European consensus on diagnosis and treatment of germ cell cancer: a report of the European Germ Cell Cancer Consensus Group (EGCCCG)

Germ cell tumour is the most frequent malignant tumour type in young men with a 100% rise in the incidence every 20 years. Despite this, the high sensitivity of germ cell tumours to platinum-based chemotherapy, together with radiation and surgical measures, leads to the high cure rate of > or = 99% in early stages and 90%, 75-80% and 50% in advanced disease with 'good', 'intermediate' and 'poor' prognostic criteria (IGCCCG classification), respectively. The high cure rate in patients with limited metastatic disease allows the reduction of overall treatment load, and therefore less acute and long-term toxicity, e.g. organ sparing surgery for specific cases, reduced dose and treatment volume of irradiation or substitution of node dissection by surveillance or adjuvant chemotherapy according to the presence or absence of vascular invasion. Thus, different treatment options according to prognostic factors including histology, stage and patient factors and possibilities of the treating centre as well may be used to define the treatment strategy which is definitively chosen for an individual patient. However, this strategy of reduction of treatment load as well as the treatment itself require very high expertise of the treating physician with careful management and follow-up and thorough cooperation by the patient as well to maintain the high rate for cure. Treatment decisions must be based on the available evidence which has been the basis for this consensus guideline delivering a clear proposal for diagnostic and treatment measures in each stage of gonadal and extragonadal germ cell tumour and individual clinical situations. Since this guideline is based on the highest evidence level available today, a deviation from these proposals should be a rare and justified exception.

The chloroplastic protein import machinery contains a Rieske-type iron-sulfur cluster and a mononuclear iron-binding protein

Transport of precursor proteins across the chloroplastic envelope membranes requires the interaction of protein translocons localized in both the outer and inner envelope membranes. Analysis by blue native gel electrophoresis revealed that the translocon of the inner envelope membranes consisted of at least six proteins with molecular weights of 36, 45, 52, 60, 100 and 110 kDa, respectively. Tic110 and ClpC, identified as components of the protein import apparatus of the inner envelope membrane, were prominent constituents of this complex. The amino acid sequence of the 52 kDa protein, deduced from the cDNA, contains a predicted Rieske-type iron-sulfur cluster and a mononuclear iron-binding site. Diethylpyrocarbonate, a Rieske-type protein-modifying reagent, inhibits the translocation of precursor protein across the inner envelope membrane, whereas binding of the precursor to the outer envelope membrane is still possible. In another independent experimental approach, the 52 kDa protein could be co-purified with a trapped precursor protein in association with the chloroplast protein translocon subunits Toc86, Toc75, Toc34 and Tic110. Together, these results strongly suggest that the 52 kDa protein, named Tic55 due to its calculated molecular weight, is a member of the chloroplastic inner envelope protein translocon.

The architecture of the heart in systole and diastole. Technique of rapid fixation and analysis of left ventricular geometry

Techniques for rapid fixation of the canine left ventricle in systole or diastole that have permitted analysis of ventricular geometry under known hemodynamic conditions are described. Six ventricles were arrested at and diastole, 7 at end ejection, and 7 in diastole following acute ventricular overdistension. The architecture of the ventricles was analyzed from measurements of the fixed ventricles and silicone-rubber casts of the ventricular cavities. In ventricles of matched weights, the average reduction, from end diastole to end ejection, of the apex to mitral valve distance was 4.6%, while that from apex to aortic valve was less than 1%. The minor internal equator was reduced by 26%, the midwall radius by 16%, and the outer radius by 8.5%. The ratio of the average end-diastolic volume minus end-systolic volume to the end-diastolic volume (analogous to stroke volume/end-diastolic volume) averaged 59%. The average wall thickness was 28% greater in systolic than in diastolic ventricles. The papillary muscle volume averaged 5.0%e of ventricular volume at end diastole and 14.7% at end systole. The area of the mitral valve orifice averaged 28% less at end systole than at end diastole; this area was 39% more in the hearts subjected to over-transfusion than in those with normal filling pressures. These data provide a framework for construction of a geometric model suitable for use in analyses of the mechanics of left ventricular contraction. Moreover, the methods described offer the possibility of correlating ventricular geometry and ultrastructure with cardiac function in normal and in abnormal hearts.

Reproducibility of patch tests. A multicenter study of synchronous left-versus right-sided patch tests by the German Contact Dermatitis Research Group

BACKGROUND

The efficiency and reproducibility of patch tests remain controversial.

OBJECTIVE

Our purpose was to determine the efficiency and reproducibility of patch tests and to identify factors influencing these features.

METHODS

We double-tested 1285 patients concomitantly with 10 standard allergens by manually filled test chambers. Additional information was obtained from all patients with a standardized protocol.

RESULTS

Patch test efficiency was good (> or = 0.94) with all 10 allergens. In contrast, nonreproducibility of patch tests was strongly allergen dependent, ranging from 0.2 for nickel sulfate to 0.6 for formaldehyde. The likelihood of nonreproducible allergic reactions increased when more than four positive reactions were seen at the same time, and with another positive reaction located in close proximity to an allergic reaction. Sex and age of patients, atopy, dermatitis at distant sites, sleeping habits, and the time of allergen exposure (24 or 48 hours) did not affect the rate of nonreproducible results.

CONCLUSION

To increase patch test reproducibility, specific preparations of patch test allergens need to be improved. Furthermore, amplification effects by synchronous neighboring positive reactions should be excluded.

Exposure in vivo vs social skills training for social phobia: long-term outcome and differential effects

This study examined the long-term effectiveness of specific exposure in vivo (individual IE or group GE) and of office-based social skills training (group SST) in two groups of patients with social inhibition (primary social skills deficits or primary social phobia). Seventy-eight outpatients were divided into these two subgroups according to clinical assessment. Twenty-seven patients received SST which consisted of 25 twice a week 90-min group sessions: 32 patients received GE and 17 IE. Exposure in vivo consisted of 4 weekly (8-hr in the group condition included 2 hr discussion; 3 hr in the individual condition included 1 hr discussion) sessions. Self-rating-assessments were carried out at pre- and post-treatment, at 3 months- and 2.5 yr follow-up. The general results indicate that all three treatment modes led to clinically and statistically-significant improvements in the main problem area (social anxiety, skills deficits), in other neurotic complaints (depression, obsessions, psychosomatic complaints) and in attribution-style. Patients with the diagnosis of primary phobia seemed to get the same profit from either treatment and showed slightly better gains (in all treatment modalities) than patients with skills deficits at long-term follow-up. Within the subgroup with skills deficits there was a tendency for superior outcome of group exposure. These results and recommendations for future research are discussed.

Pharmacokinetics and tolerability of formoterol in healthy volunteers after a single high dose of Foradil dry powder inhalation via Aerolizer

OBJECTIVE

The pharmacokinetics of the long-acting beta2-agonist formoterol fumarate, which is a racemate of the (S,S)- and (R,R)-enantiomers were evaluated in 12 healthy (eight male, four female) volunteers after a single inhaled high dose of 120 microg of formoterol fumarate. The tolerability and safety were also assessed.

METHODS

Each volunteer inhaled the single 120-microg dose through the Aerolizer device within 2-5 min, using ten 12-microg dry powder capsules for inhalation. Formoterol, i.e., the sum of both enantiomers, was determined in plasma over 24 h, whereas the separate enantiomers were determined in urine over 48 h. Incidence, seriousness and severity of adverse experiences, electrocardiogram (ECG), including the corrected QT interval (QTc) calculation, systolic blood pressure, heart rate, and plasma potassium levels were recorded.

RESULTS

In nine of the 12 volunteers, the peak plasma concentration of formoterol was observed already at 5 min after inhalation. The absorption kinetics were complex, as depicted by multiple peaks or shoulders within 0.5-6 h after inhalation. Mean with (SD; n = 12) of maximum concentration (Cmax) and area under the curve (AUC) of formoterol in plasma were 266 (108) pmol x l(-1) and 1330 (398) pmol x l(-1), respectively. The moderate inter-individual variability in systemic exposure of formoterol reflects the homogeneous pharmacokinetics of the drug. A predominant slow elimination of formoterol from plasma with a mean half-life (t1/2) of 10 h was demonstrated. Assuming linear kinetics in plasma suggested by urinary data, the steady-state trough plasma levels of formoterol for a b.i.d. dosing regimen are predicted to amount to 20% of Cmax. In urine, mean with (SD; n = 10) of the amount excreted over 48 h was 3.61 (0.89)% of dose for the pharmacologically active (R,R)-enantiomer and 4.80 (1.33)% of dose for the (S,S)-enantiomer. The terminal half-lives calculated from the excretion rate-time curves, i.e., 13.9 h and 12.3 h for the (R,R)- and (S,S)-enantiomer, respectively, confirm the slow elimination of formoterol from plasma. The dose inhaled was 10 times the most frequently recommended dose (12 microg) and 5 times the highest recommended dose (24 microg). Ten of 12 subjects experienced mild and transient nervousness. Pulse readings demonstrated the maximum mean increase of 25.8 beats x min(-1) at 6 h. The mean maximum QTc increase was 25 msec at 6 h. Pulse and QTc values returned to baseline or close to baseline values at 24 h or before. Potassium levels in plasma decreased in eight out of 12 subjects; the lowest mean value was 3.53 mmol x l(-1) at 2 h post-dose. The lowest individual potassium measurement was 2.95 mmol x l(-1) between 15 min and 6 h. By 8 h post-dose all values had returned to within the normal ranges.

CONCLUSIONS

The extremely fast appearance of formoterol in plasma shows the predominance of airways absorption shortly after inhalation. Due to a terminal elimination half-life of about 10 h, sustained systemic concentrations of formoterol are predicted for a twice daily treatment regimen without noteworthy accumulation. The excreted amounts in percent of dose of the enantiomers in urine and the enantiomer ratio are similar to data reported previously after lower doses and suggest linear kinetics for doses between 12 microg and 120 microg of formoterol fumarate. The expected side effects on heart rate, QTc interval, and plasma potassium were small and had no clinical consequences in spite of the very high dose of 120 microg (5 to 10 times the recommended therapeutic dose of Foradil). It should be noted that the impact of high doses may be greater in patients. Nevertheless these findings provide reassurance on the safety margin of formoterol after accidental and intentional overdosing.

Sagittal synostosis--its clinical significance and the results of three different methods of craniectomy

From 1973 to 1986, 50 infants with sagittal synostosis have been operated by three different methods of craniectomy (linear craniectomy and extended craniectomies, as proposed by Schut and Epstein et al.). Preoperatively, the mean cephalic index was 67 +/- 4, 35.5% had clinical findings as cerebral palsy, psychomotor retardation and/or neurological signs, and intraoperatively the epidural pressure was more than 200 mm H2O in 60% (recorded in the last 20 patients). The mean follow-up time was 4.7 (1-10.6) years. Postoperatively, only 14.5% had minor clinical signs, which were mostly not in relation to the former scaphocephaly. Half of the patients with increased ICP had clinical signs preoperatively, and none of the 20 patients had distinct findings postoperatively. Out of the 20 children operated on by linear craniectomy or by Schut's method up to 1980, two-thirds had no school problems and one-third some school problems; one-third had occasionally headaches and one-quarter ametropia. Concerning the aesthetic results, Epstein's method and, somewhat less Schut's method, were superior to linear craniectomy, as verified by craniometry and by the tracings of the outlines of the neurocranium 0.4-0.7 and 1.6-2.0 years postoperatively: mean cephalic indices 73 +/- 5 (normal in one-fourth), 74 +/- 7 (normal in half) and 79 +/- 4 (normal in nearly all patients). Epstein's method is superior to the other two methods because it renders it possible to increase the breadth the greatest during the period of greatest postnatal brain growth. In addition to the effect on the neurocranium, the extended craniectomies add to normalization of the base of the skull (in contrast to the natural history of scaphocephaly). In the long run, the results obtained remain the same. The disadvantage of residual skull defects (approximately 11% of the patients with extended craniectomies) can be avoided by performing surgery prior to 4-6 months of age or by preserving the removed bone in a deep-freeze for a limited time.

Features of autophagic cell death in Plasmodium liver-stage parasites

Analyzing molecular determinants of Plasmodium parasite cell death is a promising approach for exploring new avenues in the fight against malaria. Three major forms of cell death (apoptosis, necrosis and autophagic cell death) have been described in multicellular organisms but which cell death processes exist in protozoa is still a matter of debate. Here we suggest that all three types of cell death occur in Plasmodium liver-stage parasites. Whereas typical molecular markers for apoptosis and necrosis have not been found in the genome of Plasmodium parasites, we identified genes coding for putative autophagy-marker proteins and thus concentrated on autophagic cell death. We characterized the Plasmodium berghei homolog of the prominent autophagy marker protein Atg8/LC3 and found that it localized to the apicoplast. A relocalization of PbAtg8 to autophagosome-like vesicles or vacuoles that appear in dying parasites was not, however, observed. This strongly suggests that the function of this protein in liver-stage parasites is restricted to apicoplast biology.

Transport of anions in isolated barley vacuoles : I. Permeability to anions and evidence for a cl-uptake system

The anion contents of young barley leaves and of mesophyll protoplasts from the leaves was compared. Anion loss from the protoplasts during isolation was small. Although only about 60% of the leaf cells were mesophyll cells, phosphate and sulfate contents of the mesophyll cells accounted for almost 90% of the leaf contents. Chloride accumulated in the leaf epidermis. The rapid isolation of vacuoles from mesophyll protoplasts permitted the determination of vacuolar ion concentrations. Sodium and nitrate levels were very low in the cytoplasm, and much higher in the vacuole. When barley plants were grown in the presence of low NaCl levels, chloride concentrations were comparable in cytoplasm and vacuole, and similar observations were made with sulfate. Cytoplasmic phosphate concentrations were close to 30 millimolar and potassium concentrations 100 millimolar. During a 30 minute incubation period at room temperature, anion contents of isolated vacuoles decreased considerably. Efflux of NO(3) (-) was faster than that of Cl(-). Phosphate and sulfate crossed the tonoplast only slowly. 4,4'-Diisothiocyano-2,2'-stilbenedisulfonic acid partially inhibited the efflux of nitrate and, to a lesser extent, that of chloride. Decreased efflux was also observed in the presence of MgATP. In remarkable contrast, p-chloromercuribenzene sulfonate and HgCl(2) stimulated the efflux of nitrate and chloride, but not of phosphate. Labeled chloride was taken up by isolated vacuoles. The apparent K(m) for chloride uptake at low chloride concentrations was 2.3 millimolar. At elevated chloride concentrations, chloride did not display saturation characteristics but, rather, characteristics of a diffusional process. Uptake was stimulated by ATP.

Hypothermic reconditioning by gaseous oxygen improves survival after liver transplantation in the pig

The quality of cold-stored livers declines with the extension of ischemic time and the risk of primary dys- or nonfunction increases. Here, we provide in vivo evidence for the efficacy of the previously developed end-ischemic gaseous oxygen persufflation technique to resuscitate liver grafts after extended storage times. Porcine livers were recovered according to standard multiorgan procurement protocol. Control livers were cold stored in histidine tryptophan ketoglutarate solution for 10 h (cold storage [CS]; n = 6) at 4°C. In the treatment group (n = 6), livers were additionally subjected to hypothermic reconditioning (HR) by gaseous oxygen persufflation via the caval vein for 2 h before transplantation. Viability was assessed by orthotopic liver transplantation and 1 week follow-up. HR significantly improved pretransplant energy charge and initial graft function after transplantation. One week survival after CS was 0% whereas five of six pigs (83%) survived in the HR group. At that time, coagulation parameters were in the normal range and histological analysis disclosed healthy liver tissue with normal trabecular architecture in the treated grafts. Molecular analyses identify the prevention of ischemia-induced decline of cellular autophagy and mitigation of innate immune machinery (high-mobility group protein B1, interferon-β) as operative mechanisms among the protective effects provided by HR.

Complete spontaneous remission in a patient with metastatic non-small-cell lung cancer. Case report, review of the literature, and discussion of possible biological pathways involved

Spontaneous remission of cancer (SR) is defined as a complete or partial, temporary or permanent disappearance of all or at least some relevant parameters of a soundly diagnosed malignant disease without any medical treatment or with treatment that is considered inadequate to produce the resulting regression. We report the case of a 61-year-old man who presented with extensive metatastic disease five months after pneumonectomy for poorly differentiated large cell and polymorphic lung cancer. A vast metastatic tumour mass of the abdominal wall was confirmed histolologically and there was clinical and radiographic evidence of liver and lung metastases. Eight months later, the patient was operated on for a hernia, which had developed in the inguinal biopsy scar and the surgeon confirmed complete clinical SR of the abdominal wall metastases. Again five months later there was no longer any radiologic evidence of liver and lung metastases. Complete remission has persisted more than five years. Histology of the primary and of the abdominal metastases were reviewed by several independent pathologists. SR is an extremly rare event in lung cancer. This is the first documented case of clinically evident visceral metastases of a bronchiogenic adenocarcinoma developing after complete resection of the primary and then showing complete SR. The epidemiology of SR is reviewed and possible mechanisms involved in SR are discussed.

Treatment and outcome of the severely head injured child

Twenty-four children (aged 3 months to 14 years) with severe head injuries were treated by means of invasive neurointensive care for normalizing intracranial pressure (ICP) involving hyperventilation, control of body temperature, dexamethasone, barbiturates and continuous intracranial and arterial pressure monitoring. The Glasgow Coma Scale before initiation of treatment was 3-4 in 8, 5-6 in 9 and 7 in 7 patients. Moderately to severely elevated ICP was observed in 20 patients. Seven developed acute and subacute space occupying intracranial hematomas. Nineteen children (79%) survived, most often with good recovery and 5 (21%) died. Severely elevated ICP, presence of severe consumption coagulopathy and loss of components in brain auditory evoked potentials were significantly more frequent in the fatal group. We conclude that the prognosis of the severely head injured child can be improved by prompt resuscitation and aggressive neurointensive care but probably not, however, to the extent postulated in recent literature.

Intracranial lipomas

Intracranial lipomas are very rare tumors, mostly being localized in the midline and often asymptomatic. We report on three children with intracranial lipomas (one with extension to the cervical spinal cord) diagnosed by CT and/or MR. All three had different symptoms and neurological signs. We summarize the case reports in the literature since the CT-era.

Production and ELISA application of bispecific monoclonal antibodies against fluorescein isothiocyanate (FITC) and horseradish peroxidase (HRP)

Hybrid hybridomas producing bispecific monoclonal antibodies reacting with both horseradish peroxidase (HRP) and fluorescein isothiocyanate (FITC) were obtained by fusing two hybridoma lines and selecting the fused cells using a fluorescence activated cell sorter (FACS). FITC was used to label different monoclonal antibodies and the bispecific antibodies acted as a linking agent between FITC-labelled antibody and the marker enzyme HRP. This system was used in enzyme immunoassays for the detection of different antigens. The results suggest a wide application of bispecific anti-FITC/anti-HRP antibodies as a detection system in EIA.

Correlates of pathological gambling propensity in prison inmates

The South Oaks Gambling Inventory was administered to 136 consecutively admitted inmates in a medium-security prison in Nevada. According to the criteria of the authors of this instrument, 22.79% of these inmates had some problem and 26% were probable pathological gamblers. Significant positive correlations with the F, depression, psychopathic deviate, psychasthenia, paranoia, schizophrenia, and Mac Andrew alcoholism scales of the Minnesota Multiphasic Personality Inventory (MMPI) were found. Gambling score was negatively correlated with the Raven's Standard Progressive Matrices measure of intelligence. Clinical implications are suggested.

Sucrose transport into vacuoles isolated from barley mesophyll protoplasts

Sucrose transport has been investigated in vacuoles isolated from barley mesophyll protoplasts. Rates of sucrose transfer across the tonoplast were even higher in vitro than in vivo indicating that the sucrose transport system had not suffered damage during isolation of the vacuoles. Sucrose transport is carrier-mediated as shown by substrate saturation of transport and sensitivity to a metabolic inhibitor and to competitive substrates. A number of sugars, in particular maltose and raffinose, decreased uptake of sucrose. Sorbitol was slowly taken up but had no effect on sucrose transport. The SH-reagent p-chloromercuribenzene sulfonate inhibited sucrose uptake completely. The apparent Km of the carrier for sucrose uptake was 21 mM. Transport was neither influenced by ATP and pyrophosphate, with or without Mg(2+) present, nor by protonophores and valinomycin (with K(+) present). Apparently uptake was not energy dependent. Efflux experiments with preloaded vacuoles indicated that sucrose unloading from the isolated vavuoles is mediated by the same carrier which catalyses uptake. The vacuole of mesophyll cells appears to represent an intermediary storage compartment. Uptake of photosynthetic products into the vacuole during the light apparently minimizes osmotic swelling of the small cytosolic compartment of vacuolated leaf cells when photosynthetic productivity exceeds the capacity of the phloem for translocation of sugars.

Pharmacokinetics of a new angiotensin-converting enzyme inhibitor, benazepril hydrochloride, in special populations

To investigate the pharmacokinetics of benazepril hydrochloride in special populations, single or multiple doses between 5 and 20 mg of the new drug were given, and the pharmacokinetics of unchanged benazepril and its pharmacologically active metabolite benazeprilat were compared with those in healthy male volunteers. In elderly subjects and patients with mild and moderate renal insufficiency, there was little change in the kinetics of benazepril or benazeprilat. In patients with severe renal impairment (creatinine clearance less than 30 ml/min), benazeprilat elimination was slowed, which resulted in greater accumulation after repeated dosing. In patients with hepatic cirrhosis, the kinetics and bioavailability of benazeprilat were not affected. Therefore dose adjustment is unnecessary because of the patient's age, mild or moderate renal impairment, or hepatic cirrhosis. Dose reduction is necessary in patients with creatinine clearance less than 30 ml/min.

Perinatal ultrasonography and magnetic resonance imaging findings in congenital hydrocephalus associated with fetal intraventricular hemorrhage

OBJECTIVE

We present the case histories of three premature infants with congenital posthemorrhagic hydrocephalus.

STUDY DESIGN

The timing of the lesion was monitored in utero in two of the three cases. Magnetic resonance imaging studies (prenatal in one case, within 24 hours of birth in all three cases) established the duration of the lesions and thereby added to the ultrasonographic findings.

RESULTS

All three patients demonstrated a similar pattern of lesions, consisting of (1) unilateral germinal matrix hemorrhage with cystic resorption, (2) residual blood in the cerebrospinal fluid with a "granular" ependymal reaction, (3) asymmetric ventriculomegaly predominating on the side of the hemorrhage with mild atrophy and periventricular cysts, and (4) partial hypoplasia of the ipsilateral thalamus. On the basis of two cases in which information about the pregnancy was available and in which fetal oligohydramnios without ruptured membranes was detected, we assume that this pattern of lesions may have resulted from a hypoxic-ischemic episode followed by intraventricular hemorrhage.

CONCLUSIONS

Because these three infants with congenital hydrocephalus were born during a period of only 18 months in a perinatal center serving a region with 16,000 live births per year, we speculate that a posthemorrhagic cause for congenital hydrocephalus underestimated.

Differential mutagenic activity of IQ (2-amino-3-methylimidazo[4,5-f]quinoline) in Salmonella typhimurium strains in vitro and in vivo, in Drosophila, and in mice

IQ, a heterocyclic aromatic amine which is formed during the frying of meat, was prepared by chemical synthesis. Its genotoxic potential was studied in bacteria, Drosophila and in mice. A mutagenic effect of IQ (frameshift induction) was detected in Salmonella typhimurium in experiments without metabolic activation; this effect was several orders of magnitude lower than that observed in the presence of an activation system. Ames tests with liver-homogenate S9 fraction from PCB-induced mice and rats confirmed the high mutagenic potency of IQ metabolites (Kasai et al., 1980a). Comparative studies on diagnostic Salmonella strains revealed that the high frameshift-inducing activity is independent of the plasmid pkM101; it is, however, greatly reduced by an intact excision-repair system for DNA lesions. The mutagenic activity of the metabolite(s) formed in vitro by S9 mix has a half-life of ca. 14 min. In the fruit fly, Drosophila melanogaster, IQ induced when used at sublethal concentrations, X-chromosomal recessive lethal mutations in male germ cells in a dose-dependent manner. In mice, tests were performed to detect somatic mutations: chromosomal anomalies (micronuclei) in bone marrow, and gene mutations (affecting coat pigmentation) in mice exposed to IQ in utero. No genotoxic effects were observed in these assays. However, the formation of mutagenic metabolites in the liver of IQ-treated mice was unequivocally demonstrated in host-mediated assays using Salmonella as mutagen probes in mice. The data demonstrate genotoxic activity of IQ in prokaryotic and eukaryotic organisms. The possible reasons for the different response of mammalian systems in vivo and the Salmonella system are discussed.