[CMV-associated gastric ulcer in an immunocompetent male patient]. / CMV-assoziiertes Ulcus ventriculi bei einem immunkompetenten Patienten.

This article reports the case of a 45-year-old male immunocompetent patient who presented with acute epigastric pain and vomiting. Diagnostic tests confirmed a recent cytomegalovirus (CMV) infection as a contributory cause of a florid gastric ulcer. Primary CMV infections affecting the upper gastrointestinal tract are rare in immunocompetent adults. In this case treatment with a proton pump inhibitor and eradication of concomitant Helicobacter pylori colonization led to a full recovery. Anti-CMV treatment was not necessary.

Concomitant use of gastric acid-reducing agents is frequent among HIV-1-infected patients receiving protease inhibitor-based highly active antiretroviral therapy.

OBJECTIVE: The aim of the study was to assess the frequency of the concurrent use of gastric acid-reducing agents among HIV-1-infected patients treated with highly active antiretroviral therapy (HAART) combinations. METHODS: An anonymous, semistructured, self-administered questionnaire was consecutively distributed among HIV-1-infected patients at routine visits to specialized HIV clinics. The questionnaire contained 17 items asking specifically for information on current antiretroviral treatments and the use of gastric acid-reducing agents as well as demographic data. RESULTS: A total of 424 patients in 12 centres participated in the study: 85% were male, 88% were of German nationality, 82% were >35 years of age and 201 (47.4%) were receiving a protease inhibitor (PI)-containing HAART regimen. Of these, 74 (37%) had received an acid-reducing drug within the previous 6 months and 43 (58%) were currently still on it. Two-thirds of patients (64.9%) were treated with proton-pump inhibitors (pantoprazole, omeprazole or esomeprazole) and 56% of patients on PI-containing regimens had been taking these drugs for longer than 2 months and up to a maximum of 3 years. The majority of patients (77%) had received the prescription for the acid-reducing drugs from their HIV specialist and the remaining patients had received over the counter (OTC) medication or prescriptions from other medical personnel. CONCLUSIONS: A substantial subset of patients treated with HAART combinations, including those on PI-containing regimens, were using concomitant acid-reducing drugs, most often proton-pump inhibitors. As negative drug-drug interactions between some of the (boosted) PIs and gastric acid-reducing agents have recently been reported, HIV physicians should take this into account when prescribing PI-containing HAART combinations in order to avoid an additional risk of treatment failure.

Penetration studies of topically applied substances: Optical determination of the amount of stratum corneum removed by tape stripping.

Tape stripping is a standard measuring method for the investigation of the dermatopharmacokinetics of topically applied substances using adhesive films. These tape strips are successively applied and removed from the skin after application and penetration of topically applied substances. Thus, layers of corneocytes and some amount of topical applied substances are removed. The amount of substances and the amount of stratum corneum removed with a single tape strip has to be determined for the calculation of the penetration profile. The topically applied substances removed from the skin can be determined by classical analytical methods like high-pressure liquid chromatography, mass spectroscopy, and spectroscopic measurements. The amount of corneocytes on the tape strips can be easily detected by their pseudoabsorption. In the present paper, an easy and cheap corneocyte density analyzer is presented that is based on a slide projector. Comparing the results of the measurements obtained by the corneocyte density analyzer and by uv-visible spectrometry, identical results were obtained.

Primary care involvement in human immune deficiency virus infection-a pan-European view. The Eurosupport Study Group.

OBJECTIVE: The aim of this study was to compare the primary care experiences of human immunodeficiency virus (HIV)-positive individuals across Europe. METHODS: An anonymous self-administered questionnaire study was carried out between August 1996 and August 1997. A total of 15 HIV/AIDS treatment centres and 14 HIV support organizations in 11 European countries participated in the distribution of questionnaires. Overall, 1366 completed questionnaires were included in the analysis from a total of 2751 distributed (50% response rate). The majority of respondents were homosexual men (53.6%), and 54.2% had AIDS or symptomatic HIV disease. The main outcome measures were use of GP services in the preceding 6 months, GP involvement in HIV care provision, satisfaction with current service provision and reasons for non-involvement of the primary care services. RESULTS: Most patients (64.8%) had visited their GP at least once in the preceding 6 months, but 53.9% of respondents reported that their GP was not involved in their HIV care. Of these patients, 53.4% would like their GP to be involved. Patients from central European countries were more likely to have seen their GP than their counterparts from northern and southern countries (P < 0.005), and were less worried that the GP would not have enough knowledge about HIV (P = 0.002) or would not be sympathetic (P = 0.052). CONCLUSIONS: There are clear differences in GP utilization by HIV-positive individuals across Europe, reflecting in part local service provision but primarily patients' attitudes and beliefs. Strategies to promote the involvement of primary health care services need to address patients' core beliefs, if these are to be changed.

A spark counter as a control unit of a radio frequency surgery device.

A new approach in radio frequency (rf) electrosurgery, used for tissue treatment, is achieved by using a new process control method. An external control unit allows a commonly available rf-generator to automatically supply the appropriate power for differing tissue types, thus ensuring best cutting quality. The sparks, generated during the scalpel electrode interaction with the tissue, appear statistically distributed. The spark rate depends on various factors and is monotonic with the supplied electrical power. This allows it to be used as the controlled variable in the cutting process. The ac current passing through the tissue is evaluated by an external control unit using an analyzation algorithm to determine the number of sparks. The external unit is comprised of a system, which measures the spark rate, and a subsequent proportional integral (P.I.) controller. The functionality of the control method as well as the electrical circuitry is verified through cuts with different degrees of carbonization and cuts through tissue heterojunctions.

Scanning Kelvin Microscope: a new method for surface investigations.

Based on the well known Kelvin probe for work function measurements a new microstructure analysis system - the Scanning Kelvin Microscope - has been developed. It allows to measure simultaneously with high lateral resolution the distribution of the contact potential difference (CPD) between a conductive sample and a reference probe together with the topographical structure of the sample surface. The measurement is contact free and non-destructive and can be carried out in natural environments. At present the lateral resolution of the measurement approaches 5 microm. The results can be displayed on a computer in three dimensional colour pictures.

Endoscopic ultrasound in the diagnosis and staging of gastrointestinal Kaposi's sarcoma.

BACKGROUND AND STUDY AIMS: Endoscopic ultrasonography (EUS) has been evaluated for diagnosing and staging of a variety of gastrointestinal tumors, but there are no data on EUS in Kaposi's sarcoma (KS). The aim of the present study was to evaluate the role of EUS in addition to endoscopy in the diagnosis and staging of patients with established or suspected upper gastrointestinal KS. PATIENTS AND METHODS: 22 male acquired immune deficiency syndrome (AIDS) patients were prospectively studied, three of them before and after chemotherapy with liposomal doxorubicin. The features of gastrointestinal KS were recorded, and EUS was assessed for diagnosis in endoscopically negative or inconclusive cases, and for staging in endoscopically visible KS lesions. RESULTS: The typical EUS feature of KS was a hypoechoic and nonhomogeneous lesion leading predominantly to mucosal and submucosal thickening, whereas a few lesions presented only with submucosal involvement. EUS detected suspicious lesions in two patients with negative endoscopy, which turned out to be KS on follow-up. Restaging after chemotherapy in three patients showed regression of lesions both on endoscopy and EUS. CONCLUSIONS: EUS may contribute to better detection of early KS lesions and a more reliable delineation of the extent of gastrointestinal KS, which is valuable for assessing the effect of various forms of therapy.

Improvements in volumetric quantification of circumscribed hepatic lesions by three dimensional sonography.

The size of hepatic tumors is commonly estimated by ultrasound as well as by computed tomography by measuring the three diameters followed by computing of the volume by applicating the ellipsoid formula. Using the new technique of three-dimensional-sonography it is possible to perform volume measurement by computer-linked planimetry. Initial tests with water filled balloons of defined volume revealed the accuracy (mean error of 3.0%) and high reproducibility (low intra- and inter-observer variance) of the method applied by one investigator (intraindividual SD +/- 1.3%) as well as by four different investigators (interindividual SD +/- 2.1%). Circumscribed hepatic lesions of 63 patients were investigated by using conventional sonography (ellipsoid formula), computed tomography (ellipsoid formula) and three-dimensional-sonography (ellipsoid formula, ortrip, planimetry). As a volume of reference a mathematical approximation for infinite sonographical slices (planimetry) of a very well circumscribed hemangioma of the liver was defined. Based on these results a mean error of -6% (SD +/- 39%) was determined for conventional sonography. For computed tomography a mean error of 2+ (SD +/- 35%) was found, for three-dimensional-sonography that figure was -6% (SD +/- 5%). Follow up investigations can only demonstrate significant alterations of volume when the SD-interval is exceeded. Therefore, three-dimensional-sonography provides a more sensitive and reliable recognition of volumetric changes of liver tumors than conventional sonography or computed tomography does.

[Volume determination with 3D ultrasound exemplified by aneurysms of the abdominal aorta]. / Volumenbestimmung mit der 3D-Sonographie am Beispiel der Bauchaortenaneurysmen.

Ultrasound is the first diagnostic method concerning initial and follow-up investigations of patients with abdominal aortic aneurysms. The indication is given by threatening rupture when disease is progressing. The aim of the presented study was to find out the applicability of 3D ultrasound and volumetry and to elaborate possible advantages of the new method in comparison with 2D sonography concerning the estimation of volumes. Preliminary investigations of defined volumes of waterfilled balloons confirmed the accuracy of +/- 4% (4 investigators) and the reliability of +/- 2% (10 investigations). With well-defined rating categories 3D scans were found to be quite good as well as excellent in 55% of the processed 3D data. Estimation of volume using 2D linked ellipsoid formula showed higher results in 92% of the cases than performing 3D volumetry. For a high accuracy of 3D volume estimation, contouring of 5 representative slices was quite sufficient. The presented results suggest a high accuracy and reliability of the new method. Further clinical investigations are necessary to find out the clinical relevance concerning the follow-up of patients with abdominal aortic aneurysms.

[3D-ultrasound of soft tissues and joints]. / 3D-Sonographie an Weichteilen und Gelenken.

Sonography has become a reliable diagnostic method in musculo-skeletal diseases. It allows a simple and noninvasive examination of joints and soft tissues. Especially in rheumatic diseases meaningful findings can be obtained. In the present study first results of three-dimensional (3D) sonography of the musculo-skeletal system are reported. The method was first validated by examining healthy test persons and criteria for regular findings were defined. In the second part of the study an unselected group of patients with inflammatory and noninflammatory joint and soft tissue diseases were examined and the obtained results were compared with the findings of the conventional real-time sonography. Comparison of the 2D and 3D procedure showed a superiority of the 3D method with regard to the assessment of large (hip), middle-sized (elbow) and small joints (finger, toe). Additional information about the synovial space, the surface of the cartilage, and the thickness of the synovial membrane was provided by 3D sonography. Volumetry of joint effusions and Baker cysts was easier to perform and more reliable than with the conventional method. Soft tissue alterations could be delineated reliably, depending on their size. Our results demonstrate that 3D sonography can improve the diagnostics of musculo-skeletal diseases. In the future, 3D sonography should play an important part in the diagnosis of joint and soft tissue diseases.

[3-D ultrasound in gastroenterology]. / 3D-Sonographie in der Gastroenterologie.

Three-dimensional (3D) sonography represents a development of noninvasive diagnostic imaging by real-time two-dimensional (2D) sonography. The use of transparent rotating scans, comparable to a block of glass, generates a 3D effect. The objective of the present study was to optimate 3D presentation of abdominal findings. Additional investigations were made with a new volumetric program to determine the volume of selected findings of the liver. The results were compared with the estimated volumes of 2D sonography and 2D computer tomography (CT). For the processing of 3D images, typical parameter constellations were found for the different findings, which facilitated processing of 3D images. In more than 75% of the cases examined we found an optimal 3D presentation of sonographic findings with respect to the evaluation criteria developed by us for the 3D imaging of processed data. Great differences were found for the estimated volumes of the findings of the liver concerning the three different techniques applied. 3D ultrasound represents a valuable method to judge morphological appearance in abdominal findings. The possibility of volumetric measurements enlarges its potential diagnostic significance. Further clinical investigations are necessary to find out if definite differentiation between benign and malign findings is possible.

[Diagnosis and therapy of gastrointestinal Kaposi's sarcoma in AIDS]. / Diagnostik und Therapie gastrointestinaler Kaposi-Sarkome bei AIDS.

Gastrointestinal Kaposi's sarcoma (KS) is one of the most frequent neoplastic diseases seen in AIDS. Visceral involvement is associated with shorter survival as compared to cutaneous KS. Our aim was therefore to investigate patients with KS endoscopically. In order to improve the early diagnosis of gastrointestinal KS we also employed endoscopic ultrasonographic examinations (EUS). 22 patients recruited for a prospective trial addressing this issue were examined by endoscopy and by EUS. 21 patients had severe cutaneous KS, one patient had no cutaneous KS but showed signs and symptoms of gastrointestinal KS. 15/22 patients (68%) had gastrointestinal KS. Seven patients (32%) had endoscopically normal mucosa. In 2 patients only EUS showed findings suggestive for KS which had not been seen by endoscopy. Follow-up examinations proved typical KS lesions endoscopically in those 2 patients. Using liposomal encapsulated Doxorubicin within a trial (20 mg/m2 intravenously every 3 weeks), we were able to follow 3 patients prior to and during therapy. EUS showed a significant reduction in number and volume of KS lesions as well as a reduction of infiltration depth. In one patient macroscopic and histologic examinations showed complete remission. We conclude that EUS of the upper gastrointestinal tract can be used as a sensitive method for the detection of early gastrointestinal KS. Furthermore, EUS is a method which allows determination of tumor volume and helps in quantification of tumor response after chemotherapy.

Clinical application of three-dimensional sonography in internal medicine.

Three-dimensional sonography represents a development of non-invasive diagnostic imaging by real-time two-dimensional sonography. The use of transparent rotating scans, comparable to a block of glass, generates a three-dimensional effect. The first clinical application of this technique was in the field of gynecology and obstetrics, namely in prenatal diagnostics. In this study we describe its first application in internal medicine. In preliminary examinations on healthy volunteers we obtained specific processing data for optimal imaging results. This was followed by secondary examinations on 123 patients who had previously undergone conventional sonography with pathological findings. In more than 75% of the cases examined we found an optimal reproduction of sonographic findings with respect to the evaluation criteria developed by us for the three dimensional imaging of processed data. With the inclusion of measurement parameters such as distance determination and volume measurements the data gathered will allow the generation of reproducible results. Future studies will confirm the value of this method in diagnostic imaging.

Critical evaluation of the 'heated-hand-technique' for obtaining 'arterialized' venous blood: incomplete arterialization and alterations in glucagon responses.

In order to test the degree of 'arterialization' and the occurrence of arterio- (or capillary-) venous differences in glucose concentrations for commonly used blood sampling sites (including the retrogradely cannulated dorsal hand vein with application of dry heat to this hand/arm--the 'heated-hand-technique'), oxygen partial pressure (oxygen saturation) and plasma glucose was determined in blood drawn from different venous sites before and after an oral glucose load (75 g). Experiments with and without heating (hot air 68 degrees C) were compared in nine healthy volunteers. Basal pO2 (and oxygen saturation) increased in the order cubital fossa vein less than superficial forearm vein less than dorsal hand vein. Heating raised pO2 by approximately 20 mmHg; P = 0.008) and oxygen saturation (P = 0.008-0.02) at all sites, including those on the contralateral arm. Capillary-venous glucose differences after the glucose challenge were significantly related to the sampling site (P less than 0.0001). They were reduced by approximately 50% in response to heat exposure (P = 0.008-0.011) and could be correlated to pO2-values (r = 0.92; P = 0.01). The lowest capillary-venous glucose concentration difference was measured with the 'heated-hand-technique' (0.4 +/- 0.1 mmol l-1). Heating did not alter integrated incremental glucose (capillary values), insulin, and C-peptide-responses and late, counter-regulatory responses (120-240 min after glucose) of cortisol, growth hormone, and adrenalin. However, the late glucagon response was enhanced (P = 0.011) by heating, concomitant with a significantly reduced 'reactive' decrement in glucose concentrations. In conclusion, the 'heated-hand-technique' provides blood more similar to arterial blood that can be obtained from other venous sampling sites. However, significant residual differences in pO2 and glucose concentrations remain. In addition, altered counter-regulatory hormone responses may occur with heating.

Regulation of pacing rate by variations of mixed venous oxygen saturation.

Right ventricular oxygen saturation (SO2) may be an ideal sensor for determining the rate of an implanted pacemaker. In order to prove this hypothesis, the obtained signals were optimally analyzed; determinations of SO2 at rest and during exercise were made in healthy volunteers and in patients with pacemakers; and an algorithm was developed for varying pacing rate as a function of measured SO2. The results suggest that this method may be applicable to the long-term implantee.