Asymptomatic HIV infection is characterized by rapid turnover of HIV RNA in plasma and lymph nodes but not of latently infected lymph-node CD4+ T cells.

OBJECTIVES: To study the kinetics of plasma viraemia and HIV-infected lymph-node cells in stable asymptomatic HIV infection with high CD4+ T-cell counts. METHODS: Nine asymptomatic HIV-infected patients with stable CD4+ T-cell counts (510-1350 x 10(6)/l) were treated with a triple-drug combination. Plasma viraemia was determined at days 0, 3, 7, 10, 14, 21 and 28 of treatment [Roche polymerase chain reaction (PCR) and ultrasensitive PCR assay]. Sequential lymph-node biopsies were examined in four patients before and after 4 weeks of treatment. Productively infected cells were counted in lymph-node sections (in situ hybridization). The infection rates of FACS-sorted CD4+ lymph-node T cells and the expression of single-spliced, double-spliced and full-length HIV transcripts were determined. RESULTS: HIV plasma RNA half-lives ranged from 1.4 to 2.7 days. Viral turnover varied between 0.07 and 7.54 x 10(8) copies per day. The number of productively infected lymph-node cells as well as the amount of extracellular virus in germinal centres was markedly reduced during treatment, paralleled by a clearance of single-spliced, double-spliced and full-length HIV transcripts from CD4+ lymph-node T cells. Plasma viraemia remained detectable with an ultrasensitive PCR assay in three out of four patients. The percentage of lymph-node CD4+ T cells harbouring proviral DNA decreased only slightly. CONCLUSIONS: The kinetics of HIV replication are rapid in stable asymptomatic infection, and the magnitude of replication varies considerably. Productively infected lymph-node cells and extracellular virus in germinal centres undergo a rapid turnover, whereas latently infected CD4+ T cells have a lower rate of turnover. The latter may contribute substantially to viral persistence during therapy.

One year of experience with extended application and modified techniques of split liver transplantation.

As organ donation rates decreased in Europe, the authors started a systematic approach of liver splitting in their center in 1994. During this 1-year experience, 73 cadaveric liver transplantations were performed in 66 patients. Sixteen of these transplantations were the result of split-liver transplantation (21.9% of grafts, 24.2% of patients). Patient and graft survival rates at 3 months were 81.2% and 75%, compared with 89.1% and 76.9 % for whole organs. Two modified techniques were developed, based on the technique of living related liver procurement, and applied in 10 cases. With these new techniques, patient and graft survival rates were 90% and 90%. This systematic approach allowed the total number of transplantations in our program to be maintained, despite the decrease in organ availability.

Combined modality treatment of bone metastases: response of the rhabdomyosarcoma R1H of the rat to postoperative irradiation combined with local release of daunorubicin from acrylic cement.

Reconstruction techniques for pathological fractures caused by bone metastases often include acrylic cement to stabilise defects. The aim of this study was to test in a rodent model, whether outcome could be improved by local chemotherapy from an anticancer drug added to the acrylic cement. Tumour excision 17 days after transplantation into the femur was followed by fractionated irradiation. Supplementation of acrylic cement with daunorubicin led to a considerable reduction of TCD37% from 72.9 Gy (62.2-82.8) to 29.3 Gy (21.8-37.5) (P = 0.0007). Local chemotherapy diffusing from bone cement combined with postoperative radiotherapy was highly effective in the experimental system studied.

Release of daunorubicin from polymethylmethacrylate for the improvement of the local growth control of bone metastasis animal experiments.

Bone metastases are a sign of advanced tumor disease. Surgical therapy is only occasionally curative. Therefore, the therapeutic goals are a limited surgical excision, immediate mobilization, effective stabilization and the avoidance of local recurrence. We investigated the effect of the anthracycline daunorubicin (DNR) in conjunction with polymethylmethacrylate (PMMA) in vitro and in animal experiments for regional control of bone metastases. Previous experiments of local chemotherapy in bone metastases using methotrexate (MTX) were done by Langendorff and Hernigou. In our own experiments we improved the release of daunorubicin from polymethylmethacrylate in vitro and in vivo up to 90% by adding mannitol. In in vivo experiments we investigated the combination of DNR and PMMA in athymic nude mice and Wistar rats. Cells from human breast cancer, bronchial carcinoma, nephroma, and soft tissue sarcoma were subcutaneously implanted bilaterally under the dorsal skin of nude mice. After reaching a diameter of 0.5 cm, the tumors were marginally excised, leaving microscopic tumor residuum behind. The tumor cavities were either filled with PMMA or alternatively with DNR-PMMA. The goal was to avoid tumor recurrence in the DNR-PMMA filled resection cavities. The number of recurrences was significantly lower in the DNR-PMMA treated animals, except in the breast cancer group. Additionally we implanted a rat sarcoma intrafemorally into Wistar rats. After 17 days the tumor was marginally excised and the resection cavity was filled with either DNR-PMMA or PMMA alone. The therapeutic goal was to prevent local recurrence. Histological and pharmacological tests concerning toxicity and drug distribution within the body completed the study. We concluded that the addition of daunorubicin to PMMA supplements surgical resection. We were able to reduce the number of, or delay recurrences in our animal models. Systemic side effects could be minimized despite the achievement of high local drug concentrations.

Expression of the novel mitoxantrone resistance associated gene MXR7 in colorectal malignancies.

It was shown previously that a glypican encoding gene (MXR7/GPC3/OCl-5) was associated with mitoxantrone resistance in vitro. This study describes and investigation of an association between multidrug resistance and MXR7 in surgical cryo-specimens of 51 gastrointestinal tumors. The mRNA expression levels differ widely according to tumor species. In primary colorectal cancers, the level of MXR7 mRNA expression correlated loosely with the mRNA expression level of the multidrug-resistance-associated protein (MRP). In colorectal metastases an elevated MXR7 mRNkA expression level was observed when compared to primary colorectal carcinomas.

Acute gastrointestinal bleeding as a complication of pancreatic pseudocysts.

We report on 6 patients with chronic pancreatitis and pancreatic pseudocysts, operated on for acute bleeding into the cyst. The splenic artery and vein, the renal artery, the aorta and the splenic parenchyma were identified as bleeding sites. In 4 patients the acute hemorrhage occurred during hospitalization. In all patients the operative procedure included hemostasis and/or drainage/resection of the cyst. In 3 cases an additional splenectomy was performed. None of the patients died postoperatively. In 5 patients the pancreatitis was induced by alcohol abuse. In all patients the pseudocysts were diagnosed prior to the acute hemorrhage. CT-scan and angiography were able to localize the origin of the bleeding in 2 cases.

[Central venous access devices in treatment of patients with malignant tumors: venous port, central venous catheter and Hickman catheter. Cost-benefit analysis based on a critical review of the literature, personal experiences with 135 port implantations and patient attitude]. / Zentralvenöse Zugangsysteme in der Behandlung von Malignompatienten: Venöser Port, ZVK und Hickman-Katheter. Kosten-Nutzen-Analyse anhand einer kritischen Literaturübersicht, eigener Erfahrungen aus 135 Port-Implantationen und aus Patientensicht.

There are certain demands on central venous access devices in the ambulatory or long-term parenteral treatment of end-stage cancer-patients. The devices should offer both save and easy access, low related morbidity and acceptance of the patients. Ambulatory implantable venous ports fulfill all the these demands as own experiences with 135 implantations in cancer patients show: an overall complication rate of 6% which is - compared to other systems - very low, good acceptance of the patients and low costs. The venous ports can reduce duration of in-house treatment, bears a low morbidity and is the patients first choice. The port device is competitive and cost efficient alternative to conventional central venous access devices.

[Actinomycosis of the sigmoid colon as the etiology of lower abdominal pain]. / Aktinomykose des Sigma als Ursache von Unterbauchschmerzen.

We report a case of abdominal actinomycosis in a young woman wearing an intrauterine contraceptive device. The patient presented with right lower abdominal pain. A diagnostic laparoscopy was performed. Intraoperatively two perforations of the sigma were detected, a sigmoidectomy was performed. Postoperatively no problems occurred. Histology revealed an abdominal actinomycosis. In the literature only some case reports are published dealing with abdominal actinomycosis. Women wearing intrauterine contraceptive devices seem to have a higher risk of actinomycosis. In unproblematic cases antibiotic therapy is the treatment of choice. In cases of doubt as in our case surgery is recommended to confirm the diagnosis.

[Pancreatic pseudocysts and their interdisciplinary therapy]. / Pankreaspseudozysten und ihre interdisziplinäre Therapie.

A retrospective analysis was performed of 87 patients with pancreatic pseudocysts admitted at the Dept. of Surgery University of Hamburg from 1985 to 1989. Pseudocysts as a result of chronic pancreatitis were found in 54%. 42 patients underwent 49 operations, 35 have been drained endoscopically. In 10 cases there was spontaneous remission. 25 patients were treated by Roux-en-Y cystojejunostomy. In 14 patients a resection of the pancreas was performed. The mean follow-up interval was 26 (operative treated) and 22 months (endoscopic treatment). 50% of all patients in both groups reported pain relief. The mortality in operated patients was 7% and 0% for endoscopic treatment. In ten cases a recurrent disease was observed.

Prevalence of human immunodeficiency virus in the trauma emergency room.

Over 55,000 human immunodeficiency virus (HIV)-infections had been reported to the German Federal Health Council as of December 1992. More than 60% of a total of over 9000 overt AIDS cases has arisen in the five largest urban areas. Patients with open wounds represent a daily risk of contamination for emergency room personnel. In addition to surgical treatment and after written informed consent, we conducted HIV-antibody studies on patients with open wounds in the trauma emergency room of the University Hospital Eppendorf over a period of 6 months. Of 286 patients 220 (77%) consented to the study, and 6 HIV infections were found, corresponding to a prevalence of 2.7%.

[Small bowel obturation ileus related to ingestion of a medical device]. / Dünndarmobturationsileus im Zusammenhang mit der Einnahme eines Medizinproduktes.

We report the case of a 50-year-old woman who was admitted to the hospital with an acute abdomen and underwent exploratory laparotomy. Intraoperatively, we suspected Crohn's disease of the ileocecal valve and decided to treat conservatively. However, in the further clinical course the patient became severely sick and developed a necrotizing ileocecal inflammation in combination with multiple perforations, 4-quadrants peritonitis and several other complications. Histopathology revealed an unspecific inflammation of the ileocecal valve. Furthermore, numerous little cellulose sponges were found in the resected intestinal segment. They were obstructing the lumen and were identical with the contents of an appetite suppressing medical device. A connection between the ingestion of this medical device and the penetrating inflammation of the ileocecal valve has to be suspected.

[Surgery of bone metastases in advanced age?]. / Skelettmetastasenchirurgie im hohen Lebensalter?

Twenty-seven patients over 70 years of age (1990-1995, n = 100) achieved a stabilisation of skeletal metastasis; preventive (10), or after pathological fracture (17). Medullary pins were preferred to compound osteosynthesis. In all cases the operation was of a palliative nature, but resulted in considerable relief from pain, facilitated nursing or even improved ability to walk. Thus old age is not an indication against palliative stabilisation of skeletal metastasis.

[Cholecystectomy by mini-laparotomy with the Jako retractor system]. / Cholezystektomie durch Minilaparotomie mit dem Retraktorsystem nach Jako.

In recent years, minimally invasive operations in abdominal and thoracic surgery, especially with laparoscopic techniques, have developed rapidly. A multi-purpose retractor system, Jakoscope (Atlantis Surgical, Inc., New Brunswick, NJ, USA), developed by Jako provides a new and interesting alternative for minimally invasive and direct access surgery without pneumoperitoneum. This instrumentarium, apart from its use in various surgical specialties, allows a direct access through a 3- to 6-cm single incision for removal of the gallbladder. We used this instrumentarium with great success in patients not suited for laparoscopic surgery in comparable time. Up to now the Jakoscope has been applied in five patients. We report about our first case.

[Is there an increased risk of infection in trauma surgery emergency admission for medial personnel by unknown HIV-positive patient status?]. / Besteht in der unfallchirurgischen Notaufnahme ein erhöhtes Infektionsrisiko für das medizinische Personal durch unbekannt HIV-positive Patienten?

In the trauma emergency room 212 patients were asked--according to German law--for a blood sample for HIV-testing. Nine (4.2%) victims rejected the test, another 3 (1,4%) did not meet the study criteria since they were previously known to be HIV-positive or suffering from AIDS disease. None of the finally tested 200 patients was HIV-positive. On an anonymous questionnaire that was handed out additionally, 64% of the patients said they would accept HIV-testing without consent prior to operative treatment. 49% would reject HIV-testing without consent in non-operative treatment.

[Intracranial pressure monitoring in patients with severe craniocerebral injury]. / Hirndruck-Monitoring bei Patienten mit schwerem Schädel-Hirn-Trauma.

After severe head injury intracranial pressure (ICP) must be measured continuously for management to assess and maintain the cerebral perfusion. Therefore in our hospital epidural transducers are used. To prove the efficiency of this method in a 12-month period the clinical courses of 23 patients with intracranial pressure transducers were analysed retrospectively. Eighteen patients survived, 5 of them without residuals, 13 with residuals and 2 remained in coma. In 14 patients secondary rises of intracranial pressure were observed between days 3 and 6 post injury. The mean ICP value of the survivors revealed 25 mm Hg. whereas the expired showed 60 mm Hg. In 17 patients the measurements were considered as reliable, 6 measurements were not reliable, which included 1 of the 5 patients who died. One transduce was displaced, another one showed a hemorrhage at the drill hole. There was no infection.

[Manifestation of pneumothorax 7 days after port implantation. Report of a single case]. / Manifestation eines Pneumothorax sieben Tage nach Port-Implantation. Eine Einzelfallbeschreibung.

The subcutaneous implanted venous port device offers a safe central venous access and allows for ambulatory treatment. This case report describes a late manifestation of a pneumothorax after venous port implantation which, in fact, is a rare but significant complications. The lack of a correlation of the signs and symptoms with the interventional procedure may lead to inadequate or delayed treatment. The immediate postprocedural X-ray can be false negative when air leaks into the pleural cavity very slowly. Therefore both patients and referring physicians should be informed about the possibility of the late manifestation of a pneumothorax.

[Bile duct carcinoma after abdominal irradiation for urologic malignancies]. / Gallengangkarzinome nach abdomineller Bestrahlung urologischer Malignome.

Malignancies of the biliary tract are rare diseases. Tumor inductions after radiotherapy are reported in several papers. We report about 3 cases with consecutive biliary tract carcinoma 18-32 years after manifestation of an urogenital carcinoma. All 3 patients (52-63 years) were treated with additive radiotherapy after surgical-urological therapy. Icterus was the top-ranging symptom of this secondary carcinoma. In 2 of the 3 cases surgical tumor resection was performed (biliary duct resection with central liver resection; pancreatico-duodenectomy). Because of the bad general condition of health the third patient got only a biopsy of the tumor. All patients died within 2 years after diagnosis. The accidental accumulation of the rare biliary tract carcinoma after urogenital malignancies in our collection of clinical cases (2 seminoma; 1 bladder tumor) give rise the question about the causal association between primary carcinoma, additive therapy and the development of secondary carcinoma.

[Etiology of cerebral perfusion disorder in patients with severe craniocerebral trauma]. / Ursachen zerebraler Perfusionsstörungen bei Patienten mit schwerem Schädel-Hirn-Trauma.

In 53 patients with severe head injury, a decline of the cerebral perfusion pressure (CPP) was distinguished related to its cause, i.e., by a rise in intracranial pressure (ICP), a decline in the mean arterial pressure (MAP) or both. The mean Glasgow Outcome Scale (GOS) was 1.6 in patients with elevated ICP, 3.8 in those with decreased MAP and 2.7 when impaired CPP was due to both. It is concluded that in cases of decreased CPP, elevated ICP is the main cause of secondary brain injury and poor outcome, independent of the circulatory condition, whereas an isolated decline in the MAP does not show any influence on functional outcome.