[HIV patients with psychiatric illnesses. Treatment strategies and drug interactions]

Since the beginning of the endemic phase of the human immunodeficiency virus (HIV), about 60,000 humans have been infected in Germany by this retrovirus. Epidemiological data indicate approximately 2,500 new infections annually. Due to the multiagent antiviral therapy available, only about 600 cases progressed to the clinical picture of full-blown acquired immunodeficiency syndrome (AIDS) in 1999. [Robert-Koch-Institut (Berlin), http://www.rki.de] If an HIV infection or AIDS is current, a higher prevalence of psychiatric disorders in these persons can be anticipated. Psychoactive drugs and their dosages need to be chosen under several considerations and with regard to the HIV infection, since interactions between antiviral and psychotropic drugs occur frequently. The use of psychotropic drugs is often required and thus cannot be ignored. Therefore, psychiatric disorders, medical treatment strategies, interactions between psychotropic and antiretroviral drugs, and biotransformation mechanisms are discussed with regard to an underlying HIV infection.

Determination of 17-hydroxyprogesterone in plasma by stable isotope dilution/benchtop liquid chromatography-tandem mass spectrometry

An assay based on stable isotope dilution liquid chromatography-tandem mass spectrometry (ID/LC-MS-MS) was developed for the quantification of 17-hydroxyprogesterone, the most important indicator of 21-hydroxylase deficiency in human plasma. Plasma was extracted using ethyl acetate and Extrelut columns. LC was performed on a reversed-phase C18 column using a water/methanol gradient. A benchtop triple quadrupole mass spectrometer, operating in selected reaction monitoring mode, served as mass detector. The analytical run time was 9 min per sample. The sensitivity was high: 0.06 pmol of 17-hydroxyprogesterone yielded a signal-to-noise ratio of 13. Precision (CV) and accuracy (relative error) derived from the analyses of unspiked and spiked validation samples were 7.4-12.0% and 6.4%, respectively. When analyzing the same samples - median (range), in nanomoles per liter - from neonates and adults independently by ID/LC-MS-MS as well as by ID/gas chromatography (GC)-MS, corresponding results were obtained: neonates (n = 10), ID/LC-MS-MS 3.99 (0.48-16.05), ID/GC-MS 5.39 (1.57-13.02); adults (n = 10), ID/LC-MS-MS 2.66 (1.39-6.15), ID/GC-MS 2.54 (0.51-5.12). The technique permitted reliable detection of classical and nonclassical forms of 21- hydroxylase deficiency. The much simpler sample preparation, the faster analytical run time and the operational ease possible with ID/LC-MS-MS permit a considerable increase of sample testing per day without compromising on analytical sensitivity and specificity. We expect that benchtop tandem mass spectrometry will open new avenues in clinical steroid analysis.

Influence of positive end-expiratory pressure ventilation on peripheral tissue perfusion evaluated by measurements of tissue gases and pH. An experimental study in pigs with oleic acid lung injury

Measurements of subcutaneous oxygen tension (PscO(2)), subcutaneous carbon dioxide tension (PscCO(2)) and subcutaneous pH (pHsc) were used for evaluation of peripheral oxygenation in pigs subjected to oleic acid-induced lung injury during ventilation with increasing levels of positive end-expiratory pressure (PEEP). Lung injury resulted in a decrease of arterial oxygen tension (PaO(2)) from 93 to 37 mm Hg (p<0.01) with maintained cardiac output. PscO(2) decreased from 45 to 17 mm Hg (p<0.01) and pHsc from 7.47 to 7.39 (p<0.05), and PscCO(2) increased from 46 to 59 mm Hg (p<0.05). Increase of PEEP level between 5 and 20 cm H(2)O resulted in a continuous increase of PaO(2) from 45 to 145 mm Hg and a decrease of cardiac output from 4.1 to 2.0 liters/min (p<0.01). PscO(2) increased up to a PEEP level of 15 cm H(2)O, reaching 26 mm Hg. Further increase of PEEP level up to 20 cm H(2)O resulted in an increase of PscCO(2) from 65 to 71 mm Hg (p<0.05) and a decrease of pHsc from 7.31 to 7.29 (p<0.05).

IN CONCLUSION

measurements of tissue gases and pH can be used to evaluate optimum peripheral tissue oxygenation during titration of PEEP level. Whether these measurements can be used as the only indicator to guide therapy in an individual case remains to be studied.

The role of psychosocial factors in fibromyalgia syndrome

OBJECTIVE

The main objective of this review was to evaluate the role of psychosocial factors in the development of fibromyalgia syndrome.

METHOD

Review of the literature concerning the influence of psychosocial factors.

RESULTS

In fibromyalgia syndrome psychosocial factors are relevant at different etiological levels. They can be classified into predisposing, triggering and stabilising/"chronifying" factors.

CONCLUSION

Due to the increasing knowledge about the influence of psychosocial factors for the development of fibromyalgia, the biomedical model has to be expanded to a biopsychosocial model. The biopsychosocial concept has an impact on the therapeutic approach. Strong evidence for the model is provided by the good results of interdisciplinary treatment studies.

Independent HIV replication in paired CSF and blood viral isolates during antiretroviral therapy

BACKGROUND

The goal of highly active antiretroviral therapy in HIV-infected patients is to reduce plasma viral load (VL) below quantifiable levels. Mutations associated with drug resistance within the HIV-1 genome can limit therapeutic success. Low VL implicates a low risk of emergence of resistant mutants. Whether there is divergent development of HIV strains in different biologic compartments is not understood.

METHODS

The authors studied VL and the occurrence of mutations conferring resistance in viral genomes isolated from blood and CSF samples of 23 HIV-infected patients. They determined sequences of HIV-1 RNA by reverse transcriptase PCR amplification and direct sequencing. They measured resistance to antiretroviral drugs genotypically by detection of drug-related point mutations and VL by a branched-DNA assay.

RESULTS

Amplification of HIV was successful even in patients with plasma or CSF VL below detection limit. VL was considerably lower in CSF as compared with blood (p < 0.0001). There was no correlation between CSF and plasma VL. The mutational pattern in viral copies derived from blood and CSF was not identical. Ten (9%) of the total number of 118 mutations associated with drug resistance occurred in blood isolates only; 14 (11%) were detected exclusively in CSF strains.

CONCLUSION

There is evidence for viral replication at HIV RNA levels less than 50/mL. The results suggest divergent evolution of HIV-1 in different biologic compartments. The presence of resistant mutants in the CSF may escape regular diagnostic in blood. Therapeutic success may fail after adapting therapy to genotypic resistance patterns detected in one compartment only.

Reaction of Ni2Cp2(mu-CO)2 with the alkylgallium(I) and alkylindium(I) compounds E4[C(SiMe3)3]4 (E = Ga, In). Insertion of E-R groups into the Ni-Ni bond versus replacement of CO by the isolobal E-R ligands

The monomeric fragment In-C(SiMe3)3 was inserted into the Ni-Ni bond of Ni2Cp2(mu-CO)2 upon treatment of the carbonyl complex with the tetraindium(I) compound In4[C(SiMe3)3]4, 1, in a molar ratio of 4 to 1. The product (3) contains an indium atom coordinated to one alkyl substituent and two Ni(Cp)CO groups in a planar coordination sphere. Reaction of the starting compounds in a molar ratio of 2 to 1 led to the replacement of both CO ligands by two InR groups. A compound (4) was formed that is isostructural to the carbonyl nickel complex and has a Ni2 couple bridged by two InR ligands and two terminally coordinated cyclopentadienyl groups. The insertion product was not observed with the gallium derivative Ga4[C(SiMe3)3]4 (2); instead, a nickel gallium complex (5) analogous to 4 containing two bridging GaR ligands was isolated as the only product regardless of the ratio of the starting compounds. On the basis of quantum chemical calculations, we conclude that there is no evidence for an In-In or Ga-Ga bond in complexes 4 or 5, respectively. This, however, supports a butterfly geometry, which is isostructural to the starting carbonyl complex Ni2Cp2(mu-CO)2.

Mechanisms underlying endothelial dysfunction in diabetes mellitus

Incubation of endothelial cells in vitro with high concentrations of glucose activates protein kinase C (PKC) and increases nitric oxide synthase (NOS III) gene expression as well as superoxide production. The underlying mechanisms remain unknown. To address this issue in an in vivo model, diabetes was induced with streptozotocin in rats. Streptozotocin treatment led to endothelial dysfunction and increased vascular superoxide production, as assessed by lucigenin- and coelenterazine-derived chemiluminescence. The bioavailability of vascular nitric oxide (as measured by electron spin resonance) was reduced in diabetic aortas, although expression of endothelial NOS III (mRNA and protein) was markedly increased. NOS inhibition with N:(G)-nitro-L-arginine increased superoxide levels in control vessels but reduced them in diabetic vessels, identifying NOS as a superoxide source. Similarly, we found an activation of the NADPH oxidase and a 7-fold increase in gp91(phox) mRNA in diabetic vessels. In vitro PKC inhibition with chelerythrine reduced vascular superoxide in diabetic vessels, whereas it had no effect on superoxide levels in normal vessels. In vivo PKC inhibition with N:-benzoyl-staurosporine did not affect glucose levels in diabetic rats but prevented NOS III gene upregulation and NOS-mediated superoxide production, thereby restoring vascular nitric oxide bioavailability and endothelial function. The reduction of superoxide in vitro by chelerythrine and the normalization of NOS III gene expression and reduction of superoxide in vivo by N:-benzoyl-staurosporine point to a decisive role of PKC in mediating these phenomena and suggest a therapeutic potential of PKC inhibitors in the prevention or treatment of vascular complications of diabetes mellitus. The full text of this article is available at http://www.circresaha.org.

Dewetting hydrodynamics in 1+1 dimensions

A model for the phase transition between partial wetting and dewetting of a substrate has been formulated that explicitly incorporates the hydrodynamic flow during the dewetting process in 1+1 dimensions. The model simulates a fluid layer of finite thickness on a substrate in coexistence with a dry part of the substrate and a gas phase above the substrate. Under nonequilibrium "dewetting" conditions, the front between the dry part and the wet part of the surface moves towards the wet part inducing hydrodynamic flow inside the wet layer. In more general terms, the model handles two immiscible fluids with a freely movable interface in an inhomogeneous external force field. Handling the interface by a new variant of the phase-field model, we obtain an efficient code with well-defined interfacial properties. In particular, the (free) energy can be chosen at will. We demonstrate that our model works well in the viscosity range of creeping flow and we give qualitative results for the higher Reynolds numbers. Connections to experimental realizations are discussed.

Regulative fine-tuning of the two novel DAHP isoenzymes aroFp and aroGp of the filamentous fungus Aspergillus nidulans

Two novel genes, aroF and aroG, from the filamentous fungus Aspergillus nidulans were isolated and the regulative fine-tuning between the encoded, differentially regulated 3-deoxy-D-arabino-heptulosonate-7-phosphate (DAHP) synthases was analyzed. A wide range of DAHP synthase isoenzymes of various organisms are known, but only a few have been characterized further. DAHP synthases (EC 4.1.2.15) catalyze the first committed step of the shikimate pathway, which is a putative target for anti-weed drugs. The reaction is the condensation of erythrose-4-phosphate (E4P) and phosphoenolpyruvate (PEP) to yield DAHP. The two purified DAHP synthases showed different affinities for the substrates: 175 microM for PEP and 341 microM for E4P for the aroFp isoenzyme and weaker affinities of 239 microM (PEP) and 475 microM (E4P) for the aroGp isoenzyme. The enzymes are differentially regulated by tyrosine (aroFp) and phenylalanine (aroGp). The calculated kcat values are 7.0 s-1 for the tyrosine-inhibitable (aroFp) and 5.5 s-1 for the phenylalanine inhibitable (aroGp) enzyme. Tyrosine is a competitive inhibitor of the aroFp DAHP synthase in its reaction with PEP. Phenylalanine is a competitive inhibitor of the isoenzyme aroGp in its reaction with E4P. Both enzymes are inhibited by the chelating agent EDTA, which indicates a metal ion as cofactor.

A comparison between meperidine, clonidine and urapidil in the treatment of postanesthetic shivering

Postanesthetic shivering can be treated with many types of drugs. We compared the effects of meperidine, clonidine, and urapidil on postanesthetic shivering. Sixty patients shivering during recovery from general anesthesia were treated in a randomized, double-blinded fashion with 25 mg meperidine IV, 0.15 mg clonidine IV, or 25 mg urapidil IV in three separate groups of 20 patients each. If shivering did not stop within 5 min, the treatment was repeated once; clonidine was replaced with saline for the second dose. Rectal temperature, arterial blood pressure, heart rate, SaO(2) and vigilance were monitored. Clonidine stopped shivering in all 20 patients. A single dose of meperidine stopped the shivering in 18 of 20 patients, with the other 2 patients needing a second dose. Urapidil was less effective: the first dose stopped the shivering in only six patients; the second dose was effective in another six; the drug was ineffective in 8 of 20 patients. Meperidine and clonidine were both nearly 100% effective in treating postanesthetic shivering without negative side effects. By comparison, urapidil was only effective in 60% of patients treated (P <0.01).

IMPLICATIONS

Patients shivering during recovery from general anesthesia were treated in a randomized double-blinded fashion with meperidine, clonidine, or urapidil. Meperidine and clonidine were both very effective, whereas urapidil was only effective in 60% of patients treated.

Tu-M2-PK in the blood of testicular and cubital veins in men with testicular cancer

We wanted to verity whether M2-PK is a useful marker in testicular cancer. In a prospective study of 20 consecutive patients, blood was drawn from the testicular and the cubital vein before semicastration and later. For the detection of M2-PK we used the Assay of ScheboTech. In the testicular vein M2-PK was 11.2 U/ml. In the cubital vein it was 6.2 U/ml before semicastration, increasing in the following days. There were no significant differences between testicular and cubital vein blood, between the non-metastasized patients and the metastasized stages and between the patients with seminoma and non-seminomatous tumors. There is no profit in the diagnosis of testicular cancer using Tu-M2-PK.

[Is perfusion MRI feasible in lesions with disrupted blood-brain barrier? Pitfalls and possible solutions]

AIM

When using perfusion-weighted magnetic resonance imaging (MRI) in lesions with blood-brain barrier (BBB) disruption two methods are normally applied to eliminate the influence of contrast material uptake on T2* dynamics: injection of contrast agent before starting perfusion imaging (pre-injection) and simultaneous acquisition of T1- and T2*-dynamics using a dual echo (DE)-FLASH sequence. The purpose of this study was to examine both methods with regard to their reliability.

MATERIAL AND METHODS

We performed four perfusion measurements in a patient with a primary cerebral lymphoma located in the corpus callosum: two measurements with a DE-FLASH sequence and two measurements with a gradient-echo echo-planar-imaging (GE-EPI) sequence, respectively. In both cases there was one measurement with and one without pre-injection of contrast material.

RESULTS

Pre-injection of contrast material reduced the influence of T1 and allowed us to monitor the transient signal drop when using the GE-EPI sequence. Analysis of the time-course of DE-FLASH, however, showed that there was still a T1 decrease even after pre-injection. After the first pass the T2*-dynamics showed a distinct long-term T2*-decrease.

DISCUSSION

Neither pre-injection nor DE-FLASH allow us to eliminate the effects of contrast agent uptake completely. Both methods, however, increase the reliability of perfusion MRI. Their efficacy depends on the extent of the BBB disruption.

[Interdisciplinary consensus on diagnosis and therapy of testicular tumors. Results of an update conference based on evidence-based medicine. German Testicular Cancer study Group (GTCSG)]

BACKGROUND

An "Interdisciplinary Consensus Statement on the Diagnosis and Therapy of Testicular Tumors" was prepared in 1996 by the "Interdisciplinary Testicular Tumor Working Group" (IAH) with input from representatives from diagnostic and therapeutic disciplines of various working groups of the German Cancer Society (Strahlenther Onkol 1997;173:397-406). In 1998 the IAH met again together with the "Testicular Tumor Working Party" of the Urooncology Working Group (AUO) and formed the "German Testicular Cancer Study Group" (GTCSG). Defined and accepted interdisciplinary standards from the initial meeting were revised based on current scientific developments and clinical results. This cooperating effort increased the quality of the initial recommendations and helped to put the recommendations for diagnosing and treating testicular tumor on a broader scientific basis.

METHODS

According to the principles of "evidence-based medicine" (EBM), the Consensus from 1996 was modified, based on the current level of evidence from the published literature. The methodological process and evaluation criteria used were that of the "Cochrane Collaboration".

RESULTS

An "Interdisciplinary Update Consensus Statement" summarizes and defines the diagnostic and therapeutic standards according to the current scientific practices in testicular cancer. For 21 separate areas scientifically based decision criteria are suggested. For treatment areas where more than one option exist without a consensus being reached for a preferred strategy, such as in seminoma in clinical Stage I or in non-seminoma Stages CS I or CS IIA/B, all acceptable alternative strategies with their respective advantages and disadvantages are presented. This "Interdisciplinary Update Consensus" was presented at the 24th National Congress of the German Cancer Society on March 21st and subsequently evaluated and approved by the various German scientific medical societies.

Screening for and characterization of phospholipase A1 hypersecretory mutants of Tetrahymena thermophila

We have described a procedure for the isolation of mutants of Tetrahymena thermophila with hypersecretion of phospholipase A1 (PLA1). Using random chemical mutagenesis, uniparental cytogamy, genetic crossing and a new, fast and effective screening procedure, four PLA1-hypersecretory mutants were isolated. The screening procedure is based on the formation of a halo appearing around cylindrical holes in a lecithin-containing agar plate filled with cell-free supernatants. About 3,940 clones were tested with this procedure in primary screening for hypersecretory features, of which 60 putative hypersecretory mutants were isolated, subcloned and tested in a secondary screening. Of these, four selected mutants showed 1.8-2.2 more PLA1 activity in the cell-free supernatants compared to the wild-type strain CU 438.1. Hypersecretion was only observable for PLA1; no increased activity for two other lysosomal enzymes could be detected. These hypersecretory mutants of T. thermophila can be very useful for increasing the yield of PLA1 in fermentation processes. This is particularly relevant because, in contrast to other phospholipases, PLA1 is not available on the commercial market for fine chemicals and little is known about the role of PLA1 in cell signaling and metabolism.

Effects of a nitrate-free interval on tolerance, vasoconstrictor sensitivity and vascular superoxide production

OBJECTIVES

In the present study, we tested whether a nitrate-free interval is able to prevent increases in vascular superoxide (O2*-) and the development of hypersensitivity to vasoconstrictors and whether this may result in restoration of vascular nitroglycerin (NTG) sensitivity.

BACKGROUND

Intermittent NTG-patch treatment (12 h patch on/patch-off) has been shown to increase ischemic periods in patients with stable coronary arteries, suggesting a rebound-like situation during the patch-off period. Recently, we demonstrated that long-term treatment with NTG induces tolerance, which was in part related to increases in vascular O2*- and increased vasoconstrictor sensitivity.

METHODS

New Zealand white rabbits received a continuous application of NTG patches (0.4 mg/h) or an intermittent application of NTG patches (12 h patch on, 12 h patch off) for three days. Isometric tension studies were performed with aortic rings, and vascular O2*- was estimated using lucigenin-derived chemiluminescence (5 micromol/liter). Expression of the copper/zinc (Cu/Zn) superoxide dismutase (SOD) was assessed by Western blotting, and SOD activity was measured by autooxidation of 6-hydroxydopamine.

RESULTS

Continuous treatment with NTG caused tolerance to NTG, cross-tolerance to the endothelium-dependent vasodilator acetylcholine, increased vascular O2*-, reduced Cu/Zn SOD expression and increased sensitivity to vasoconstrictors such as phenylephrine, serotonin and angiotensin II. On/off treatment with NTG improved tolerance, corrected endothelial dysfunction and decreased vascular O2*-. In addition the reduction in SOD expression was less pronounced, whereas increases in the sensitivity to vasoconstrictors such as phenylephrine and serotonin remained nearly unchanged.

CONCLUSIONS

Enhanced vasoconstrictor sensitivity may explain, at least in part, the rebound phenomena observed in patients during a 12-h NTG patch-off period.

Disseminated Penicillium marneffei infection in an HIV-positive female from Thailand in Germany

We report the case of a 33 year old Thai female, who was married in Germany for eight years and used to travel to Thailand every year for several weeks. She presented with abdominal and back pain, prolonged fever, generalized lymphadenopathy, and a recent history of oral thrush. She was diagnosed HIV positive with initial CD4 counts of 18/microliter and an HI virus load of 59,000 copies/ml. Antiviral therapy was installed with zidovudin, lamivudin, and efavirenz. Abdominal CT scans revealed greatly enlarged abdominal lymph nodes. Fine needle aspirates of cervical and retroperitoneal lymph nodes, sputum samples, blood samples, and a bone marrow biopsy were microscopically positive for Penicillium marneffei and grew P. marneffei. The isolates were sensitive to amphotericin B, flucytosine, itraconazole, and fluconazole. Both universal and specific fungal polymerase chain reaction assays were positive in various samples. Serum Aspergillus galactomannan antigen, which is known to crossreact with P. marneffei, was elevated and subsequently used for monitoring of therapy. With antifungal treatment (intravenous amphotericin B 0.6 mg/kg/d for two weeks, oral itraconazole 400 mg/d for 10 weeks and 200 mg/d as maintenance therapy), the fever declined in 6 days, the size of the enlarged lymph nodes gradually decreased in the CT scans, and the initial abdominal and back pain vanished.

MRI of acute experimental intracerebral hematoma

The purpose of the study was to evaluate the ability of different MR-sequences to detect and delineate experimentally produced hyperacute intracerebral hematomas in rats. Twenty male Sprague-Dawley rats received a unilateral hematoma of various volumes by stereotactic injection of fresh autologous arterial blood into the right caudatoputamen. MRI was performed up to 30 min after-generation of each hematoma. We obtained coronal T2- and T1-weighted spin-echo images. Furthermore we acquired RF-spoiled 2D- and 3D-FLASH images. MR-images were evaluated for signal behavior, location, configuration, size, and volume of each hematoma on a dedicated work station. MR volumetry was correlated to volumetric data obtained from the serial stained histological sections. All hematomas produced signal abnormalities on all sequences in each case. In the majority of cases the hematomas were hypointense. RF-spoiled FLASH 2D- and 3D-sequences showed the best detection of the hematoma owing to their high sensitivity to susceptibility effects. The best correlation between MR- and histological volumetry was found on RF-spoiled FLASH 2D- (corr. 0.81), SE T2- (corr. 0.79), and T1- (corr. 0.74) weighted images. The lowest correlation index was found on the RF-spoiled FLASH 3D-images (corr. 0.51). Signal loss of hematomas on gradient-echo images and--to a lesser extent--spin-echo T2-weighted images due to susceptibility effects can reliably delineate an acute state, whereas conventional MR scans of ischemic stroke may be normal. MRI may thus be the imaging modality of choice in patients with acute brain attack, especially when it is planned to perform diffusion and perfusion MRI before thrombolytic therapy.

Hormonal diagnosis of 21-hydroxylase deficiency in plasma and urine of neonates using benchtop gas chromatography-mass spectrometry

We aimed at measuring the first plasma concentrations of 17-hydroxyprogesterone (17OH-P) determined by benchtop isotope dilution/gas chromatography-mass spectrometry (ID/GC-MS) in term neonates with or without 21-hydroxylase deficiency. Plasma samples from normal cord blood specimens (n=30), unaffected neonates (n=38) and neonatal patients with classical 21-hydroxylase deficiency (eight salt-wasters, three simple virilizers) were analyzed. Steroid profiling of random urinary specimens by GC-MS served as a confirmatory test for 21-hydroxylase deficiency. 17OH-P (nmol/l) in cord blood plasma lay between 11.66 and 75.92 (median 24.74). It declined shortly after birth. In the first 8 days of life, the time that screening for 21-hydroxylase deficiency is performed, 17OH-P ranged between undetected levels and an upper limit of 22.87 (median 4.11). Thereafter (days 9-28) its concentrations lay between 2.18 and 20.30 (median 6.22). Except one simple virilizer, all other patients with 21-hydroxylase deficiency had clearly elevated plasma 17OH-P at the time that screening for 21-hydroxylase deficiency would be performed. We suggest ID/GC-MS, which provides the highest specificity in steroid analysis, for checking suspicious concentrations of 17OH-P in neonates and underscore the potential of urinary steroid profiling by GC-MS as a rapid, non-invasive and non-selective confirmatory test for congenital adrenal hyperplasia.

[Hashimoto encephalopathy: steroid-sensitive encephalopathy in Hashimoto thyroiditis]

Hashimoto's encephalopathy is a steroid-responsive, relapsing or progressive encephalopathy associated with Hashimoto's thyroiditis. Characteristic clinical features are confusion, seizures, alteration in conscious level, stroke-like episodes, myoclonus, and tremulousness. High CSF protein levels without pleocytosis and a diffusely abnormal EEG are typical findings. Brain CT and MRI and cerebral angiogram are usually normal. We present two case reports of Hashimoto's encephalopathy in 55- and 77-year-old patients who both responded well to steroid therapy, and review the literature.

Production of basic fibroblast growth factor and interleukin 6 by human smooth muscle cells following infection with Chlamydia pneumoniae

Chlamydia pneumoniae infection has been associated with asthma and atherosclerosis. Smooth muscle cells represent host cells for chlamydiae during chronic infection. In this study we demonstrated that C. pneumoniae infection of human smooth muscle cells in vitro increased production of interleukin 6 (IL-6) and basic fibroblast growth factor (bFGF) as shown by reverse transcription-PCR, immunoblotting, and enzyme-linked immunosorbent assay. In contrast, levels of platelet-derived growth factor A-chain mRNA were not affected after infection. The stimulation of bFGF and IL-6 production was most effective when viable chlamydiae were used as inoculum. Furthermore, inhibition of bacterial protein synthesis with chloramphenicol prevented up-regulation of IL-6 and bFGF in infected cells. Addition of IL-6 antibody to infected cultures diminished bFGF expression, indicating involvement of produced IL-6. These findings suggest that chlamydial infection of smooth muscle cells elicits a cytokine response that may contribute to structural remodeling of the airway wall in chronic asthma and to fibrous plaque formation in atherosclerosis.

RPLND or primary chemotherapy in clinical stage IIA/B nonseminomatous germ cell tumors? Results of a prospective multicenter trial including quality of life assessment

BACKGROUND

In order to reduce therapy-related morbidity in patients with nonseminomatous testicular germ cell tumors in clinical stage IIA/B, we performed a prospective multicenter trial comparing the standard retroperitoneal lymph node dissection (RPLND) +2 cycles of chemotherapy (arm A) with 3-4 cycles of primary chemotherapy (arm B).

METHODS

From February 1991 to July 1995, 57 participating centers from Germany and Austria recruited 187 evaluable patients. 109 received primary RPLND and 78 primary chemotherapy. Two different chemotherapies were applied (PEB and CEB as adjuvant or inductive treatment). The quality of life (QoL), therapy-related morbidity, suspected predictive factors (histology and size of metastases), and outcome were assessed.

RESULTS

In arm A, 12% had pathological stage (PS) I, 70% PS II A/B, and 18% PS II C/III. In arm B, 67% achieved complete remission with chemotherapy alone, 33% required a secondary RPLND. After a median follow-up of 36 months, 7% of the patients in arm A and 11% in arm B had relapsed. Two patients died due to complications of chemotherapy. Surgical complications amounted to 12% in arm A and 27% of 26 postchemotherapy RPLNDs (9% in arm B). Loss of ejaculation occurred in 32% in arm A, and 16% in arm B. Acute toxicity of chemotherapy was higher in the group receiving primary chemotherapy.

CONCLUSION

We recommend primary RPLND because adjuvant chemotherapy can be spared in PS I, two cycles of chemotherapy are less toxic than 3 or 4 cycles, the primary operation is associated with less complications than that following chemotherapy and, with modern surgical procedures, ejaculation can be preserved in most of the patients, provided that the operation is carried out by an experienced surgeon. No statistically significant differences in the QoL outcome occurred between the treatment groups, suggesting that chemotherapy alone is not superior to primary or secondary RPLND in this respect.