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Study Objective. To determine if exposure to trimethoprim-sulfamethoxazole (TMP-SMX) causes a defect in peripheral B-cell function among patients with the human immunodeficiency virus (HIV) who are receiving zidovudine antiretroviral therapy. Design. Prospective, single-center, single-group, case-crossover design with a 4-week exposure period. Setting. University-affiliated infectious diseases outpatient clinic. Patients. Fourteen HIV-infected adult men receiving zidovudine, who had CD4+ cell counts above 350 cells/mm3 and undetectable viral loads. Intervention. Patients were administered a 28-day course of TMP 160 mg-SMX 800 mg/day (one double-strength tablet/day). Peripheral blood mononuclear cells (PBMCs) were obtained and isolated before and after exposure to TMP-SMX. Cells were cultured ex vivo with three mitogens of differing immunologic properties: pokeweed mitogen ([PWM] T-cell-dependent B-cell mitogen), Staphylococcus aureus Cowan ([SAC] T-cell-independent B-cell mitogen), and phytohemagglutinin A ([PHA] T-cell mitogen). Functionality of the B and T lymphocytes was then assessed. Measurements and Main Results. Proliferative capacity, cytokine secretion, and antibody production were measured and compared before and after TMP-SMX exposure. Reduced proliferative capacities of both PBMC and B cells stimulated with mitogens were observed at the 3-day culture time point in response to PWM, PHA, and SAC (p=0.029, 0.028, and 0.026, respectively). Proliferative capacity at day 7 of culture was not significantly different for any condition examined. Cytokine production was not altered by combination drug exposure after 10 days of culture when cells were stimulated with either PWM or PHA. Although antibody responses to PWM and PHA were similar, total immunoglobulin G concentration was lower in cells stimulated with SAC in samples obtained after TMP-SMX regimen completion compared with those obtained before exposure (p=0.005). Conclusion. Although these data were affected by limitations in power and study design, they suggest that peripheral B-lymphocyte function is altered as a result of TMP-SMX exposure in HIV-infected patients concurrently receiving zidovudine. Further study of this effect is warranted.

A continuous ambulatory peritoneal dialysis patient developed eosinophilic peritonitis and was followed for 7 months. After 1 month, the peritonitis resolved, with a concomitant drop in percentage of hypodense eosinophils (Eos) recovered from peritoneal dialysate (PD) as well as a drop in fluid major basic protein levels. Blood eosinophil differential percentages were low, but the percentage of hypodense Eos in the blood tended to be relatively increased. Stool samples showed no evidence of parasitic infection, and epicutaneous skin tests were negative. Leukotriene C4 levels remained relatively constant as did white blood cell counts. Flow cytometric analysis of lymphocytes and granulocytes from PD and blood revealed high levels of CD23-positive lymphocytes.

Since androgens may increase the sensitivity of the erythroid progenitors to erythropoietin, the present studies were designed to investigate the effect of administration of androgens on the actions of exogenous erythropoietin (EPO) in hemodialysis patients. Studies were performed in a group of 15 adult male hemodialysis patients. Seven patients were treated with EPO alone at a dose of 2,000 U intravenously (IV) three times a week. An additional group of eight patients was treated with 2,000 U of EPO three times a week and also received 100 mg of nandrolone decanoate intramuscularly (IM) each week. After 12 weeks of therapy, hematocrit values increased slightly in the group receiving EPO alone, from 25.3 +/- 0.8 to 27.4 +/- 1.5. In contrast, EPO in combination with nandrolone decanoate resulted in a greater increase in hematocrit values, from 24.4 +/- 1.4 to 32.9 +/- 1.8 (P less than 0.001). The results show that the groups receiving low-dose EPO alone had a poor erythropoietic response. In contrast, patients receiving androgen in addition to EPO had a significantly greater increase in hematocrit values with treatment. Transfusions were eliminated in both groups of patients. These data show that androgen therapy significantly augments the action of exogenous EPO such that lower doses of EPO are sufficient for an adequate hematopoietic response.

Objective. To determine the relationship between joint symptoms and radiographically identifiable erosions in patients on maintenance hemodialysis for 4 or more years. Patients and design. A prospective study was carried out on 21 patients who underwent rheumatological evaluation and radiographic surveys of all clinically examined joints. The radiologist was masked to the clinical information and the clinicians were masked to the radiographic findings. Cuprophane dialyzers were used on all patients. The statistical analysis was performed by unpaired t-test and Fisher’s exact test. Results and conclusions. Ten men and 11 women comprised the 21 patients, of whom 10 had joint symptoms and clinical signs whereas 11 did not. Age, gender, and duration of hemodialysis did not differ significantly between the symptomatic and asymptomatic group. Of the 21 patients, 10 had radiological evidence of erosions and 11 did not. The average age of patients with erosions was 64.9 years; this was significantly different from the age of the group without erosions, which was 54.1 years. The group with radiographic evidence of erosions had been on dialysis for an average of 9.6 years, while those without erosions had received dialysis for an average of 6.4 years. Of the 11 patients without radiographic evidence of erosions, three were symptomatic. Of the 10 patients with erosions, seven had musculoskeletal symptoms, but only in four was there concordance between radiological findings and symptoms of the corresponding joints. The positive predictive value of radiographic erosions in predicting clinically significant disease was 40%. There was poor correlation between the presence of radiographic erosions and clinical signs and symptoms of joint disease.

The IBM POWER7® microprocessor, which is the next-generation IBM POWER® processor, leverages IBM's 45-nm silicon-on-insulator (SOI) process with embedded dynamic random access memory to achieve industry-leading performance. To deliver this complex 567-mm2 die, the IBM design team made significant innovations in chip design methodology. This paper describes the most critical methodology innovations specific to POWER7 design, which were in modularity, timing closure, and design efficiency.

A direct effect of calcitriol on the regulation of the secretion of parathyroid hormone (PTH) has been shown in vitro and in vivo. In patients with renal failure on maintenance hemodialysis, it has been shown that intravenous (IV) administration of calcitriol appears to be superior to continuous oral administration. This may be due to the higher levels of calcitriol obtained in blood with consequent improved delivery of calcitriol to peripheral target tissues including the parathyroid glands. However, IV administration of calcitriol, is not practical for patients with end-stage renal disease (ESRD) who are maintained on continuous ambulatory peritoneal dialysis (CAPD). The present studies were designed to investigate whether intermittent administration of large doses of calcitriol orally ("pulse therapy") could mimic the effects of IV calcitriol in hemodialysis patients and achieve suppression of PTH secretion. Studies were performed in five patients who had been maintained on CAPD for more than 6 months. After basal determinations of calcium, phosphorus, and PTH, therapy was begun with calcitriol administered orally in a dose of 5 micrograms given twice per week. Calcium carbonate was continued as a phosphate binder. Dialysate calcium concentration was 1.75 mmol/L (3.5 mEq/L). With this therapy, PTH levels decreased rapidly, and, after 4 to 6 weeks of therapy, reached values 60% lower than pretreatment values. Mean values for serum calcium did not change significantly (2.29 +/- 0.12 mmol/L [9.6 +/- 0.5 mg/dL] before treatment compared with 2.32 +/- 0.08 mmol/L [9.7 +/- 0.25 mg/dL] after therapy). Mean serum phosphorus was also unchanged.(ABSTRACT TRUNCATED AT 250 WORDS)

CONGRESS has mandated that the renal networks "shall be responsible. . . for encouraging. . . the use of those treatment settings most compatible with the successful rehabilitation of the patient and the participation of patients, providers of services, and renal disease facilities in vocational rehabilitation programs."! The intent of Congress is obvious. It is to maximize the "productivity" of the patients with endstage renal disease (ESRD) who receive benefits under this act. Is this goal realistic? Are patients, providers of service, renal dialysis facilities, and society achieving this goal? Elsewhere in this issue, Ifuda et al report the results of a study from eight dialysis centers, which again verify the low incidence of rehabilitation in hemodialysis patients. Rehabilitation has been a goal since the inception of the ESRD program in 1972. Before this time, when only the "select" were fortunate enough to receive dialysis, most patients chosen for chronic dialysis were younger people with established jobs and no comorbid conditions. The composition of the ESRD patient in the 1990s has changed markedly in 20 years. Not only is the average patient much older, but as the report by Ifuda et al points out, 36% have a Karnofsky score below 70, which limits them to activities only within the home. In addition, many of the patients have comorbid conditions in addition to renal failure. However, these findings are not new. In 1981, Gutman et al reported similar low employment rates in a multicenter dialysis patient population. This study also had a high percentage of patients with low Karnofsky scores, especially in patients with diabetes as a comorbid condition. At that time, Gutman et al called for more data on the quality of life on dialysis. These data are now available and other questions need to be asked besides whether or not we are rehabilitating our dialysis population. The meaning of rehabilitation in the ESRD patient needs redefinition. As alluded to in the report by Ifuda et aI, one can discuss the vocational rehabilitation of the younger dialysis patient with a high Karnofsky score and no comorbid conditions. This is the type of patient and rehabilitation to which Congress referred to in its mandate. This group needs to be distinguished from the older dialysis patient with a much lower Karnofsky score and multiple comorbid conditions. In the latter group, vocational rehabilitation should not be a goal. Rehabilitation, if any, will only be to maintain or maximize their physical abilities to maintain their 'daily activities. These patients should not be included in the denominator of any future study that chooses to look at rehabilitation rates. Further studies of dialysis populations to document this overall low rehabilitation rate are no longer needed. What is needed now are studies that examine the reason why those dialysis patients who have the potential for vocational rehabilitation fail to receive this rehabilitation. Several reasons for this failure are possible. The initial questions then might be what effort does the patient make to gain employment or retraining for alternative employment? How successful are dialysis patients in gaining employment in comparison to the national average? Are employers willing to hire dialysis patients? Does the potential for higher medical insurance rates discourage the employer from hiring patients with dialysis or other medical disabilities? Are the financial rewards for remaining on disability comparable to the take-home pay patients would receive through employment? If the employer will not hire the dialysis patient, or if the financial rewards for not working are almost as good as

To estimate the relationship between characteristics of the third party and jealousy, 185 subjects read different jealousy-evoking scenarios and then indicated how jealous they would feel. Analysis indicated that two of the manipulated characteristics, prestige and attractiveness, significantly affected the experience of jealousy.

A total of 185 undergraduates who had dating partners completed a number of measures on relationship characteristics and jealousy. Analysis showed that insecurity was significantly related to both direct and indirect jealous behaviors but satisfaction was only related to indirect behaviors.

• Numerous anatomic and physiologic alterations occur in the kidney with aging. These changes affect the ability of elderly patient(s) to maintain homeostasis and alter response to medications, stress, illness, or changes in diet, mobility, or environment. Drug-induced illness and drug interactions are major problems in the elderly. Bone disease and fractures are associated with negative calcium balance and decreased production of 1,25-dihydrocholecalciferol seen with aging. The geriatric patient is not immune to the primary glomerular diseases that occur in younger patients, although the relative incidence of pathologic diagnoses may differ. The high incidence of membranous glomerulonephritis in the elderly, and the well-known association between malignancy and membranous nephropathy strongly favor aggressive evaluation of the nephrotic syndrome in the geriatric age group. Attention must be given to consideration of appropriate end-stage renal disease treatment alternatives for the geriatric population, which now comprises the fastest-growing segment of the endstage renal disease population. ( Arch Intern Med 1986;146:1790-1796)