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Sexual assault is a persistent problem on college campuses that disproportionately impacts sexual and gender minority identified students. Objective: This study explores how circumstances of the crime, disclosure to informal sources, training and campus climate are associated with reporting sexual assault to college officials by these students. Participants : A total of 409 lesbian, gay, bisexual, transgender and queer/questioning college students who experienced sexual assault while attending their current four-year college. Results: Chi-square and t-test analysis found that reporting to college officials was significantly associated with the type of assault experienced, disclosure to a campus advocates, disclosure to a parent/guardian, and the campus climate for LGBTQ students. Conclusion: These findings suggest that practitioners and college officials may support reporting behavior amongst sexual and gender minority identified students through enhanced campus support systems and strategic educational efforts.

How institutions of higher education respond to campus sexual assault impacts the well-being and academic success of student survivors. Researchers at the Center for Institutional Courage developed an 11-step framework for campuses to respond to sexual assault in a manner that minimizes harm. This mixed-methods study uses the framework to understand college victim advocate perceptions of campus response to sexual assault. Results from a national survey and four focus groups found that advocates identify courageous response efforts as strong relationships across campus units, availability of trauma-informed services, and when resources were available to meet students' direct needs. The critical role of leadership throughout the framework was also identified. Implications for policy and practice are discussed., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Federal law in the United States mandates that institutions of higher education address sexual assault within their communities. Colleges and universities have increasingly hired full-time professionals to manage response efforts, including campus-based victim advocates. Campus-based advocates provide emotional support, help students access and understand report options, and ensure students receive appropriate accommodations. Very little is known about the experience or perceptions of campus-based victim advocates. In this study, 208 professional campus-based advocates from across the United States completed an anonymous online survey focused on their perceptions of campus response to sexual assault. Multiple regression analysis was applied to investigate how psychosocial factors (burnout, secondary trauma, and compassion satisfaction) and organizational factors (perceptions of leadership, organizational support, and community relational health) were associated with advocate perceptions of institutional response to sexual assault. Findings indicate that while advocates experience burnout and secondary trauma, and have lower than average compassion satisfaction scores, these psychosocial outcomes do not influence their perception of response efforts. However, all the organizational factors significantly contribute to how advocates view response. The more positively advocates viewed leadership, campus support, and relational health, the more positive they viewed the response efforts on campus. In order to improve response efforts, administrators should engage in meaningful training on sexual assault, include campus advocates in high-level discussions of campus sexual assault and ensure appropriate resources are provided to advocacy services.

Sexual minority college students are disproportionately impacted by sexual assault in college, however, there is a paucity of research exploring the role of the college environment in victimization. This study explores the relationship of campus climate with sexual assault victimization for these students. This sample included 1,110 current college students in the United States who identified as a sexual minority. Logistic regression results indicated that the more observations of harassment and discrimination of sexual minority students by participants, the more likely they were to experience sexual assault victimization in college. Also, the more out a participant was on campus, and the stronger sense of belonging they had to their college, the less likely they were to experience sexual assault victimization. Sexual assault prevention efforts on college campuses would benefit from programming and policies that support belonging and address discrimination and harassment.

Plasmin-alpha2-antiplasmin complex (PAP) is an index of recent fibrinolytic activity. We examined PAP levels in patients with atrial fibrillation (AF) to determine whether these levels are correlated with clinical characteristics associated with stroke risk. We obtained blood for measurement of PAP in a non-random sample of 586 patients with AF on entering the Stroke Prevention in Atrial Fibrillation III Study. PAP levels were measured with an ELISA assay. PAP values were transformed with a natural logarithm (PAPln) prior to all analyses. Older age, female gender, recent congestive heart failure, decreasing fractional shortening, recent onset of AF, and coronary artery disease were each univariately associated with higher levels of PAP (all p<0.05, two-sample t-test, simple linear regression). Older age, recent congestive heart failure, decreasing fractional shortening, and recent onset of AF were independently associated with higher PAP levels by multivariate analysis (linear regression). Among patients receiving warfarin, PAP levels were not correlated with INR levels (linear regression, p=0.60). Patients classified as high-risk for thromboembolism by our risk stratification criteria (systolic blood pressure > 160 mm Hg, prior thromboembolism, recent congestive heart failure, poor left ventricular function, and women over age 75) had higher PAP levels than low-risk patients (antilog mean PAPln 5.6 vs 4.9. p<0.001, two-sample t-test). PAP levels in patients with AF are associated with clinical characteristics predictive of thromboembolism. Elevated PAP levels are particularly associated with poor left ventricular function and are not affected by anticoagulation. PAP levels may be a marker of stroke risk in patients with AF.

We compared the efficacy of a 400-mg once-weekly dosage versus a 200-mg daily dosage of fluconazole for the prevention of deep fungal infections in a multicenter, randomized, double-blind trial of 636 human immunodeficiency virus-infected patients to determine if a less intensive fluconazole regimen could prevent these serious but relatively infrequent complications of AIDS. In the intent-to-treat analysis, a deep fungal infection developed in 17 subjects (5.5%) randomly assigned to daily fluconazole treatment and in 24 (7.7%) given weekly fluconazole during 74 weeks of follow-up (risk difference, 2.2%; 95% confidence interval [CI], -1.7% to 6.1%). Thrush occurred twice as frequently in the weekly versus daily fluconazole recipients (hazard ratio, 0.59; 95% CI, 0.40-0.89), and in a subset of patients evaluated, fluconazole resistance was infrequent. Fluconazole administered once weekly is effective in reducing deep fungal infections in patients with AIDS, but this dosage is less effective than the 200-mg-daily dosage in preventing thrush.

Background and Purpose: The prothrombin time (expressed as the international normalized ratio [INR]) is the standard method of monitoring warfarin therapy in patients with atrial fibrillation. Prothrombin activation fragment F1.2 provides an index of in vivo thrombin generation and might provide a better index of the effective intensity of anticoagulation. We examined the relationship between F1.2 and INR in patients with atrial fibrillation., Methods: We measured INR and F1.2 levels in 846 patients with atrial fibrillation participating in the Stroke Prevention in Atrial Fibrillation III study. Two hundred nineteen (26%) were taking aspirin alone, 326 (39%) were taking adjusted-dose warfarin, and 301 (36%) were taking a low fixed dose of warfarin (1 to 3 mg) plus aspirin (combination therapy). F1.2 levels were measured with an enzyme-linked immunosorbent assay., Results: Patients receiving adjusted-dose warfarin or combination therapy had significantly higher INR and significantly lower F1.2 values than those on aspirin alone (P < or = .0001 for each of the four comparisons). F1.2 values (nanomolar) were inversely correlated with INR (F1.2 = -0.1 + 2.3[1/INR]; R2 = .37; P < .0001; simple linear regression). However, significant variability remained. Among patients receiving warfarin, older patients had higher F1.2 values than younger patients after adjustment for INR intensity (P < .001) in the model. There was no difference in the relationship between F1.2 and INR between men and women., Conclusions: Increasing intensity of anticoagulation, as measured by the INR, is associated with decreasing thrombin generation as measured by the F1.2 level, but significant variability exists in this relationship. Older anticoagulated patients have higher F1.2 values than younger patients at equivalent INR values. The clinical significance of these differences is not clear. F1.2 measurement might provide information regarding anticoagulation intensity in addition to that reflected by the INR.

Infection due to the Mycobacterium avium complex (MAC) accounts for the most frequent AIDS-related opportunistic infections, but MAC infection is usually not the first AIDS-defining event that a patient infected with HIV experiences. The incidence increases linearly over time, at a rate of 20 to 25% per year, after a patient's first AIDS-defining event, and the incidence increases exponentially as the CD4+ cell count approaches zero. There is evidence that MAC may eventually infect most if not all HIV-infected patients who do not die from another HIV-related event. Since MAC infection contributes substantially to the morbidity and mortality of AIDS patients, prophylaxis appears to be mandatory. Rifabutin was the first drug which was shown to be effective in preventing MAC infection, and, recently, prophylaxis with clarithromycin was also found to prevent the disease. The optimal approach to prophylaxis still needs to be defined. Since a large majority of MAC infections occur in patients with CD4+ cell counts below 50/microliter, recommendations regarding the prophylaxis of patients with a history of an AIDS-defining opportunistic event and a CD4+ cell count between 50 and 200/microliter can be individualized, depending for example on how well the patient seems to be responding to antiretroviral treatment. Prophylaxis against MAC should be provided for any HIV-infected patient with a CD4+ cell count less than 50/microliter.

Acute psychosis was observed in two patients with AIDS who were treated with clarithromycin for disseminated Mycobacterium avium complex infection. The psychosis resolved when treatment with clarithromycin was discontinued and recurred when it was resumed. An adverse response to clarithromycin therapy is a rare but curable cause of acute psychosis in patients with AIDS.

Thirty-seven bone marrow core biopsy specimens from 21 human immunodeficiency virus-infected patients with Mycobacterium avium-intracellulare complex bacteremia were stained using rabbit polyclonal antibodies against Mycobacterium bovis strain Bacillus-Calmette-Guerin (BCG) and Mycobacterium duvalii, as well as Kenyon and Fite stains, to compare sensitivities of these techniques and evaluate possible response to therapy. The patients in this study had participated in a phase I/II trial of liposome-encapsulated gentamicin therapy. Two biopsy specimens had inadequate tissue for evaluation. Thirty-two specimens demonstrated bacilli with anti-M duvalii, 33 with anti-BCG, 20 with Kenyon, and 23 with Fite. Two were negative with all stains. Fifteen biopsy specimens had epithelioid granulomas, 12 had histiocytic granulomas, and 1 had a granuloma of indeterminate type. The remaining seven biopsy specimens had no granulomas. Four of these seven demonstrated bacilli with anti-M duvalii, 5 with anti-BCG, 1 with Kenyon, and 2 with Fite. The number of M avium-intracellulare organisms per milliliter of blood decreased in 14 of 21 patients after liposome-encapsulated gentamicin therapy. However, none of the 11 patients whose pre- and post-therapy bone marrow core biopsy specimens were both evaluable demonstrated a reduction in the number of M avium-intracellulare organisms. The authors concluded that anti-M duvalii and anti-BCG are more sensitive than acid-fast stains for identifying M avium-intracellulare infection in bone marrow core biopsy specimens of patients who have acquired immunodeficiency syndrome (AIDS) with M avium-intracellulare bacteremia. Bone marrow core biopsy specimens may provide a perspective on M avium-intracellulare infection in AIDS patients that differs from the one provided by blood cultures.

Bone marrow biopsies from 114 human immunodeficiency virus (HIV)-infected patients were stained with an anti-p17 monoclonal antibody to detect active HIV replication and associated factors. Immunoreactive p17 was found as virus-like particles in macrophages and dendritic cells and occasionally in megakaryocytes in 62 of 114 marrows and was considered evidence of active HIV replication. Immunoreactive p17 was not found significantly more often in the marrows of patients with lower CD4 cell counts; however, it was found significantly more in the marrows of patients with concurrent mycobacterial or fungal infections or lymphoma (chi 2 = 12.1, P < .001). Immunoreactive p17 was even more frequent when these opportunistic diseases were found in the biopsied marrow (chi 2 = 20.5, P < .001). The association of active HIV replication with certain opportunistic diseases, but not with lower CD4 cell counts, raises the possibility that these opportunistic diseases may under some circumstances be a cause as well as a consequence of active HIV replication.

Data from 65 medical students and residents support the hypothesis that scores on a measure of androgyny are predictive of those on an index of empathy but relatively modest predictive accuracy was observed for sympathetic responses. Further exploration is suggested.

TLC G-65, a liposome-encapsulated gentamicin, was given intravenously twice weekly for 4 weeks to AIDS patients with Mycobacterium avium-M. intracellulare complex (MAC) bacteremia at 1.7 mg of gentamicin per kg of body weight per infusion (4 patients), 3.4 mg/kg (10 patients), and 5.1 mg/kg (7 patients). MAC colony counts in blood fell by 75% or more in all three groups (P < 0.005). Drug resistance did not emerge during the study period. Transient renal insufficiency developed in one patient; no other adverse effects were detected. Liposome-encapsulated gentamicin is a potential therapy for MAC infections in AIDS patients.

Background: An experimental sustained release intraocular device has been designed to deliver ganciclovir over a long period of time. As part of an efficacy trial, the ganciclovir intraocular device was used to treat cytomegalovirus (CMV) retinitis in patients with acquired immune deficiency syndrome (AIDS)., Methods: All patients had active CMV retinitis that had progressed despite intravenous ganciclovir therapy. The ganciclovir intraocular device was inserted into the vitreous cavity by making an inferotemporal full-thickness circumferential sclerotomy and anchored to the incision. Intravenous therapy was then discontinued and patients were followed up at 2-week intervals until death. Seven eyes from five patients were obtained 2 to 10 hours postmortem and submitted for histopathologic examination. Light and electron microscopic studies were performed and correlated to the clinical outcome. Follow-up period after device placement ranged from 16 to 82 days (median, 70 days)., Results: All seven eyes showed clinical stabilization of the CMV retinitis. Light microscopy showed varying degrees of retinal atrophy with areas of gliosis. In addition, we observed syncytial megalic cells containing Cowdrey type A inclusions affecting all layers of the retina. Concurrent choroidal infections with Pneumocystis carinii (1) and Mycobacterium avium (2) also were seen. Electron microscopy showed virus particles located mostly at the junction of uninvolved and "healed" retinitis. No evidence of retinal toxic effects or inflammation at the site of ganciclovir intraocular device implant was noted., Conclusion: The ganciclovir intraocular device appeared to be effective in controlling the progression of CMV retinitis. The clinical and pathologic results are similar to those observed in the eyes of patients with intravenously administered ganciclovir. The lack of toxic effects and sustained levels of intravitreal ganciclovir may provide an improved therapeutic method of local treatment of CMV retinitis.

Background: Survival, and the incidence of events that define the acquired immunodeficiency syndrome (AIDS), are known to be inversely related to the CD4 count in patients with human immunodeficiency virus infection. We wished to quantify this relationship more precisely, particularly for patients with CD4 counts of less than 50/mm3., Methods: Prospective surveillance for survival and for all AIDS-defining events was performed on all 2682 patients with human immunodeficiency virus infection who had at least one CD4 count performed at a large urban public hospital during a 3-year period. Product-limit survival and incidence of AIDS-defining events were calculated as a function of baseline CD4 count., Results: The 1-year product-limit survival was 17% +/- 6% for patients after a baseline CD4 count of 1 to 4/mm3; 44% +/- 6% after a count of 5 to 9/mm3; 48% +/- 5% after a count of 10 to 19/mm3; 51% +/- 4% after a count of 20 to 39/mm3; 62% +/- 5% after a count of 40 to 59/mm3; 71% +/- 4% after a count of 60 to 99/mm3; 79% +/- 3% after a count of 100 to 199/mm3; and 92% +/- 2% after a count of 200 to 499/mm3. One-year survival and baseline CD4 count were related by the following formula: percent 1-year survival = 10 + 32(log10 CD4 count) (R2 = .97; P < .001). The 1-year incidence of a first AIDS-defining event and baseline CD4 count were related by the following formula: percent developing AIDS in 1 year = 104-36(log10 CD4 count) (R2 = .89; P < .001). Similar relationships were calculated between the logarithm of the baseline CD4 count and the 1-year incidence of most AIDS-defining events. These relationships were linear over the CD4 range of 1 to 499/mm3 and over follow-up periods of 6 months to 2 years., Conclusions: The relationship of the CD4 count to survival, and to the incidence of AIDS-defining events, is logarithmic. This relationship helps explain the substantial differences in 1-year survival associated with baseline CD4 counts in the range below 50/mm3.

An experimental intravitreal sustained-release device containing ganciclovir was used to treat 22 patients with acquired immunodeficiency syndrome-associated cytomegalovirus retinitis. Fourteen eyes were excluded (five not involved and nine with macular scarring and/or severe debility). Thirty eyes received the ganciclovir intraocular device implant and were prospectively followed up from 16 to 419 days (median, 125 days). Twenty-seven (90%) of 30 eyes showed stabilization of the retinitis. Nine (33%) of 27 eyes showed reactivation of the retinitis once the device was empty of ganciclovir; seven received a replacement device, with subsequent stabilization of the retinitis. Postoperative complications included vitreous hemorrhage (n = 1), endophthalmitis (n = 1), and progressive retinitis (n = 2). Late retinal detachment was seen in three eyes (11%) at 35 to 140 days. Survival analysis of all 30 eyes revealed the mean time to progression of retinitis to be 19 weeks (133 days). The ganciclovir intraocular device offers a promising alternative for the treatment of cytomegalovirus retinitis associated with acquired immunodeficiency syndrome.

Cytomegalovirus (CMV) retinitis occurs in immunocompromised patients and can be treated by repeated intravenous or intravitreal injections of ganciclovir (GCV) or foscarnet. Due to toxicity and complications these modalities are not ideal. The development of alternative administration routes is hindered by a lack of pharmacokinetic data. Devices giving pseudo zero order release of GCV were implanted intravitreally first in rabbits and then in patients with AIDS associated CMV retinitis as part of a Phase I clinical trial. Steady state intravitreal GCV levels were obtained immediately after death and the elimination rate constants were calculated assuming first order pharmacokinetics. Normalizing for retinal surface area, distribution volume and anatomic volume, the retinal elimination rate constants were calculated. These were found to be 0.017 cm-2hr-1 in rabbits and 0.015 cm-2hr-1 in man. This indicates that the rabbit eye is a good model for studying intravitreal pharmacokinetics of ganciclovir and suggests a common elimination mechanism which may be trans-retinal.

The product-limit incidence of Mycobacterium avium-intracellulare complex (MAC) bacteremia in 1006 human immunodeficiency virus (HIV)-positive patients followed at one institution over a 3-year period from the day of AIDS diagnosis with monthly lysis-centrifugation blood cultures was 21% +/- 2% SE at 1 year and 43% +/- 3% at 2 years. The product-limit incidence of MAC bacteremia at 1 year after the patients' first CD4 cell count was related to both the CD4 cell count and to whether they had an AIDS diagnosis (both P less than .0001) but not to age, sex, or race. This incidence was 39% +/- 6% for CD4 cell counts of less than 10/mm3, 30% +/- 5% for 10-19/mm3, 20% +/- 4% for 20-39/mm3, 15% +/- 4% for 40-59/mm3, 8% +/- 3% for 60-99/mm3, and 3% +/- 1% for 100-199/mm3. MAC may eventually infect most if not all HIV-positive patients who do not die from another HIV-related event.

Monoclonal 3F6 anti-Pneumocystis carinii antibody (MAB-3F6) was used to stain cell blocks from 164 bronchial lavage specimens from patients with the acquired immune deficiency syndrome (AIDS) and AIDS-related complex and compared with slides stained with Grocott's modification of the Gomori methenamine silver stain. Pneumocystis organisms were present in 83 of 164 cases using MAB-3F6 stain, whereas Grocott's modified silver stain demonstrated Pneumocystis organisms in 48. MAB-3F6 demonstrated Pneumocystis organisms in 38 cases with negative silver stains, whereas silver stain identified Pneumocystis organisms in only three MAB-3F6-negative cases. Of 70 patients with clinical Pneumocystis pneumonia at the time of the specimen was obtained, 59 had MAB-3F6-positive specimens, whereas 39 had organisms detected using Grocott's modified silver stain. Of 37 patients without clinically apparent Pneumocystis pneumonia any time in their course, 4 had abundant organisms and 33 had negative stains with MAB-3F6. MAB-3F6 detected Pneumocystis organisms in 22 of 31 cases of Pneumocystis pneumonia that had no organisms identified using Grocott's silver stain (X2 = 5.76, P = 0.016). MAB-3F6 immunochemical staining is a more sensitive method than Grocott's modified silver stain to detect Pneumocystis organisms.

Objective: To investigate the efficacy of fluconazole prophylaxis against systemic fungal infections in HIV-positive patients., Design: Open label treatment compared with historical controls., Setting: Patients were seen at the Parkland Memorial Hospital HIV Clinic, Dallas, Texas, USA between 1 March 1990 and 28 February 1991., Patients, Participants: Three hundred and thirty-seven historical controls were followed for 157 patient-years, and 329 fluconazole-treated patients for 145 patient-years., Interventions: Fluconazole (100 mg daily) was administered to all patients with CD4 lymphocyte counts less than 68 x 10(6)/l seen at our HIV clinic after 1 March 1990., Main Outcome Measures: Lysis-centrifugation blood cultures were recorded monthly for all patients during both study periods., Results: Twenty infections (16 cryptococcosis, four histoplasmosis) occurred in 337 historical reference control patients (product-limit 1-year incidence, 7.5 +/- 2.0/year). Four infections (one cryptococcosis, three histoplasmosis) occurred in the treated patient group (product-limit 1-year incidence, 1.8 +/- 0.9/year)., Conclusions: Fluconazole warrants further evaluation for prophylaxis against systemic fungal infections in HIV-positive patients.

A surgically implantable device for sustained intravitreal release of ganciclovir has been developed. The device delivers ganciclovir intraocularly over approximately 4 to 5 months. Eight patients with acquired immunodeficiency syndrome (AIDS) and associated cytomegalovirus (CMV) retinitis were recruited as part of a phase 1 study. Thirteen eyes with active CMV retinitis underwent surgical implantation of the ganciclovir device. All eyes showed resolution of the CMV retinitis; none showed progression. Visual acuity remained unchanged in three eyes, improved in six eyes, and decreased in four eyes. Surgical complications included mild vitreous hemorrhage, astigmatism, and suprachoroidal placement of the device. Retinal detachment occurred in three eyes as the retinitis resolved. This new intraocular drug delivery system offers many advantages compared with intravenous therapy or repeated intravitreal ganciclovir injections for the management of CMV retinitis in patients with AIDS.

Physician decisions concerning allocation of health care resources to patients are highly variable and poorly understood. Psychological androgyny theory (PAT) has been employed as a model of the interpersonal and task activities required of physicians for care of their patients. Several studies have successfully predicted physician resource utilization using measures derived from PAT. Using a sample of 97 first-year medical students, the authors explored the relationship between PAT and risk preference in loss-framed gambles in order to elucidate the process whereby variables derived from PAT predict resource utilization. As hypothesized, students selecting the certain loss had significantly higher mean androgyny scores than did students selecting uncertainty. Research involving these constructs is integrated in the context of a theoretical "causal model," which highlights issues deserving of future research.

Psychological androgyny theory (PAT) was employed as a model of the interpersonal (social) and task activities required of physicians for care of their patients. According to PAT, individuals with a large repertoire of task and social skills ("androgynous" individuals) should be optimally adaptable to contingencies reflecting varying combinations of task and social challenges. The authors examined the relationship between androgyny and preference for intubation on a patient management problem involving end-stage lung disease for 67 general internists and internal medicine housestaff from two hospitals. Results revealed a negative relationship between androgyny and preference for intubation, suggesting that androgynous and nonandrogynous physicians respond differently to complex and difficult decision-making tasks. Indirect evidence is offered to suggest that this response reflects a general tendency to utilize fewer health care resources. Discussion focuses on the need to improve the precision of measurement of these latent constructs.

Disseminated histoplasmosis was diagnosed in 36 (4%) of 980 patients with AIDS seen at Parkland Memorial Hospital in Dallas, Texas before September 30, 1989. Diagnostic sensitivity of blood culture plus examination of peripheral smear was 88%; sensitivity of bone marrow aspiration and blood culture was 80%. Median CD4 lymphocyte count at diagnosis was 33/cu mm. Median actuarial survival from the date histoplasmosis was diagnosed was 188 days. Thirteen (36%) of the 36 patients died before adequate antifungal therapy could be administered, while 13 survived long enough to receive 1,500 mg of amphotericin B; actuarial survival of the latter group from the date 1,500 mg of amphotericin B had been infused was 47% at 1 year. The substantial early mortality of AIDS-associated disseminated histoplasmosis and the modestly encouraging survival of those who were diagnosed in time to receive adequate therapy raise the issues of surveillance, prophylaxis, and empiric therapy for this infection in selected HIV-positive patients.

Intrarenal concentrations of doxycycline were measured in 48 normal canine kidneys during wide variations in urine pH and the systemic state of hydration of the experimental animals. The results were compared with the renal parenchymal levels achieved in 10 severely diseased human kidneys. Although the state of hydration, the urine pH, and renal disease all significantly influenced the urinary concentrations and rate of renal clearance of doxycycline, there was no detectable difference between concentrations in normal renal tissue and those in severely diseased kidneys. This result is in contradistinction of the findings for previously evaluated antibiotics. The levels of doxycycline measured in renal tissue averaged twice the concentration in serum without notable difference among levels in renal cortex, medulla, and papilla. Prospective clinical trials will be necessary for identification of any solid correlation between the remarkable characteristics of accumulation of doxycycline in diseased renal parenchymal tissue and the clinical, therapeutic importance of such an observation.

Physician attitudes towards risk may influence their behavior in critical care situations. To explore this hypothesis, physicians' responses to a questionnaire about risk were compared to their preferences towards "intubation" or "current therapy without intubation" for a hypothetical patient with end-stage lung disease, and to the length of time they performed cardiopulmonary resuscitation before they declared their efforts unsuccessful. When the choices on the questionnaire were framed in terms of loss, choice of the risky alternative was associated with greater preference for "intubation," and with longer duration of resuscitation efforts (both p less than .005). At least part of the variation in physician attitudes and practices towards the care of the critically or terminally ill is associated with measurable psychologic differences among individual physicians.

Ten members of 3 generations of a family have IgM-IgG cryoglobulins and rheumatoid factors in their sera; one additional member has rheumatoid factor but not cryoglobulins. The disorder occurs in an autosomal dominant pattern. Here we describe an antigen, first identified on the cryoglobulin IgM of the index case, which is present in the sera of all 11 members of this kindred with rheumatoid factor. This antigen has the serologic properties of an IgM rheumatoid factor idiotype.

The risk preferences in situations of potential gain, and of potential loss, expressed by 67 physicians were correlated with the numbers of laboratory tests they selected after review of identical copies of two outpatient charts. Physicians who chose a 50/50 gamble of losing ten or no years of life expectancy over an equivalent certain loss of five years selected twice as many tests as those who chose the loss (p less than 0.025). Risk preferences may provide some insight into why some physicians order more laboratory tests than do others.

One hundred thirty-seven physicians were asked to choose between a certain loss of five years of life expectancy and a 50/50 gamble of losing either ten years or zero years of life expectancy. These choices were presented as hypothetical options for a patient with cancer. The 46 who chose the certain loss ordered 23% fewer laboratory tests/patient visit in our General Medicine Clinic over an eight-week period than those who chose the gamble (p less than 0.05). This risk preference was further stratified by sequentially offering five, four, three, two, and one years of certain loss against the same 50/50 gamble of ten or zero years of loss; greater preference for the gamble correlated with greater laboratory use (p less than 0.002). To exclude physician knowledge or case mix as a cause of this result, this risk preference was correlated with total score, and with the cost of tests ordered in patient management problems, of 49 physician on the American Board of Internal Medicine Certifying Examination. Cost of tests ordered was 23% less for the 17 who chose the certain loss (p less than 0.001); total score did not vary with risk preferences. There was no association between risk preference in the face of gain and laboratory use, and none between an individual's risk preferences in the face of gain and in the face of loss. The cognitive processes that determine risk preference in the face of loss, whatever they may be, appear to have a substantial influence on physician test-ordering behavior.

This paper describes a family in which 10 members of 3 generations have IgM-IgG cryoglobulinemia. Their pedigree is characteristic of autosomal dominant inheritance. No underlying disease that could account for the cryoglobulinemia has been identified in any patient, and no linkage of the cryoglobulinemia to HLA-A and -B locus haplotypes, blood group antigens, or immunoglobulin Gm allotypes has been detected. The rheumatoid factors of this kindred react with some, but not all, human IgG; however, their rheumatoid factors are not antibodies to any known human Gm or Km allotype. This family demonstrates that "essential" mixed cryoglobulinemia can be inherited, and that the clinical manifestations of an inherited cryoglobulinemia may vary among family members.

A diabetic patient exhibited glucose-induced hyperkalemia despite normal plasma and urinary aldosterone levels. The patient received no diuretics, was not acidotic, and had a creatinine clearance of 39 ml/min. Insulin or pharmacologic doses of desoxycorticosterone acetate eliminated the glucose-induced hyperkalemia. Normal aldosterone levels may be insufficient to protect certain diabetic patients from glucose-induced hyperkalemia.