A rare desmoid tumor of the shoulder – excision, implantation of brachytherapy applicators and wound closure by pedicle musculus latissimus dorsi flap

Desmoid tumors are non-metastatic mesenchymal tumors with an aggressive local growth. Depending on the anatomic location, morbidity varies. We report of a patient with a desmoid tumor of the right shoulder which was treated in our department by surgical excision, plastic-surgical wound closure and postoperative adjuvant radiation

Wandel des ländlichen Raumes in der Wissensgesellschaft

In der Wissensgesellschaft differenziert sich die Raumstruktur in eine Vielzahl von Raumtypen aus; auch der ländliche Raum stellt sich nicht als ein homogenes Gebilde dar. Die "reflexive Moderne" der Wissensgesellschaft scheint keinen Determinismus in Bezug auf räumliche Entwicklungsunterschiede zu kennen, sondern den Menschen Spielräume für eine Aneignung und Inwertsetzung unterschiedlicher Räume zu öffnen. Diese erweiterten Gestaltungsmöglichkeiten könnten auch in dem bisher als zurückbleibend eingeschätzten ländlichen Raum neue Entwicklungsimpulse auslösen. Zur Überprüfung dieser Annahmen wird in diesem Beitrag aus einem theoretischen Blickwinkel gefragt, wie die kulturellen, sozialen, wirtschaftlichen und technischen Dimensionen der Wissensgesellschaft mit dem Raum interagieren und welche Herausforderungen sowie Strategien sich daraus für den ländlichen Raum ergeben können. Die empirische Überprüfung stützt sich auf Ergebnisse einer Arbeitsgruppe der Akademie für Raumforschung und Landesplanung (ARL) zur Wissensgesellschaft in ländlich-peripheren Regionen sowie ergänzend auf weitere quantitative und qualitative Studien zum Thema. Aus diesen Untersuchungen geht hervor, dass sich in vielen, wenn auch nicht in allen Regionen neuartige wissensgesellschaftlich geprägte Lebenskulturen in Abgrenzung zu städtischen Lebensmodellen entfalten. Sie belegen eine neue Attraktivität des ländlichen Raumes, die sich auch in wissensbasierten Projekten der Kultur, Bildung, Daseinsvorsorge und des unternehmerischen Engagements niederschlägt. Beispiele finden sich besonders in wirtschaftlich wettbewerbsfähigen Regionen, aber auch in den peripheren Regionen, die unter Bevölkerungsverlusten leiden. Es bleibt weiteren Untersuchungen vorbehalten zu eruieren, wie diese Ansätze von öffentlichen Akteuren strategisch genutzt werden können, um den wissensgesellschaftlichen Wandel voranzutreiben. Sie können helfen, in erfolgreichen Regionen gesammelte Erfahrungen für eine politische und planerische Unterstützung peripherer Städte und Regionen im ländlichen Raum zu nutzen.In the knowledge society, spatial structure is differentiated, and as a result of this process the rural area no longer appears as a homogenous entity. The "reflexive modernity" of the knowledge society does not seem to know any determinism concerning spatial development-differences, but rather provides new scope to people for acquiring and valorizing different areas. New development impulses could be triggered in the so far peripherally assessed rural area through those extended options. In order to review these assumptions, this paper asks from a theoretical perspective how the cultural, social, economic and technical dimensions of the knowledge society interact with space, and what challenges and strategies may arise for rural areas. The empirical verification is based on results of a working group of the Academy of Spatial Research and Planning (ARL) about the knowledge society in rural-peripheral regions and more qualitative and quantitative studies about the topic. Analysis shows that in many, but not in all regions new knowledge society shaped life cultures evolved differentiating from urban social models. They prove a new attractiveness of the rural area, which are also expressed in knowledge-based projects of culture, education, public services and entrepreneurial commitment. There are a lot of examples especially in economic competitive regions but also in peripheral regions suffering population loss. It needs more studies to determine how the approaches can be used by public and private players to promote the knowledge-society based change. They could help using the gained experience in successful regions for political and planning support in peripheral rural towns and regions

Wissensgesellschaft als Herausforderung für ländlich-periphere Regionen: Beispiele aus Nordostdeutschland

Die Heuristik einer dreidimensionalen Wissensgesellschaft wird in diesem Band aufgegriffen und weiterentwickelt. Die soziale, die ökonomische und die technische Dimension der Wissensgesellschaft werden im theoretischen Teil ausdifferenziert und anhand charakteristischer Ausprägungen strukturiert, z.B. individuelle Kompetenzen, kollektive Lernprozesse, Wirtschaftsfaktor Wissen, Zentralität, Mobilität oder Einbindung in globale Institutionensysteme. Diese strukturierenden Elemente bilden die Grundlage für die Auswahl von vertiefenden Studien im ländlichen, peripher gelegenen Raum Nordostdeutschlands im Hinblick auf Wachstumskerne in Brandenburg, Gesundheitsinfrastruktur, Mobilitätsangebote und Anschluss an Kommunikationstechnologien sowie Aus- und Weiterbildung, Bildungsnetzwerke und Bildungslandschaften. Beim Vergleich von Theorie und Praxis, von heuristischem Modell und Fallstudien, ist die Auswahl der Beispiele nicht repräsentativ und deckt nicht die ganze Vielfalt und Vielschichtigkeit der Wissensgesellschaft in ländlich- peripheren Räumen ab. Erste Konturen, wie die Wissensgesellschaft in diesen Räumen zum Ausdruck kommt, welche strategischen Herausforderungen dies mit sich bringt und welchen Anteil die räumliche Planung an den anstehenden strategischen Ansätzen haben kann, zeigen sich dennoch. Der Fachkräftemangel scheint eine zentrale Ausprägung und Herausforderung der Wissensgesellschaft in der ländlichen Peripherie zu sein. Die scharfe, theoretisch begründete Trennung der Dimensionen ist in der Praxis nicht in dieser Form aufrechtzuerhalten: So sind die für die ökonomische Dimension charakteristischen Innovationen nicht ohne soziale Lernprozesse und brückenschlagende Institutionensysteme, die hier der technischen Dimension zugerechnet werden, denkbar. Letztere wiederum funktionieren nur dann tatsächlich, wenn Menschen und Wissen mobilisiert werden und damit Wissensnetzwerke entstehen. Die peripher gelegenen ländlichen Räume sind genauso wie die Metropolräume Teil der Wissensgesellschaft. Damit sind beide Raumtypen gleichermaßen Wettbewerbs- und Selektionsprozessen ausgesetzt. Aus dieser Konstellation ergeben sich für ländlich-periphere Regionen Kernherausforderungen, die sich in zwei sich ergänzenden strategischen Ansätzen manifestieren: eine mitnehmende Basisstrategie und eine flankierende Profilierungsstrategie. Der Beitrag der räumlichen Planung zur Steuerung der wissensgesellschaftlich relevanten Veränderungsprozesse beschränkt sich weitgehend auf folgende Funktionen: Sensibilisierung für räumliche Zusammenhänge, Organisation räumlichen Wandels und Umsetzungsbegleitung sowie damit verbunden Interessenausgleich der vielen unterschiedlichen Akteure einer Region.The heuristics of a three-dimensional knowledge society has been addressed and further developed in this volume. The social, economic and technical dimensions are differentiated and structured in accordance to characteristic manifestations such as individual competences, collective learning processes, knowledge as an economic factor, centrality, mobility, or integration in global institutional systems. These structuring elements provide the basis for the choice of in-depth studies in the rural, peripherally located area of northeast Germany with regard to regional growth cores in Brandenburg, health infrastructure, mobility offerings, access to communication technologies, and educational networks and educational landscapes. Regarding the comparison of theory and practice, of the heuristic model and the case studies, the choice of examples is not representative and does not cover the entire diversity and complexity of the knowledge society in rural peripheral areas. However, the case studies do provide an initial picture of how the knowledge society finds expression in these areas, the strategic challenges it brings with it, and the role that spatial planning can play in necessary strategic approaches. The shortage of skilled workers seems to be a central feature of and a challenge for the knowledge society in the rural periphery. The sharp, theoretically founded differentiation made between the dimensions cannot be sustained in this form in practice. Thus the innovations characteristic for the economic dimension are not feasible without social learning processes and bridging institutional systems, which are here regarded as part of the technical dimension. Furthermore, these processes and systems will only actually function when people and knowledge are mobilised and knowledge networks develop. The peripherally located rural areas are just as much part of the knowledge society as the metropolitan areas. Both types of area are thus similarly subject to processes of competition and selection. This constellation gives rise to key challenges for rural peripheral regions that manifest themselves in two complementary strategic approaches: a participatory basic strategy and a flanking strategy focused on profiling. The contribution of spatial planning to the processes of change related to the knowledge society is thus mainly restricted on raising awareness of spatial interrelations, organising spatial transformation and guiding implementation while ensuring the interests of the many different regional actors

A randomized trial of the efficacy and safety of sequential intravenous/oral moxifloxacin monotherapy versus intravenous piperacillin/tazobactam followed by oral amoxicillin/clavulanate for complicated skin and skin structure infections

Item does not contain fulltextOBJECTIVES: The primary aim of the RELIEF study was to evaluate the efficacy and safety of two sequential intravenous (iv)/oral regimens: moxifloxacin iv/oral versus piperacillin/tazobactam (TZP) iv followed by oral amoxicillin/clavulanate (AMC). PATIENTS AND METHODS: The study had a prospective, randomized, double-dummy, double-blind, multicentre design. Patients >/=18 years were prospectively stratified according to complicated skin and skin structure infection (cSSSI) subtype/diagnosis (major abscess, diabetic foot infection, wound infection or infected ischaemic ulcer), surgical intervention and severity of illness. Diagnoses and disease severity were based on predetermined criteria, documented by repeated photographs, and confirmed by an independent data review committee. Patients were randomized to receive either 400 mg of moxifloxacin iv once daily followed by 400 mg of moxifloxacin orally once daily or 4.0/0.5 g of TZP iv thrice daily followed by 875/125 mg of AMC orally twice daily for 7-21 days. The primary efficacy variable was clinical response at test of cure (TOC) for the per-protocol (PP) population. Clinical efficacy was assessed by the data review committee based on repeated photographs and case descriptions. Clinical trials registry number: NCT 00402727. RESULTS: A total of 813 patients were randomized. Clinical success rates at TOC were similar for moxifloxacin and TZP-AMC in the PP [320/361 (88.6%) versus 275/307 (89.6%), respectively; P = 0.758] and intent-to-treat (ITT) [350/426 (82.2%) versus 305/377 (80.9%), respectively; P = 0.632] populations. Thus, moxifloxacin was non-inferior to TZP-AMC. Bacteriological success rates were high in both treatment arms [moxifloxacin: 432/497 (86.9%) versus TZP-AMC: 370/429 (86.2%), microbiologically valid (MBV) population]. Moxifloxacin was non-inferior to TZP-AMC at TOC in both the MBV and the ITT populations. Both treatments were well tolerated. CONCLUSIONS: Once-daily iv/oral moxifloxacin monotherapy was clinically and bacteriologically non-inferior to iv TZP thrice daily followed by oral AMC twice daily in patients with cSSSIs

Sequential surgical resection of hepatic and pulmonary metastases from colorectal cancer

# The Author(s) 2010. This article is published with open access at Springerlink.com Background Resection of isolated hepatic or pulmonary metastases from colorectal cancer is widely accepted and associated with a 5-year survival rate of 25–40%. The value of aggressive surgical management in patients with both hepatic and pulmonary metastases still remains a controversial area. Materials and methods A retrospective review of 1,497 patients with colorectal carcinoma (CRC) was analysed. Of 73 patients identified with resection of CRC and, at some point in time, both liver and lung metastases, 17 patients underwent metastasectomy (resection group). The remaining 56 patients comprised the non-resection group. Primary tumour, hepatic and pulmonary metastases of all patients were surgically treated in our department of surgery, and the results are that of a single institution. Results The resection group had a 3-year survival of 77%, a 5-year survival of 55 % and a 10-year survival of 18%; median survival was 98 months. The longest overall survival was 136 months; six patients are still alive. In the resection group, overall survival was significantly higher than in the non-resection group (p<0.01). Independent from the chronology of metastasectomy, 5-year survival was 55 % with respect to the primary resection, 28 % with respect to the first metastasectomy and 14 % with respect t

Personalized medicine with IgGAM compared with standard of care for treatment of peritonitis after infectious source control (the PEPPER trial): study protocol for a randomized controlled trial

Background: Peritonitis is responsible for thousands of deaths annually in Germany alone. Even source control (SC) and antibiotic treatment often fail to prevent severe sepsis or septic shock, and this situation has hardly improved in the past two decades. Most experimental immunomodulatory therapeutics for sepsis have been aimed at blocking or dampening a specific pro-inflammatory immunological mediator. However, the patient collective is large and heterogeneous. There are therefore grounds for investigating the possibility of developing personalized therapies by classifying patients into groups according to biomarkers. This study aims to combine an assessment of the efficacy of treatment with a preparation of human immunoglobulins G, A, and M (IgGAM) with individual status of various biomarkers (immunoglobulin level, procalcitonin, interleukin 6, antigen D-related human leucocyte antigen (HLA-DR), transcription factor NF-κB1, adrenomedullin, and pathogen spectrum). Methods/design: A total of 200 patients with sepsis or septic shock will receive standard-of-care treatment (SoC). Of these, 133 patients (selected by 1:2 randomization) will in addition receive infusions of IgGAM for 5 days. All patients will be followed for approximately 90 days and assessed by the multiple-organ failure (MOF) score, by the EQ QLQ 5D quality-of-life scale, and by measurement of vital signs, biomarkers (as above), and survival. Discussion: This study is intended to provide further information on the efficacy and safety of treatment with IgGAM and to offer the possibility of correlating these with the biomarkers to be studied. Specifically, it will test (at a descriptive level) the hypothesis that patients receiving IgGAM who have higher inflammation status (IL-6) and poorer immune status (low HLA-DR, low immunoglobulin levels) have a better outcome than patients who do not receive IgGAM. It is expected to provide information that will help to close the knowledge gap concerning the association between the effect of IgGAM and the presence of various biomarkers, thus possibly opening the way to a personalized medicine. Trial registration: EudraCT, 2016–001788-34; ClinicalTrials.gov, NCT03334006. Registered on 17 Nov 2017. Trial sponsor: RWTH Aachen University, represented by the Center for Translational & Clinical Research Aachen (contact Dr. S. Isfort)