Compliance with antimalarial chemoprophylaxis in German soldiers: a 6-year survey.

PURPOSE: Since 1992, German soldiers have been deployed in areas where malaria is endemic. Antimalarial chemoprophylaxis (CP) is directed according to the assessed risk and is provided free of charge. Compliance is crucial if its effect is to be reliable. This study analysed compliance with directed CP in German soldiers as well as its determinants. METHODS: Between 2003 and 2009, standardized questionnaire-based interviews were performed with 2,149 out of approximately 100,000 German soldiers who were deployed during this period in areas where malaria is endemic. The questionnaires dealt with information that the soldiers had received about malaria prior to their missions, with their adherence to mosquito-protective and antimalarial chemoprophylactic procedures, and their estimations of their individual level of exposure. RESULTS: About 1,308 out of 2,149 interviewed soldiers had been ordered to take CP, allowing for an assessment of the outcome parameter "CP-compliance". About 76.9 % out of 1,308 soldiers to whom regular CP was directed took it regularly. The exposure variables "age", "satisfaction with malaria counselling", "perceived threat due to insects or mosquitoes" and "use of insect repellents" were positively associated with compliance with directed antimalarial CP. CONCLUSIONS: The study confirms the findings of the French and US armies that even free-of-charge access to antimalarial medication will not lead to 100 % acceptance. The compliance problem is aggravated by the generally low age of deployed soldiers. Adequate counselling is crucial to increase adherence to antimalarial CP.

[Thoracoscopy: surgical technic]. / Thorakoskopie: Chirurgische Technik.

Presentation of a surgical method in thoracoscopy, pleura biopsy and open lung biopsy using an intercostally introduced mediastinoscope and unilateral contralateral respiration. The results and advantages are explained.

Small cell carcinoma of the lung--to operate or not? Surgical experience and results.

From 1962 to 1979, out of 549 patients with small cell bronchial carcinoma (= 15% of all bronchial carcinomas) treated in our clinic, 109 (20%) underwent thoracotomy and 94 (17%) resection. The recurrence free 3-year survival rate for resected patients was 22%, and after 5 years 14 of the 94 (15%) were still alive, using absolute numbers including postoperative deaths. From 1962 to 1975 only patients in stages T1 N0 M0 or T2 N0 M0 survived, with one survivor in stage T1 N2 M0. In the period from 1976 to 1979 patients with tumors in more advanced stages were resected: now those with T1 N1 M0, T1 N2 M0 and predominantly with T2 N1 M0 survived, which can be attributed to the effect of more intensive chemotherapy. Sixty-eight percent of the operations were pneumonectomies; the exploratory thoracotomy rate was 14%. Surgical therapy was seen as an integral part of an oncological regime applied in suitable types of tumor. When the tumor was identified only after resection, 3 courses of a combined chemotherapy including cranial radiation were performed, with additional topical radiation in cases of N2 or T3 forms. When the diagnosis was ascertained preoperatively, 2 (to 3) courses of chemotherapy were followed by resection of the entire area affected, and then by a further 2 (to 3) courses of combined chemotherapy with cranial radiation. A prerequisite for resection in these cases was that the tumor had regressed as a result of the first courses of chemotherapy. In cases of initially inoperable tumors, "residual surgery" appears justified if adequate regression occurs as a result of chemotherapy in view of the large number of local recurrences following chemo(/radio-)therapy alone. Palliative resection is not indicated in small cell bronchial carcinomas, nor is surgery indicated in cases of primarily inoperable tumors which do not react to chemotherapy.

Tracheal resection--state of the art.

Sleeve resection of the trachea and reconstruction by end-to-end anastomosis is seen as the method of choice in the treatment of short and long stenoses of the trachea following long-term artificial respiration and tumors. The experience with tracheal resection in 73 patients operated upon at 2 different thoracic units is analyzed. Postintubation was the main indication for operation in 63% of the patient population. The 30-day postoperative mortality rate was 8% with a total mortality of 19%. A satisfactory functional result was attained in 73% of the patients operated upon including those with malignant tumors. Restenoses occurred in 6 of the 73 patients who underwent surgery. Different approaches to tracheal resection were chosen in the 2 clinics and the possibility of mobilizing the larynx was used in a different way. A preference for resorbable material was noted regardless of the operative technique and has prevented restenosis. The diagnostic procedures considered mandatory, the indications for surgery and the various operative techniques are discussed.

The role of surgery in the treatment of small cell carcinoma of the lung.

The role of surgical treatment of non-small-cell carcinoma of the lung is controversial. Surgical therapy of small cell carcinoma of the lung has been the subject of criticism for two decades - in contrast to our opinion about the important role of initial surgical therapy in limited disease of this type of lung carcinoma. In a review of the results of surgical therapy in 109 patients with undifferentiated small cell carcinoma of the lung in the period from 1962 to 1979 and an attempt to define the role of the curative effect, we report on 109 thoracotomies after negative preoperative mediastinoscopy and exclusion of hematogenous spread of the cancer. The resection rate (94/109) was considerably lower than in differentiated lung carcinoma. Pneumonectomy (40%) and extended pneumonectomy (27%) were more frequently performed for small cell carcinoma than for differentiated tumors; thus, the rate of lobectomy and segmental resection (28/94 = 30%, and 3/94 = 3%, respectively) was low. When we included the postoperative lethality in the calculation rather than using the life-table method, we found in a follow-up study of 99% of the patients who had undergone resection, in absolute numbers, 3-year survival in 21/93 patients (23%). In the different stages I, II, and III, we noted 3-year survival rates of 32%, 25%, and 14%. Correlation to the N and T stages was N0 (10/29) 35%; N1 (6/34) 18%; N2 (5/30), 17%; N1 + 2 (11/64) 17%; T1 (11/28) 39%; T2 (8/35) 23%; T3 (2/30) 7%; and T2 + 3 (9/34) 14%.(ABSTRACT TRUNCATED AT 250 WORDS)

Bullectomy.

The aims of this study were to investigate whether a relevant functional improvement before and after bullectomy was achieved in cases of a localized bulla and generalized bullous changes early and late postoperatively and to establish clear criteria for bullectomy. For this purpose, 21 patients with a localized bulla compressing the rest of the lung, and 19 with generalized bullae with emphysematous changes of the remaining lung were examined before and after (1 1/2 months and 1 1/2 years) surgery. Comparison of the preoperative and postoperative data and the follow-up included X-ray studies with planimetric assessment of the size of the bullae, lung function tests, perfusion scintigrams and clinical findings. The preoperative and postoperative statistical values of lung volume and respiratory mechanics showed the most significant differences. Bullectomy for a localized bulla with compression of the rest of the lung led to an improvement in gas exchange and respiratory mechanics. This operation, however, produced no functional improvement in cases of generalized bullous changes. Functional and clinical success is greater, the larger and more delimited the bulla is to be seen on X-ray, the more the healthy lung tissue is compressed, and, finally, the less associated diseases such as chronic bronchitis are present. Indication for bullectomy should be limited to these cases. The size of the bulla should amount to at least 2/3 of the hemithorax, preoperative function should be clearly reduced and the patient should be suffering from dyspnea.

Functional diagnosis in surgery of the large airways.

The main indications for surgery of the airways are (1) non-tumorous airway stenosis and (2) tumors of the large airways with and without relevant stenoses. The aim of the following study was to find out which degree of stenosis is an absolute indication for resection and to what extent the functional disturbances are reversible following surgery. We investigated various groups of patients (stenosis of the trachea, lobectomy with sleeve resection, extended pneumectomy with resection of the distal trachea, pneumectomy with resection of the bifurcation, resection of the main bronchus and lobectomy, rupture of the main bronchus) from 1978 to 1982, before and up to 3 years after surgery. Body-plethysmography (one second forced expiratory volume = FEV1; one second forced inspiratory volume = FIV1; Residual volume = RV; total lung capacity = TLC; airway resistance = Raw; specific airway conductance = sGaw), flow volume relation measurements (maximal inspiratory flow = Vmax insp; maximal expiratory flow = Vmax exp; and flow at various lung volumes), blood gas analysis and an endoscopic estimation of the tracheal diameter were performed. Tracheal resection with end-to-end anastomosis in patients with non-tumerous tracheal stenosis improved the tracheal diameter from 6.0 to 11.7 mm, the sGaw from 0.04 to 0.08 (cmH2O s)-1 and the severity of dyspnea significantly. There was no measurable change in airway caliber following administration of beta 2-adrenergics. The most sensitive parameters for describing the tracheal stenosis are the resistance and flow volume values. A tracheal diameter smaller than 6.5 mm corresponding to a sGaw smaller than 0.03 (cmH2O s)-1 procedured severe dyspnea, which is incompatibly with normal life.(ABSTRACT TRUNCATED AT 250 WORDS)

The extrapleural treatment of main bronchial stump fistulae using a contralateral approach.

When dealing with a left main bronchial stump fistula with chronic empyema, a contralateral extrapleural approach is recommended for reamputation and closure at both the proximal and distal sections. By these means a secure closure can be achieved and, at the same time, infection of the pleural cavity on the right side can be avoided, the preserved and unopened mediastinal pleura reliably covers the operative site, and postoperative respiratory disturbances can also be avoided.

Regional and global lung function in unilateral fibrothorax after conservative therapy and decortication.

Twenty-six patients suffering from unilateral fibrothorax were investigated before surgery or conservative therapy (decortication, n = 15; conservative treatment, n = 11) and followed up after 24.5 and 18.6 months respectively. Global lung function analysis was done by body plethysmography, ventilation and gas exchange analysis and blood-gas analysis under resting and exercise conditions. Regional lung function analysis included the semiquantitative description of fibrothorax by X-ray photos, and ventilation-perfusion scintigraphy. The functional result of unilateral fibrotic pleurisy is restriction which is also persistent after therapy, but to a lesser degree. This restriction is shown in an increased dead space ventilation as well as in ventilatory inhomogeneities, which causes a distortion of respiratory gas exchange. A decrease of compliance of the lung and chest wall is not measurable after therapy. Conservative treatment leads to a functional improvement to the same degree as decortication in cases of severe preoperative functional disturbances of the operated patients. After a course of 1.5 and 2 years respectively, the reference value has not been reached in either group. The regional pattern after therapy is characterized by a restriction and under-perfusion of the formerly affected site. The regional improvement of lung function is independent of the type of therapy, however, it shows a close correlation to the amount of pleurisy prior to therapy. Conservative treatment is the therapy of choice as long as no complications of insufficient recovery impede the course of the illness.