Angiotensin type 1 and type 2 receptor blockade in chronic allograft nephropathy

Angiotensin-II (Ang-II) type 1 (AT(1)) receptor blockers may delay the progression of chronic allograft nephropathy (CAN). However, neither the optimal time for initiating AT(1) receptor blockade in order to delay CAN potentially nor the role of Ang-II type 2 (AT(2)) receptors under AT(1) receptor blockade is known. Both AT receptors can regulate p53 expression and apoptosis. We investigated what time of initiation with AT(1) blockers most effectively delayed CAN as well as the role of the AT(2) receptor, and how angiotensin receptor blockade affected apoptosis and its regulating factors in this context in a rat model. Kidneys of Fisher (F344) rats were transplanted into Lewis rats. Animals were treated with AT(1) (candesartan) and/or AT(2) (PD123319) receptor antagonists, a calcium channel blocker, or vehicle (treatment periods: day -7 before to week 24 after transplantation (long term), week 12 to week 24 (late), day -7 to day +5 (early)) and observed the animals for 24 weeks. Reduction of proteinuria, grade of CAN, and number of apoptotic cells was most pronounced in animals receiving long-term AT(1) receptor blockade. A combined AT(1)/AT(2) blocker treatment reduced CAN similarly to AT(1) blocker treatment alone. The number of apoptotic cells and the level of p53 mRNA were significantly lower in long-term AT(1) blocker-treated animals. In summary, AT(1) receptor blockade delayed the progression of CAN, particularly in animals treated long term. Reduction of apoptosis could be related to these beneficial effects. The AT(2) receptor does not appear to play an important role in CAN.

Genotyping of Giardia in Dutch patients and animals: a phylogenetic analysis of human and animal isolates

Giardia duodenalis (syn. Giardia lamblia, Giardia intestinalis) is a protozoan organism that can infect the intestinal tract of many animal species including mammals. Genetic heterogeneity of G. duodenalis is well described but the zoonotic potential is still not clear. In this study, we analysed 100 Giardia DNA samples directly isolated from human stool specimens, to get more insight in the different G. duodenalis assemblages present in the Dutch human population. Results showed that these human isolates could be divided into two main Assemblages A and B within the G. duodenalis group on the basis of PCR assays specific for the Assemblages A and B and the DNA sequences of 18S ribosomal RNA and the glutamate dehydrogenase (gdh) genes. Genotyping results showed that G. duodenalis isolates originating from Dutch human patients belonged in 35% of the cases to Assemblage A (34/98) and in 65% of the cases to Assemblage B (64/98) whereas two human cases remained negative in all assays tested. In addition, we compared these human samples with animal samples from the Netherlands and human and animal samples from other countries. A phylogenetic analysis was carried out on the DNA sequences obtained from these Giardia and those available in GenBank. Using gdh DNA sequence analysis, human and animal Assemblage A and B Giardia isolates could be identified. However, phylogenetic analysis revealed different sub-clustering for human and animal isolates where host-species-specific assemblages (C, D, E, F and G) could be identified. The geographic origin of the human and animal samples was not a discriminating factor.

Inter-observer agreement of ultrasonographic measurement of alpha and beta angles and the final type classification based on the Graf method

BACKGROUND

The aim of our study was to investigate the agreement of the assessment of hip ultrasonograms by different observers.

METHODS

In the period from June 3rd to December 9th 2002, four different (by experience and field) groups of observers rated all first time sonograms obtained in our hospital. The results in terms of angle and type classification were compared.

RESULTS

158 ultrasonographic images were evaluated. The inter-observer agreement for the classification "normal" (type I) versus "abnormal" (types IIa+ to IV) varied from 83% to 90% with kappa coefficients which indicated moderate (kappa 0.55) to substantial (kappa 0.71) inter-observer agreement. For one pair of observers, a better agreement could be demonstrated for the assessment of immature hips than for mature ones. The deviation for the a-angle was 0 to 16 degrees with a standard deviation of 3.15 degrees (95% CI 2.95, 3.37), and for the b-angle 0 to 26 degrees with a standard deviation of 6.1 degrees (95% CI 5.7, 6.5). The intra-class correlation coefficient was estimated to be 0.72 and 0.34 for the alpha and beta angles respectively. If the hip was immature there was no increase in the discrepancy in assessment between observers. The least agreement existed between the less experienced and the most experienced. It has not been possible to make a statement on the discrepancy with regard to initial signs of instability or decentralization of the hip joints because of the small number of hips of this type.

CONCLUSIONS

Although the spread in measured a- and b-angles is large, the inter-observer agreement for the classification showed good results. No disagreement occurred in the diagnosis of normal vs. dysplastic hips, so no severe cases have been missed. The experience and training of the investigators seemed to play an important role with regard to variability and agreement. The agreement in the assessment of immature hips was better than that of mature hips. Therefore, ultrasound examination of infant hips would appear to be a trustworthy screening method.

Inter-observer agreement of ultrasonographic measurement of alpha and beta angles and the final type classification based on the Graf method

BACKGROUND

The aim of our study was to investigate the agreement of the assessment of hip ultrasonograms by different observers.

METHODS

In the period from June 3rd to December 9th 2002, four different (by experience and field) groups of observers rated all first time sonograms obtained in our hospital. The results in terms of angle and type classification were compared.

RESULTS

158 ultrasonographic images were evaluated. The inter-observer agreement for the classification "normal" (type I) versus "abnormal" (types IIa+ to IV) varied from 83% to 90% with kappa coefficients which indicated moderate (kappa 0.55) to substantial (kappa 0.71) inter-observer agreement. For one pair of observers, a better agreement could be demonstrated for the assessment of immature hips than for mature ones. The deviation for the a-angle was 0 to 16 degrees with a standard deviation of 3.15 degrees (95% CI 2.95, 3.37), and for the b-angle 0 to 26 degrees with a standard deviation of 6.1 degrees (95% CI 5.7, 6.5). The intra-class correlation coefficient was estimated to be 0.72 and 0.34 for the alpha and beta angles respectively. If the hip was immature there was no increase in the discrepancy in assessment between observers. The least agreement existed between the less experienced and the most experienced. It has not been possible to make a statement on the discrepancy with regard to initial signs of instability or decentralization of the hip joints because of the small number of hips of this type.

CONCLUSIONS

Although the spread in measured a- and b-angles is large, the inter-observer agreement for the classification showed good results. No disagreement occurred in the diagnosis of normal vs. dysplastic hips, so no severe cases have been missed. The experience and training of the investigators seemed to play an important role with regard to variability and agreement. The agreement in the assessment of immature hips was better than that of mature hips. Therefore, ultrasound examination of infant hips would appear to be a trustworthy screening method.

Cross sectional study of automated blood pressure measurements throughout pregnancy

OBJECTIVE

To generate reliable new reference ranges for pregnancy blood pressure from a large population.

DESIGN

A prospective cross sectional study.

SETTING

Obstetric outpatient clinic, Zurich University Hospital.

SAMPLE

Accurately dateable singleton pregnancies (Caucasian: n= 3234; Asian [predominantly from Sri Lanka, Thailand and the Philippines]: n= 577; Black n= 212).

METHODS

Between January 1996 and February 2000 blood pressure was determined in 4023 pregnant women using an oscillometric automated device (Dinamap) according to British Hypertension Society recommendations. Women receiving antihypertensive medication were excluded.

MAIN OUTCOME MEASURE

Blood pressure.

RESULTS

Only the means of duplicate measures at the booking visit (5-42 weeks) were used in the analysis. Mean blood pressure decreased from early to mid pregnancy before increasing to levels 4 mmHg higher at term than in early pregnancy. Values >130/80 and <90/50 mmHg were above the 95th and below the 5th centiles, respectively. Parity, age and body mass index were significant determinants in Caucasians. Blood pressure was slightly lower in Asians and Blacks.

CONCLUSIONS

The current World Health Organisation definition of high diastolic blood pressure (>or=90 mmHg on two occasions) reflects values >2 standard deviations from the mean. This may be too conservative as threshold for detecting women at risk of pre-eclampsia. Further studies are required to determine the prognostic implications of gestational values >or=95th centile (>or=130/80 mmHg) and <or=5th centile (<or=90/50 mmHg).

Relative biological effectiveness of 144 keV neutrons in producing dicentric chromosomes in human lymphocytes compared with 60Co gamma rays under head-to-head conditions

The RBE for neutrons was assessed in a head-to-head experiment in which cultures of lymphocytes from the same male donor were irradiated simultaneously with 144 keV neutrons and with 60Co gamma rays as the reference radiation and evaluated using matched time, culture conditions, and the end point of chromosomal aberrations to avoid potential confounding factors that would influence the outcome of the experiment. In addition, the irradiation time was held constant at 2 h for the high-dose groups for both radiation types, which resulted in rather low dose rates. For the induction of dicentric chromosomes, the exposure to the 144 keV neutrons was found to be almost equally as effective (yield coefficient alpha(dic) = 0.786 +/- 0.066 dicentrics per cell per gray) as that found previously for irradiation with monoenergetic neutrons at 565 keV (alpha(dic) = 0.813 +/- 0.052 dicentrics per cell per gray) under comparable exposure and culture conditions (Radiat. Res. 154, 307-312, 2000). However, the values of the maximum low-dose RBE (RBE(m)) relative to 60Co gamma rays that were determined in the present and previous studies show an insignificant but conspicuous difference: 57.0 +/- 18.8 and 76.0 +/- 29.5, respectively. This difference is mainly due to the difference in the alpha(dic) value of the 60Co gamma rays, the reference radiation, which was 0.0138 +/- 0.0044 Gy(-1) in the present study and 0.0107 +/- 0.0041 Gy(-1) in the previous study. In the present experiment, irradiations with 144 keV neutrons and 60Co gamma rays were both performed at 21 degrees C, while in the earlier experiment irradiations with 565 keV neutrons were performed at 21 degrees C and the corresponding reference irradiation with gamma rays was performed at 37 degrees C. However, the temperature difference between 21 degrees C and 37 degrees C has a minor influence on the yield of chromosomal alterations and hence RBE values. The large cubic PMMA phantom that was used for the gamma irradiations in the present study results in a larger dose contribution from Compton-scattered photons compared to the mini-phantom used in the earlier experiments. The contribution of these scattered photons may explain the large value of alpha(dic) for gamma irradiation in the present study. These results indicate that the yield coefficient alpha(dic) for 144 keV neutrons is similar to the one for 565 keV neutrons, and that modification of the alpha(dic) value of the low-LET reference radiation, due to changes in the experimental conditions, can influence the RBE(m). Consequently, alpha(dic) values cannot be shared between cytogenetic laboratories for the purpose of assessment of RBM(m) without verification of the comparability of the experimental conditions.

[Reliability of active range-of-motion measurement of the rotation in the forearm: comparison of three measurement devices]

AIM

The aim of this study is to prove the intra- and interobserver reliability of three different methods to measure the active range-of-motion in the forearm.

METHODS

These three different methods were tested on forty volunteers. In the first method pictures were made in full supination and pronation, measurement of the two angles was performed with a dedicated software. Active range-of-motion was defined as the magnitude of forearm rotation between maximum pronation and supination. The second method used a standard goniometer. The third method of assessment used a gravity goniometer (plurimeter). We randomised both the side of the patient to be examined and the sequence of the methods. Two examiners measured subsequently the range-of-motion twice with these three devices.

RESULTS

We found a significant intraobserver reproducibility with the gravity goniometer. There was no significance with the goniometer or pictures. The intraobserver reproducibility of the latter two methods was poor. The interobserver reproducibility of the gravity goniometer and pictures was significant, for the goniometer it was poor. Agreement between the pictures and gravity goniometer assessment of the range-of-motion was good. None of these two methods was significantly correlated with the goniometer assessment.

CONCLUSION

For reproducibility of measurement of range-of-motion in the forearm the gravity goniometer is the best method, although the measured values were 5 % greater.

[Fifty years of dental nurse education in Finland]

The first training-course for dental nurses was arranged by the Finnish Dental Association in 1947-1948. Professional help was needed in dental offices in assisting the dentists, taking care of the patients, particularly children, and in cleaning the equipment. As early as 1922 the Scandinavian Dental Association had pointed out that "clinic sisters" would be needed in dental training centers, but the suggestion was not put into effect. The first nine-month curriculum for dental nurses already included all disciplines of dentistry. Lectures in pharmacology, bacteriology and first-aid were also given. Practical training was arranged at the Institute of Dentistry, University of Helsinki. The students further trained for three-week periods both at dental clinics and at privat dental offices. Nine students completed the course and received their diplomas at the end of May, 1948.

The replicated ftsQAZ and minB chromosomal regions of Escherichia coli segregate on average in line with nucleoid movement

The average cellular positions of the ftsQAZ region (2 min) and the minB region (26.5 min) during the cell cycle was determined by fluorescent in situ hybridization using the position of oriC as a reference point. At the steady-state growth conditions used, newborn cells had replicated about 50% of the chromosome. By measuring the distances of the labelled oriCs with respect to mid-cell, we found two well-separated average oriC positions in cells of newborn length. These average oriC positions moved further apart along with cell elongation. The cellular position of the ftsQAZ gene region resembled the position of oriC, although its average position was closer to mid-cell. In contrast, a single minB focus was observed at cell birth. Separated minB foci appeared towards the end of DNA replication. The average positions of oriC, ftsQAZ and minB relative to each other fitted a model in which DNA replication takes place in the cell centre and subsequent gene regions pass sequentially through this centre. We have interpreted the polarized orientation of the studied gene regions as a consequence of the mode of DNA segregation.

Experiments on movement of DNA regions in Escherichia coli evaluated by computer simulation

During the cell cycle of Escherichia coli DNA is replicated and segregated over two prospective daughter cells. Nucleoids as a whole separate gradually in line with cell elongation, but sub-nucleoid DNA regions may behave differently, separating non-gradually. We tested the ability of three models to predict the outcome of a fluorescent in situ hybridisation (FISH) experiment. We did this by comparing computer-simulated data with experimental data. The first model predicts gradual separation in line with cell elongation. The second model predicts that origins stick together for some time after duplication before one copy jumps to the other side of the cell (non-gradual separation). The simulated data of these models are very similar, indicating that FISH is not a suitable method to distinguish between these two models. The third model predicts that origins may be anywhere within the nucleoid(s). We found that simulated data using the third model resemble the experimental data most. However, DNA regions are not randomly localised in the cell, although their localisation is fuzzy. We propose that movement of DNA regions is the result of a combination of factors. Nucleoid segregation (or the forces behind it) dictates the overall direction of movement. Other factors, of which we show that diffusion could be an important one, move DNA in other directions giving rise to non-gradual movement in individual cells and contributing to variation in intracellular position per cell length in a population of cells.

Involvement of multiple genetic loci in Staphylococcus aureus teicoplanin resistance

Teicoplanin resistance was transformed from a teicoplanin-resistant Staphylococcus aureus into the susceptible strain BB255 to give strain BB938. The cell wall composition, amidation of the iD-glutamate, and peptide crosslinking were identical in BB938 as in BB255 except for a 60% increased length of the glycan chain. Transductional crosses revealed that at least two distinct loci contributed in a cumulative fashion to teicoplanin resistance. One of these loci correlated with a mutation inactivating the anti-sigma factor RsbW. This mutation must have occurred during transformation and selection for teicoplanin resistance in BB938. Genetic manipulations involving the sigB operon showed that transcription factor SigB contributed to decreased teicoplanin susceptibility.

Slower decline of plasma HIV-1 RNA following highly suppressive antiretroviral therapy in primary compared with chronic infection

OBJECTIVES

To study the effect of highly suppressive antiretroviral therapy on the slopes of HIV-1 RNA decline in primary compared with chronic HIV-1 infection.

METHODS

Slopes of HIV-1 RNA decline in plasma were compared before and after the start of highly suppressive antiretroviral therapy from five acutely infected patients who started treatment 2 to 5 weeks following the onset of clinical symptoms. Slopes of decline after the initiation of therapy were also compared with those found in 12 chronically infected individuals on the same therapy. Numbers and percentages of activated CD4 and CD8 T cells at baseline were compared as well.

RESULTS

The pre-treatment slopes of HIV-1 RNA decline in the acutely infected individuals increased significantly (P = 0.0001) after the start of anti-retroviral therapy. However, these post-treatment slopes were lower than those found in the chronically infected individuals (P= 0.012). Slopes were inversely correlated (P= 0.012) with baseline HIV-1 RNA. Although the number of CD38+HLA-DR+ CD4 cells was higher in primary infection (P= 0.02), the percentage did not differ between primary and chronic infection.

CONCLUSIONS

These findings indicate that antiretroviral therapy contributes significantly to the clearance of HIV-1 during primary infection. Based on the mathematical model the less steep RNA slope following the start of treatment in primary infection can be predicted to be the result of lower clearance of productively infected cells and higher burst size per cell per unit time. This may indicate a growing immune response to HIV-1 in this very early stage of infection.

Spontaneous growth in German children and adolescents with genetically confirmed Prader-Willi syndrome

Height and weight in children with Prader-Willi syndrome, diagnosed by standard clinical criteria, follow a specific developmental pattern resulting in early childhood obesity, absent pubertal growth spurt and adolescent short stature. New molecular techniques (methylation analysis, fluorescence in situ hybridization) now allow the unequivocal diagnosis of Prader-Willi syndrome (PWS). We investigated the possibility of a bias in syndrome-specific growth standards based on clinically diagnosed patients by comparing these standards with new standards derived from 100 German patients with molecularly confirmed PWS, none of whom had received a growth-promoting therapy. Height centile curves of the German patients fall in the tall range of standards derived from American patients. This is mainly due to an elevation of the lower centile ranges in both sexes. When the height standards derived from German patients are compared to those of a large multinational cohort of patients, 78% of whom were not confirmed by genetic testing, only minor differences in the height centiles become apparent. The population background therefore does not appear to play a major role for the observed differences. In a marked proportion of patients a decreased sitting height/height ratio is found. This was usually associated with scoliosis. Weight standards from our study group show that after 14 y of age German girls with PWS are heavier than their American counterparts. Standards for the body mass index of German patients of both sexes are increased over normal reference standards (p < 0.0001) and do increase with age (boys: p = 0.0038; girls: p = 0.0004). PWS genotypes or sex had no apparent influence on SDS for height, weight and body mass index.

CONCLUSIONS

Because of the observed differences to other growth standards, use of the newly constructed centile curves is advocated in German patients with molecularly confirmed PWS to avoid delay in the diagnosis of additional growth-compromising conditions.

Glutamine synthetase and heteroresistance in methicillin-resistant Staphylococcus aureus

Inactivation of femC in methicillin-resistant Staphylococcus aureus (MRSA) results in lowered methicillin resistance and a reduction in the amidation of the iso-D-glutamate of the peptidoglycan stem peptide. The femC phenotype is due to insertional inactivation of the glutamine synthetase repressor gene glnR by Tn551, which has a polar effect on glutamine synthetase (glnA) transcription. The complete glutamine synthetase operon (glnRA) of S. aureus was cloned and sequenced, and its transcriptional start was determined. The deduced amino acid sequence of the staphylococcal glutamine synthetase showed 76% identity and 87% similarity to the Bacillus subtilis glutamine synthetase. The staphylococcal glnRA operon was shown to complement an Escherichia coli glutamine synthetase-negative mutant and to restore methicillin resistance in femC mutants. femC mutants revert to resistance in the presence of high concentrations of methicillin. These revertants, which still carried the femC lesion, were shown to retain the lowered amidation of the iso-D-glutamate peptidoglycan stem peptide. A new chromosomal locus hmrC was postulated to have mutated to allow expression of high methicillin resistance in these femC revertants. Although the highly resistant hmrC revertant resembled phenotypically the highly methicillin-resistant subclones occurring in heterogeneously resistant MRSA, we could show by transduction that the locus hmrC was distinct from chr*, a chromosomal site postulated to confer high methicillin resistance in heterogeneous MRSA. This suggests that S. aureus can adopt multiple ways to achieve high methicillin resistance.

Staphylococcal peptidoglycan interpeptide bridge biosynthesis: a novel antistaphylococcal target?

In staphylococci, crosslinking of the peptide moiety of peptidoglycan is mediated via an additional spacer, the interpeptide bridge, consisting of five glycine residues. The femAB operon, coding for two approximately 50-kDa proteins is known to be involved in pentaglycine bridge formation. Using chemical mutagenesis of the beta-lactam-resistant strain BB270 and genetic, biochemical, and biophysical characterization of mutants selected for loss of beta-lactam resistance and reduced lysostaphin sensitivity it is shown that peptide bridge formation proceeds via three intermediate bridge lengths (cell wall peptides with no, one, three, and five glycine units). To proceed from one intermediate to the next, three genes appear necessary: femX, femA, and femB. The drastic loss of beta-lactam resistance after inactivation of FemA or partial impairment of FemX even beyond the level of the sensitive wild-type strains renders these proteins attractive antistaphylococcal targets.

Effects of penicillin-binding protein 4 overproduction in Staphylococcus aureus

The pbp4 gene of a Staphylococcus aureus strain selected stepwise in vitro for growth on increasing concentrations of penicillin and of its susceptible parent strain showed overall identity except in the promoter region. In the mutant a deletion upstream of the pbp4 structural gene removed 90 nucleotides (nt) that were framed by a 12 nt inverted repeat. This deletion occurred in step 4 of the in vitro selection procedure and was paralleled by a significant increase in the penicillin-binding protein 4 (PBP4) production. The in vitro step selected mutant showed a remarkable increase in the cross-linking of the peptidoglycan compared to its parent. This was linked to morphological changes in the appearance of the cells, which were surrounded by a very thick and fuzzy cell wall.

Mucosal dose prescription in endobronchial brachytherapy: a study based on CT-dosimetry

PURPOSE

To investigate the consequences of using different dose prescription methods for endobronchial brachytherapy (EB), both with and without the use of a centered applicator.

MATERIALS AND METHODS

A CT scan was performed during EB procedures in 13 patients after insertion of the lung applicator. A dosimetric analysis was subsequently performed in five of these patients using a 3D-brachytherapy treatment planning system (PLATO v13.3, Nucletron).

RESULTS

Dose prescription to the mucosa yields uniform dose distributions to the bronchial mucosa when a centrally positioned applicator is used. When non-centrally positioned applicators are used, mucosal dosing results in a significant underdosage to parts of the target volume. Due to the rapid dose fall-off in EB, dose prescription to the mucosa resulted in inadequate coverage of the outer portion of the bronchial wall and adjacent peribronchial space. When compared to mucosal dose prescription, prescription to the outer aspect of the bronchial wall appears to improve target coverage while limiting the hyperdose (i.e., 200%) volume. The diameters of the different bronchial segments, as determined by CT measurements in 13 patients, correlated well with calculated values based upon the tracheal diameter.

CONCLUSIONS

Mucosal dose prescription should only be used in combination with centered EB applicators. Given the rapid dose fall-off in EB mucosal dose prescription should be used with caution in curative treatments where EB, without additional external radiotherapy, is used as the sole treatment modality. In curative EB, both improved target coverage and a limited hyperdose volume can be achieved by dose prescription to the outer aspect of the bronchial wall.

Epidemiology of drug exposure and adverse drug reactions in two swiss departments of internal medicine

AIMS

To explore drug exposure, frequency of adverse drug reactions (ADRs), types of ADRs, predisposing risk factors and ADR-related excess hospital stay in medical inpatients.

METHODS

Structured data regarding patient characteristics, 'events' (symptoms, laboratory results), diagnoses (ICD10) and drug therapy were collected using a computer-supported data entry system and an interface for data retrieval from electronic patient records. ADR data were collected by 'event monitoring' to minimize possible bias by the drug monitor. The causality of each event was assessed in relation to disease(s) and drug therapy.

RESULTS

The analysis included 4331 (100%) hospitalizations. The median observation period was 8 days. The median number of different drugs administered per patient and day was 6 and varied between 4 (Q1 ) and 9 (Q3 ) different drugs in 50% of all hospital days. In 41% of all hospitalizations at least one disease-unrelated event could be possibly attributed to drug therapy. Clinically relevant ADRs occurred in 11% of all hospitalizations. In 3.3% of all hospitalizations ADRs were the cause of hospital admission. The incidence of possibly ADR-related deaths was 1.4. Factors predisposing for clinically relevant ADRs were female gender and polypharmacy. ADR-related excess hospital stay accounted for 8. 6% of hospital days.

CONCLUSIONS

These data demonstrate the feasibility of the developed 'event monitoring' system for quantitative analysis of ADRs in medical inpatients. With increasing numbers of recorded patients the pharmacoepidemiological database provides a valuable tool to study specific questions regarding drug efficacy and safety in hospitalized patients.

Effects of early antiretroviral treatment on HIV-1 RNA in blood and lymphoid tissue: a randomized trial of double versus triple therapy. Swiss HIV Cohort Study

To assess the effects of early initiation of antiretroviral therapy on cell-free and cell-associated viral load in blood and lymphoid tissue, we performed a randomized, open-label, multicenter trial comparing a double (zidovudine + lamivudine) and triple (zidovudine + lamivudine + ritonavir) drug combination in treatment-naive, asymptomatic patients with CD4 counts >400 cells/microl. HIV-1 RNA was measured in plasma, peripheral blood mononuclear cells, and sequential tonsil or lymph node biopsies (27 patients); the study follow-up was 2 years. Among 42 randomized patients, the proportion with plasma HIV-1 RNA <50 copies/ml was 16% and 74% at week 24 (p<.001) in those randomized to double and triple therapy, respectively, necessitating frequent treatment intensification in the double arm. After a rapid decline within 4 weeks in both arms, cell-associated HIV-1 RNA decreased further only in those patients with sustained suppression of plasma viral load, but remained almost always detectable at low levels, indicating persisting transcription of viral RNA. CD4 counts increased by 200 to 250 cells/microl at week 96 in both arms without significant differences (intent-to-treat analyses). Thus, even if treatment is initiated early in asymptomatic patients with preserved CD4 counts, three drugs are necessary to achieve sustained decreases of HIV load in blood and lymphoid tissue.