 [95% CI 0·46-0·69], p<0·0001); 87% were alive versus 83%, respectively (0·67 [0·48-0·92]; p=0·01). Chemoimmunotherapy was more frequently associated with grade 3 and 4 neutropenia (136 [34%] of 404 vs 83 [21%] of 396; p<0·0001) and leucocytopenia (97 [24%] vs 48 [12%]; p<0·0001). Other side-effects, including severe infections, were not increased. There were eight (2%) treatment-related deaths in the chemoimmunotherapy group compared with ten (3%) in the chemotherapy group. INTERPRETATION: Chemoimmunotherapy with fludarabine, cyclophosphamide, and rituximab improves progression-free survival and overall survival in patients with chronic lymphocytic leukaemia. Moreover, the results suggest that the choice of a specific first-line treatment changes the natural course of chronic lymphocytic leukaemia. FUNDING: F Hoffmann-La Roche.

[Pneumothorax following nasogastric feeding tube insertion : Case report and review of the literature]. / Pneumothorax nach Anlage einer Magensonde : Darstellung eines Fallbeispiels und Literaturreview.

A 54-year-old alcohol-dependant male patient suffering from severe alcohol withdrawal syndrome had to be intubated and artificially ventilated because of autonomic instability, convulsions and pulmonary dysfunction. A nasogastric tube (NGT) was inserted for enteral feeding and although placement was difficult the NGT was finally inserted after repeated attempts. Correct positioning of the NGT was evaluated by clinical means using insufflation of air and epigastric auscultation. As a typical "bubble" sound was epigastrically audible it has been assumed that the NGT was in the correct position. However, a routine control chest X-ray revealed a right-sided pneumothorax due to misplaced insertion of the tube into the bronchial system. Furthermore the patient developed massive cutaneous emphysema. The pneumothorax was treated successfully using pleural drainage. The patient was transferred to a peripheral ward 3 weeks after admission to the intensive care unit. The presented case report shows the importance of a correct position control of NGTs to avoid severe complications.