Response expectancies have been proposed as the major determinant of placebo effects. Here we report that different expectations produce different analgesic effects which in turn can be harnessed in clinical practice. Thoracotomized patients were treated with buprenorphine on request for 3 consecutive days, together with a basal intravenous infusion of saline solution. However, the symbolic meaning of this basal infusion was changed in three different groups of patients. The first group was told nothing about any analgesic effect (natural history). The second group was told that the basal infusion was either a powerful painkiller or a placebo (classic double-blind administration). The third group was told that the basal infusion was a potent painkiller (deceptive administration). Therefore, whereas the analgesic treatment was exactly the same in the three groups, the verbal instructions about the basal infusion differed. The placebo effect of the saline basal infusion was measured by recording the doses of buprenorphine requested over the three-days treatment. We found that the double-blind group showed a reduction of buprenorphine requests compared to the natural history group. However, this reduction was even larger in the deceptive administration group. Overall, after 3 days of placebo infusion, the first group received 11.55 mg of buprenorphine, the second group 9.15 mg, and the third group 7.65 mg. Despite these dose differences, analgesia was the same in the three groups. These results indicate that different verbal instructions about certain and uncertain expectations of analgesia produce different placebo analgesic effects, which in turn trigger a dramatic change of behaviour leading to a significant reduction of opioid intake.

Lung tumors with mixed histologic pattern are rare tumors. Adenosquamous carcinoma and combined SCLC + LCNEC/NNEC present a more aggressive clinico-pathologic behaviour and reduced survival as compared to the single histology population of resected lung tumors.

The management of foreign bodies in the heart should be individualized: (1) symptomatic foreign bodies should be removed irrespective of their location; (2) asymptomatic foreign bodies diagnosed immediately after the injury with associated risk factors should be removed; (3) asymptomatic foreign bodies without associated risks factors or diagnosed late after the injury may be treated conservatively, particularly if they are completely embedded in the myocardium or in the pericardium.

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The prognosis of primary angiosarcoma of the pulmonary system is generally poor, irrespective of whether the location is in the pulmonary parenchyma or the main airway. Angiosarcoma of the pulmonary parenchyma is invariably fatal within months because metastases are usually present at the time of detection, and chemotherapy thus far has not proved effective. The clinical course of solitary angiosarcoma of the main airway is also dismal in previous reports. 2,4 However, mortality of these patients was mainly caused by massive and intractable hemoptysis of the small resectable tumor rather than by the invasiveness of the disease. From the experience of successful treatment of this patient, angiosarcoma should be considered in the differential diagnosis of a primary tracheal tumor. Furthermore, prompt surgical intervention with adequate resection margins is recommended in the management of these patients when the disease is localized at detection. References

possible complications. However, incomplete resection of the hematoma resulted in uncontrollable bleeding from the subcapsular lesion or recurrence of hematoma within several years in some publications. 2,7 Complete extirpation, including the capsule, would be desired for cure.In our patient acute massive hemoptysis was treated with emergency tracheal intubation, balloon occlusion of the bleeding bronchus, and bronchial artery embolization. In the literature neither massive hemoptysis nor emergency management for chronic expanding hematoma of the thorax has been reported. Because the bleeding spread to the contralateral lung, the operation was intentionally delayed until the remaining lung function recovered. Thereafter, the patient successfully underwent a pneumonectomy with extirpation of the hematoma. Division of the hilum first and sequential distal dissection of the lung and hematoma through a median sternotomy might have worked well for bleeding control. References

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