[Operability and Pathological Response of Non-Small Cell Lung Cancer (NSCLC) after Neoadjuvant Therapy with Immune Checkpoint Inhibition]. / Operabilität und pathologisches Ansprechen des Lungenkarzinoms nach neoadjuvanter Therapie mit Immun-Checkpoint-Inhibitoren.

BACKGROUND: The blockade of immune escape mechanisms (e. g. PD1 /PD-L1) using immune checkpoint inhibition (ICI) can significantly prolong survival and induce remission in patients with advanced non-small cell lung cancer (NSCLC). Less is known about neoadjuvant ICI in patients with resectable (UICC stage III) or oligometastatic (UICC stage IVa) NSCLC. METHODS: Tissue biopsies from patients with advanced or oligometastatic NSCLC were screened for PD-L1 expression. In case of PD-L1-expression > 50 %, ECOG status of 0 or 1 and expected operability, patients received ICI. After about four weeks, patients underwent thoracic surgical resection. In all patients, a complete staging, including PET-CT, cMRI, and endobronchial ultrasound, was performed. The tolerability, the radiological and the histopathological tumor response as well as the surgical and oncological outcomes were analyzed. FINDINGS: Four patients (2 male, 2 female, age 56 - 78 years, n = 3 adenocarcinoma, n = 1 squamous cell carcinoma) with local advanced tumors received ICI before surgical resection. In three cases the mediastinal lymph nodes were positive. One patient had a single cerebral metastasis which was treated with radiotherapy. All four patients underwent therapy with two to six cycles of ICI (3â€Š× pembrolizumab, 1â€Š× atezolizumab) without any complication, and ICI did not delay the time of surgical resection. According to iRECIST, three patients showed partial response (PR), one patient had stable disease (SD). All tumors were completely resected. The thoracic surgical procedures proved to be technically unproblematic despite inflammatory changes. There were neither treatment-related deaths nor perioperative complications. In the resectates, complete pathological response (CPR, regression grade III ) and regression grade IIb were detected twice. The average time of follow-up was 12 (1 - 24) months. Patients with PPR developed distant metastasis after six months or a local recurrence after four months. The CPR patient is relapse free to date. CONCLUSION: In selected patients, neoadjuvant therapy with ICI is well tolerated and can induce a complete remission of the tumor. Treatment with ICI has no negative impact on the surgical procedure. Prognosis seems to be promising in CPR and limited in PPR.

Results of plate fixation for humerus fractures in a large single-center cohort.

INTRODUCTION: This study aims to describe the results of plate fixation in one of the largest single-center cohorts that employs plate fixation as the golden standard. Additionally, risk factors related to a negative outcome were identified. MATERIALS AND METHODS: This was a retrospective cohort study of all patients treated for a humeral shaft fracture in a level-one trauma center between January 2010 and December 2017 with a mean follow-up of 1 year. RESULTS: Plate fixation was performed in 102 patients with a humeral shaft fracture. The mean age was 50 (SD 20) years with 54.9% (n = 56) being male. Forty-eight percent (n = 48) had an AO type-A, 34.3% (n = 35) type-B, and 18.7% (n = 19) type-C fracture. Deep surgical site infections and non-union occurred in 1% (n = 1) and 3.9% (n = 4) of patients, respectively. Revision of the implant was performed in 15.7% (n = 16) mainly due to implant-related complaints. Only one patient developed radial nerve palsy after surgery. The median duration to radiological fracture healing and full-weight bearing was 18 (range 7-65) weeks and 14 (range 6-56) weeks, respectively. Risk factors for negative outcome included higher age, osteoporosis, open and higher AO class fractures, performing surgery during out-office hours, and the use of LCP 3.5-mm plate and an anterolateral approach. CONCLUSION: Plate fixation for humeral shaft fractures has low risks of complications. It should be emphasized that the complications can be further minimized with a greater surgical expertise and by refraining from performing a surgery during out-office hours.

Absolute or relative stability in plate fixation for simple humeral shaft fractures.

INTRODUCTION: Minimal invasive plating (MIPO) techniques for humeral shaft fractures appear to have fewer complications and higher union rates compared to open reduction and internal fixation (ORIF). It is questionable if this also applies to simple humeral shaft fractures, as simple fractures are generally treated with absolute stability which cannot be obtained with MIPO. This raises the question whether biology or biomechanics is more important in fracture healing. This study was developed to investigate the biomechanical part of this equation. The aim of the study was to compare relative stability to absolute stability in simple humeral shaft fractures with regard to fracture healing METHODS: This was a retrospective study of all patients treated with plate fixation for AO/OTA type A1-B3 humeral shaft fractures. Patients were categorized into two groups: absolute stability and relative stability. Both groups were compared with regard to time to radiological union and full weight bearing RESULTS: Thirty patients were included in the relative-stability-group with either an AO/OTA type A (n = 18) or type B (n = 12) humeral shaft fracture and a mean age of 55 (SD 21) years. A total of 46 patients were included in the absolute-stability-group: 27 patients had a type A and 19 type B fracture. The mean age in this group was 45 (SD 19) years. Median follow-up was 12 months (IQR 8-13). Minimally invasive approach was used in 15 (50%) patients in the relative stability group. Time to radiological union was significantly shorter in the absolute-stability-group with a median of 14 (IQR 12-22) versus 25 (IQR17-36) weeks and HR 2.60 (CI 1.54-4.41)(p < 0.001). This difference remained significant after correction for type of approach (adjusted HR 3.53 CI 1.72-7.21) (p 0.001). There was no significant difference in time to full weight bearing. The addition of lag screws in the absolute stability group did not influence time to radiological healing or full weight bearing. CONCLUSION: Absolute stability for simple humeral shaft fractures leads to a significantly shorter time to radiological union compared to relative stability. The addition of lag screws to gain interfragmentary compression does not reduce fracture healing time.

[Teaching in Perspective - How Medical Students Assess Their Practical Clinical Training in Surgery]. / Lehre im Fokus ­ Wie beurteilen Studierende ihre praktisch-klinische Ausbildung in der Chirurgie?

Introduction: Practical clinical expertise is a crucial part of medical professionalism. Several studies have shown that medical students are poorly trained in practical skills during their undergraduate training. Even the students rated their own expertise in practical skills as poor. The amendments to the German Regulating Licenses in Practical Medicine are intended to strengthen practical clinical training. The aim of the present study is to use focus groups to analyse practical clinical training with respect to organisation, difficulties and problems from the learners' perspective. Methods: The present qualitative study uses the focus group approach. Each focus group was composed of a maximum of 6 students per group with the same level of training. Using a standardised interview manual, a total of 31 students and four first-year residents participated in the study. Data interpretation was performed using structured qualitative content analysis. Results: The present work demonstrates that students of all levels of training greatly value their training in practical clinical expertise, especially in clinical skills. Due to the lack of defined learning objectives for practical skills, students training in clinical internships and medical registrar positions are highly dependent on the motivation and interest of the individual clinical teacher and the learner himself. Students struggle to estimate their actual level of expertise due to the lack of defined learning objectives. This is exacerbated by the fact that students rarely receive feedback about their expertise. Students complain that many teachers do not know the level of training required of their students. Conclusion: The definition of basic and specific learning objectives and the communication of this between learners and teachers is an essential part of practical clinical training.