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Background: Life expectancy of people with human immunodeficiency virus (HIV) is now estimated to approach that of the general population in some successfully treated subgroups. However, to attain these life expectancies, viral suppression must be maintained for decades., Methods: We studied the rate of triple-class virologic failure (TCVF) in patients within the Collaboration of Observational HIV Epidemiological Research Europe (COHERE) who started antiretroviral therapy (ART) that included a nonnucleoside reverse-transcriptase inhibitor (NNRTI) or a ritonavir-boosted protease inhibitor (PI/r) from 1998 onwards. We also focused on TCVF in patients who started a PI/r-containing regimen after a first-line NNRTI-containing regimen failed., Results: Of 45 937 patients followed up for a median (interquartile range) of 3.0 (1.5-5.0) years, 980 developed TCVF (2.1%). By 5 and 9 years after starting ART, an estimated 3.4% (95% confidence interval [CI], 3.1%-3.6%) and 8.6% (95% CI, 7.5%-9.8%) of patients, respectively, had developed TCVF. The incidence of TCVF rose during the first 3 to 4 years on ART but plateaued thereafter. There was no significant difference in the risk of TCVF according to whether the initial regimen was NNRTI or PI/r based (P = .11). By 5 years after starting a PI/r regimen as second-line therapy, 46% of patients had developed TCVF., Conclusions: The rate of virologic failure of the 3 original drug classes is low, but not negligible, and does not appear to diminish over time from starting ART. If this trend continues, many patients are likely to need newer drugs to maintain viral suppression. The rate of TCVF from the start of a PI/r regimen after NNRTI failure provides a comparator for studies of response to second-line regimens in resource-limited settings.

Background: The authors have previously reported asymptomatic hypoglycemia in non-diabetic patients on hemodialysis. The present study was designed to assess the effect of hemodialysis on plasma glucose, glucagon, cortisol and catecholamines in diabetic patients., Methods: Eighteen diabetic patients with chronic renal failure were hemodialyzed using a glucose-free dialysis fluid. They did not take any medication prior to dialysis and were asked not to eat during the first hour on hemodialysis. Blood and dialysate were sampled at regular intervals during the first hour of dialysis for analysis., Results: Plasma glucose fell below 4.0 mmol/l (72 mg/dl) in 7 of the 18 patients, below 3.5 mmol/l (63 mg/dl) in 3 and below 3.0 mmol/l (54 mg/dl) in one. The lowest recorded value was 2.8 mmol/l (50 mg/dl). The mean glucose loss in the waste dialysate was 9.2 g/h. In none of the group of 7 patients whose plasma glucose fell below 4.0 mmol/l (72 mg/dl) did symptoms of hypoglycemia occur. When 6 patients from this group were subsequently dialyzed with a dialysis fluid containing 5.5 mmol/l (100 mg/dl) glucose, their plasma glucose became stabilized within the fasting reference range. There were no significant hormonal changes during the dialysis or between non-hypoglycemic and hypoglycemic patients., Conclusions: Patients undergoing hemodialysis may become hypoglycemic and not be aware of it. There is no hormonal imbalance causing the hypoglycemia and the hormonal response to the hypoglycemia is blunted. Patients with an initial plasma glucose of 5.5 mmol/l (100 mg/dl) or less who are hemodialyzed and who do not eat during dialysis may be particularly at risk, especially if they are on insulin or taking glucose-lowering medication. These should be dialyzed with a dialysis fluid containing at least 5.5 mmol/l (100 mg/dl) glucose.

Background: Previous studies have ignored hypoglycemia in patients undergoing hemodialysis. The fall in plasma glucose may not have been considered to be clinically relevant because the patients were asymptomatic. The present study was designed to assess the effect of hemodialysis on plasma glucose, insulin, glucagon, cortisol and catecholamines in non diabetic patients., Methods: 21 non diabetic patients with chronic renal failure were hemodialyzed using a glucose-free dialysis fluid. They did not take any medication prior to dialysis and were asked not to eat during the first hour on hemodialysis. Blood and dialysate fluid was sampled at regular intervals during the first hour of dialysis for analysis., Results: Plasma glucose fell below 4.0 mmol/l (72 mg/dl) in 9 of the 21 patients, below 3.5 mmol/l (63 mg/dl) in 6 and below 3.0 mmol/l (54 mg/dl) in 3. The lowest recorded value was 2.1 mmol/l (38 mg/dl). The mode glucose loss in the waste dialysate fluid was 6 g/h. In the group of 9 patients whose plasma glucose fell below 4.0 mmol/l (72 mg/dl), no symptoms of hypoglycemia were shown but 4 of the 7 patients who felt very hungry and ate were in this group. When 7 patients from this group were subsequently dialysed with a dialysis fluid containing 5.5 mmol/l (100 mg/dl) glucose, their plasma glucose became stabilized within the fasting reference range. There were no significant hormonal changes during the dialysis or between euglycemic and hypoglycemic patients., Conclusions: Patients undergoing hemodialysis may become hypoglycemic and not be aware of it. There is no hormonal imbalance causing the hypoglycemia and the hormonal response to the hypoglycemia is blunted. Patients with an initial plasma glucose of 4.5 mmol/l (81 mg/dl) or less who are hemodialyzed and who do not eat during dialysis may be particularly at risk. They should be dialysed with a dialysis fluid containing at least 5.5 mmol/l (100 mg/dl) glucose.

Between November 1988 and January 1989 a prospective survey was undertaken on patients aged 65 years and over who were discharged from the care of geriatricians in seven District General Hospitals. The survey aimed to provide a regional perspective on patient dependency by relating dependency at discharge to the discharge destination. The findings show that the majority of patients were relatively independent and most returned home. A significant number of the very dependent patients were discharged to the community with private residential and nursing homes making an important contribution to the placement of highly dependent patients.