Energy consumption in a baffled membrane bioreactor (B-MBR): estimation based on long-term continuous operation.

We investigated the operating conditions of a baffled membrane bioreactor (B-MBR) under which long-term stable operation can be achieved through the continuous operation of a pilot-scale B-MBR. Under appropriate operating conditions, the B-MBR was capable of achieving excellent treated water quality in terms of biochemical oxygen demand and concentration of total nitrogen. Excellent removal of total phosphorus was also achieved. In addition, the degree of membrane fouling was acceptable, indicating that stable continuous operation of a B-MBR is possible under the operating conditions adopted in the present study. Estimation of the specific energy consumption in hypothetical full-scale B-MBRs operated under the conditions recommended by the findings was also performed in this study. The results suggest that energy consumption in full-scale B-MBRs would be in the range of 0.20-0.22 kWh/m3. These results strongly suggest that energy consumption in MBR operation can be significantly reduced by applying the concept of a B-MBR.

Effects of recirculation and separation times on nitrogen removal in baffled membrane bioreactor (B-MBR).

In this study, we investigated the effects of recirculation and separation times on removals of organic matter, nitrogen, and phosphorus in a baffled membrane bioreactor (B-MBR) treating real municipal wastewater. A pilot-scale B-MBR experimental apparatus was operated under two different sets of recirculation and separation times. The results revealed that, irrespective of operating conditions, the biochemical oxygen demand (BOD) and concentration of total nitrogen (T-N) in the treated water can be lowered to less than 3 and 5 mg/L, respectively. Although T-N was effectively removed in the two different operating conditions, increase in the fraction of recirculation time results in tiny deterioration of nitrogen removal efficiency in the B-MBR. Phosphorus removal efficiency was also slightly decreased as the fraction of recirculation time (ratio between recirculation and separation times) was increased. The results of the measurement of dissolved oxygen (DO) profiles at different points of the B-MBR apparatus indicate that the increase in DO concentration in the anoxic zone of the B-MBR becomes much more pronounced by increasing recirculation intensity. On the basis of the results obtained in this study, it can be concluded that efficient removal of BOD, T-N, and total phosphorus can be achieved by the B-MBR as long as appropriate recirculation intensity is selected.

Hypothalamic ATF3 is involved in regulating glucose and energy metabolism in mice.

AIMS/HYPOTHESIS: The pancreas and hypothalamus are critical for maintaining nutrient and energy homeostasis, and combined disorders in these organs account for the onset of the metabolic syndrome. Activating transcription factor 3 (ATF3) is an adaptive response transcription factor. The physiological role of ATF3 in the pancreas has been controversial, and its role in the hypothalamus remains unknown. To elucidate the roles of ATF3 in these organs, we generated pancreas- and hypothalamus-specific Atf3 knockout (PHT-Atf3-KO) mice in this study. METHODS: We crossed mice bearing floxed Atf3 alleles with Pdx1-cre mice, in which cre is specifically expressed in the pancreas and hypothalamus, and analysed metabolic variables, pancreatic morphology, food intake, energy expenditure and sympathetic activity in adipose tissue. We also used a hypothalamic cell line to investigate the molecular mechanism by which ATF3 regulates transcription of the gene encoding agouti-related protein (Agrp). RESULTS: Although PHT-Atf3-KO mice displayed better glucose tolerance, neither plasma glucagon nor insulin level was altered in these mice. However, these mice exhibited higher insulin sensitivity, which was accompanied by a leaner phenotype due to decreased food intake and increased energy expenditure. We also observed decreased hypothalamic Agrp expression in PHT-Atf3-KO mice. Importantly, an increase in ATF3 levels is induced by fasting or low glucose in the hypothalamus. We also showed that ATF3 interacts with forkhead box-containing protein, O subfamily 1 (FoxO1) on the Agrp promoter and activates Agrp transcription. CONCLUSIONS/INTERPRETATION: Our results suggest that ATF3 plays an important role in the control of glucose and energy metabolism by regulating Agrp.

Estradiol supports in vitro development of bovine early antral follicles.

Antrum formation and estradiol (E(2)) secretion are specific features of oocyte and granulosa cell complexes (OGCs). This study investigates the effect of E(2) on the in vitro development of bovine OGCs derived from early antral follicles as well as on the expression of genes in granulosa cells (GCs). The supplementation of culture medium with either E(2) or androstenedione (A(4)) improved the in vitro development of OGCs and the nuclear maturation of enclosed oocytes. When OGCs were cultured in medium containing A(4), developmentally competent OGCs secreted more E(2) than OGCs that were not competent. In addition, fulvestrant inhibited the effect of both E(2) and A(4) on OGCs development. Comprehensive gene expression analysis using next-generation sequence technology was conducted for the following three types of GCs: i) GCs of OGCs cultured for 4 days with E(2) (1 µg/ml; E(2)(+)), ii) GCs of OGCs cultured for 4 days without E(2) (E(2)(-)) or iii) OGCs that formed clear antrum after 8 days of in vitro culture in medium containing E(2) (1 µg/ml; AF group). GCs of the E(2)(+) group had a similar gene expression profile to the profile reported previously for the in vivo development of large follicles. This genetic profile included factors implicated in the up-regulation of E(2) biosynthesis and down-regulation of cytoskeleton and extracellular matrices. In addition, a novel gene expression profile was found in the AF group. In conclusion, E(2) impacts the gene expression profile of GCs to support the in vitro development of OGCs.

Pisiferdiol and pisiferic acid isolated from Chamaecyparis pisifera activate protein phosphatase 2C in vitro and induce caspase-3/7-dependent apoptosis via dephosphorylation of Bad in HL60 cells.

Protein phosphatase 2C (PP2C) dephosphorylates a broad range of substrates and regulates apoptosis, stress response and growth-related pathways. In the course of screening for PP2C activators from natural sources, we isolated abietane-type diterpenes, pisiferdiol and pisiferic acid from Chamaecyparis pisifera. Pisiferdiol having a unique seven-membered ring showed more specific PP2C activation activity (1.3-fold at 100 microM) than pisiferic acid having a normal six-membered ring and oleic acid, which is known to activate PP2C. Pisiferdiol and pisiferic acid showed mixed-type activation with respect to alpha-casein, and this differed from the non-competitive activation of oleic acid in vitro. In vivo, the cytotoxicity of pisiferdiol toward human promyelocytic leukemia cell line HL60 with an IC(50) value of 18.3 microM was 2-fold and 7-fold stronger than those of pisiferic acid and oleic acid, and pisiferdiol induced apoptosis through a caspase 3/7-dependent mechanism involving the dephosphorylation of Bad(1), which is a PP2C substrate. We thus conclude that pisiferdiol and pisiferic acid are novel PP2C activators, and the more specific activator, pisiferdiol, may be a useful chemical probe to study PP2C-mediated signaling pathways, and a lead compound for pharmaceutical agents.

Autologous blood transfusion for kidney transplant recipients.

Autologous blood transfusion (ABT) is rarely employed in patients with end-stage renal disease (ESRD); these patients are usually anemic. Since 1998, we have attempted ABT for ESRD patients undergoing living-related kidney transplantation. Among 20 patients enrolled in this study the preoperative hemoglobin and hematocrit levels were 10.0 +/- 1.2 mg/dL (range, 8.1-11.7) and 30.0 +/- 3.7% (range, 24.7-34.3), respectively. Blood volume collected on each occasion was 235.7 +/- 57.7 mL (range, 200-400), and the number of blood collections was 2.45 +/- 0.9 (range, 1-4). Total collected volume was 567.5 +/- 157.5 mL (range, 400-800). Symptomatic hypotension was seen in two patients, but vital signs recovered spontaneously. No other problems related to blood collection were observed. Allogeneic transfusion was need in only one patient (5%). ABT was safe and efficacious in ESRD patients scheduled for living-related kidney transplantation.

Variation of major neutral oligosaccharides levels in human colostrum.

OBJECTIVES: Human colostrum is known to be important for the protection of infants against infection by pathogenic microorganisms. This protection is thought to be due, partially, to various neutral and acidic oligosaccharides that are present in colostrum and milk. However, the concentrations of each of the oligosaccharide of human colostrum have not yet been determined. The aim of this present study was to determine the concentration of each of the major neutral oligosaccharide for three consecutive days from the start of lactation. METHOD: We analyzed the level of each neutral oligosaccharide in human colostrum, for three consecutive days from the start of lactation, obtained from 12 healthy Japanese women (ranging in age from 21 to 35 years; primipara 6 and multipara 6). The ABO blood groups of the donors were determined: A, three; B, three; O, five; AB, one. The determined human milk oligosaccharides were 2'-fucosyllactose (2'-FL), 3-fucosyllactose (3-FL), lactodifucotetraose (LDFT), lacto-N-tetraose (LNT), lacto-N-neotetraose (LNnT), three lacto-N-fucopentaose (LNFP I, II and III) and two lacto-N-difucohexaose (LNFDH I and II) using high-performance liquid chromatography (HPLC) with two derivatization techniques. RESULTS: The concentrations of 2'-FL and LDFT in colostrum on day 1 were significantly higher than those on days 2 and 3 (P<0.05). An increase in LNT was observed on day 3 compared with day 1 (P<0.05). CONCLUSION: These changes in concentrations of 2'-FL, LDFT and LNT may reflect the requirements for prebiotics and anti-infection agents by human infants during early lactation.

The effect of glucose on the progression of the nuclear maturation of pig oocytes.

The progression of the nuclear maturation of oocytes is a useful marker for the estimation of the subsequent developmental competence of oocytes. In this study, we examined the effect of energy substrates in an in vitro maturation medium on the progression of the nuclear maturation of oocytes. In experiment 1, the supplementation of the maturation medium with 0, 5 and 10 mM of glucose lead to increase in the total cell number of the blastocysts. In experiments 2 and 3, the maturation phase was divided into two stages (germinal vesicle (GV) stage: 0-20 h and nuclear maturation stage: 20-44 h), and the effects of glucose or pyruvate added at each stage on the kinetics of nuclear maturation were examined. The addition of glucose at the nuclear maturation stage rather than at the GV stage of maturation effected greater acceleration in the progression of nuclear maturation. However, the addition of pyruvate at both stages had the same effect on the progression of nuclear maturation was the same. In addition, when glucose was added to the medium containing pyruvate, an additive effect on the progression of nuclear maturation was observed (experiment 4). In experiment 5, the inhibitors of glucose-6-phosphate dehydrogenase (G6PD), dehydroepiandrosterone (DHEA) and 6-aminonicotinamide (6-AN) decreased the rate of the final maturation of oocytes and reduced the difference between the rates of the final maturation of oocytes cultured with glucose and those cultured with pyruvate. In the experiment 6, when the activator of G6PD, brilliant cresyle blue (BCB), was added to the maturation medium, the progression of nuclear maturation was significantly accelerated. The results of this study suggested that in addition to the role of an energy substrate, glucose or its metabolites play a role in nuclear maturation. This role was more pronounced at the second stage of maturation (transition from GV breakdown (GVBD) to M2), probably due to the metabolism of glucose via the pentose phosphate pathway (PPP) rather than the glycolysis pathway.

Hybrid membrane bioreactor for water recycling and phosphorus recovery.

This paper deals with the performance of hybrid membrane bioreactor (MBR) combining the precoagulation/sedimentation and membrane bioreactor. The hybrid MBR not only produces the treated water with excellent permeate quality but also shows much lower membrane fouling than the conventional MBR. It may come from its extremely low F/M ratio to maintain the low viscosity even in the high MLSS concentration range of about 20,000 mg/L. Some results of microbial community analysis in MBRs was conducted to demonstrate the other reason for its lower membrane fouling. Hybrid MBR has a high potential to be used for the recycling use of the municipal wastewater. Coagulated sludge produced in the hybrid MBR is a promising phosphorus resource. This paper also contains a recent progress of phosphorus recovery technology, which uses a new phosphoric acids absorbent, i.e. the hexagonal mesostructured zirconium sulfate (ZS). The ZS has the extremely high adsorption capacity of phosphoric acids through anion exchange. The adsorbed phosphoric acids are released from the ZS in a high pH range of about 13.

Effect of pre-coagulation on mitigating irreversible fouling during ultrafiltration of a surface water.

Membrane fouling can be divided into two types: reversible fouling and irreversible fouling. The former can be easily canceled by physical cleaning (e.g., backwashing) while the latter needs chemical cleaning to be mitigated. For more efficient use of membranes, the control of irreversible membrane fouling is of importance. In this study, the effectiveness of pre-coagulation/sedimentation on irreversible membrane fouling was investigated, based on the pilot-scale operation of the membrane unit installed at an existing water purification plant. The membrane employed was a low-pressure ultrafiltration (UF) membrane made of polysulfone and having a molecular weight cut-off of 750,000 daltons. Although pre-coagulation/ sedimentation significantly mitigated membrane fouling mainly through the reduction of reversible membrane fouling, the degree of irreversible fouling was not reduced by the pre-treatment. This was because the irreversible fouling observed during this study was mainly attributed to polysaccharides/protein like fractions of organic substances that cannot be efficiently removed by coagulation/sedimentation. Aluminium used as coagulant was thought to cause irreversible fouling to some extent but did not in the pilot operation, which could probable be explained by the fact that coagulation was conducted at relatively high pH (7.0) in this study.

Modification of ovary stock solution with magnesium and raffinose improves the developmental competence of oocytes after long preservation.

During ovary storage oocytes lose some of their developmental competence. In the present study, we maintained storage solutions of phosphate-buffered saline (PBS) at various temperatures (20 or 35 degrees C) or supplemented them with magnesium (Mg), raffinose and sucrose. Subsequently, we examined the kinetics of electrolytes in the follicular fluid (FF) during the ovary storage period (9 h), the survival rate of granulosa cells in the follicles, and the developmental competence of oocytes after the storage. Lowering the temperature from 35 to 20 degrees C increased the total cell number of blastocysts that developed at 7 days after in vitro maturation and in vitro fertilization of oocytes. In stock solution with supplements of 15 mM Mg or a combination of 5 mM Mg and 10 mM raffinose or sucrose, a significantly higher number of oocytes developed into blastocysts with a large number of cells in each blastocyst, and a significantly higher number of living granulosa cells were obtained as compared with stock solutions without any supplements. During ovary storage, the concentrations of potassium and chloride in the FF were increased, and the addition of Mg to the stock solution increased the concentration of Mg in the FF. Germinal vesicle breakdown in oocytes that were collected from ovaries stored in the solution supplemented with 15 mM Mg or a combination of 5 mM Mg and 10 mM of raffinose occurred at a slower rate than that in oocytes collected from ovaries stored in PBS alone. On the other hand, the oocytes collected from ovaries stored in the solution supplemented with 15 mM Mg or a combination of 5 mM Mg and 10 mM raffinose reached the metaphase II (MII) stage more rapidly than the oocytes collected from ovaries stored in the PBS alone. In conclusion, the modification of stock solution by the addition of Mg and raffinose improved the developmental competence of oocytes obtained from ovaries preserved for a long period.

Baffled membrane bioreactor (BMBR) for advanced wastewater treatment: easy modification of existing MBRs for efficient nutrient removal.

In this study, a novel membrane bioreactor (MBR) in which nitrification and denitrification simultaneously proceed in a single reaction chamber is proposed for advanced municipal wastewater treatment. Anoxic/aerobic environments are alternatively created in the proposed MBR by inserting baffles inside the membrane chamber. The performance of the proposed baffled membrane bioreactor (BMBR) was examined at an existing municipal wastewater treatment facility based on long-term operation. Although the procedure was simple, insertion of the baffles actually created the alternative anoxic/aerobic environments in the chamber at a constant interval and showed a great improvement in the nutrient removal. The insertion did not cause any adverse effect on membrane permeability. In this study, almost complete elimination of NH4+-N was observed while around 8 mg/L of NO(3-)-N was detected in the treated water. The modification proposed in this study can immediately be applied to most existing MBRs and is highly recommended for more efficient wastewater treatment.

Effects of supplemental energy on metabolic and immune measurements in periparturient dairy cows with Johne's disease.

The present study was designed to evaluate whether feeding supplemental energy would improve the metabolic profile and alleviate some of the immunosuppression typically noted during the periparturient period in dairy cows with Johne's disease. Twelve dairy cows naturally infected with Mycobacterium paratuberculosis were fitted with rumen cannulas in late gestation and assigned to treatment groups: control, n = 6; or stuffed, n = 6. Cows in the control group were allowed to consume feed ad libitum. Cows assigned to the stuffed treatment group were also fed ad libitum but received additional total mixed rations by manually stuffing their rumens with refused feed to maintain dry matter intake of 2% body weight per day before calving and 2.5% body weight per day after calving. Serum nonesterified fatty acid levels were significantly decreased in stuffed cows compared with control cows, indicating that stuffing to maintain dry matter intake improved the energy balance in the cows. In addition, periparturient serum calcium and magnesium concentrations were significantly higher in stuffed cows. Stuffing modulated cell-mediated immunity by reducing lymphocyte proliferative responses to T-cell mitogens during early lactation. Stuffing resulted in an increase in the secretion of in vitro immunoglobulin by peripheral blood mononuclear cells after parturition when compared to control cows. These data demonstrate that energy balance is improved by providing additional energy in this manner and suggest energy supplementation can improve some aspects of immune function during the periparturient period.

Concentrations of sialyloligosaccharides in bovine colostrum and milk during the prepartum and early lactation.

Sialyloligosaccharides and sialylglycoconjugates in colostrum and milk are regarded to be important biological components with respect to be source of brain gangliosides in infant and to be antiinfectional components for the attack by the pathogenic bacteria and virus. Several acidic oligosaccharides have been characterised in both bovine and human milk or colostrum. The sialyloligosaccharide content of human colostrum and milk has been extensively studied, whereas that of cows milk and colostrum has received less attention. In this study, the concentrations of three sialyloligosaccharides of bovine colostrum and milk were determined at various stages during the prepartum and the first 7 d postpartum. The concentration of 3'SL (Neu5Ac(alpha2-3)Gal(beta1-4)Glc) reached a maximum value of 0.85 mg/ml immediately following parturition while the concentrations of 6'SL (Neu5Ac(alpha2-6)Gal(beta1-4)Glc) and 6'SLN (Neu5Ac(alpha2-6)Gal(beta1-4)GlcNAc) of 0.14 and 0.12 mg/ml, respectively, were much lower at this initial stage, although these concentration were maximum immediately following parturition. Bovine colostrum, especially that collected immediately after parturition, may be suitable as a source of 3'SL and other sialyloligosaccharides for use as additives by the food or pharmaceutical industries.

A multicenter, double-blind study on triple therapy with lansoprazole, amoxicillin and clarithromycin for eradication of Helicobacter pylori in Japanese peptic ulcer patients.

BACKGROUND: Two triple therapies with lansoprazole (LPZ)/amoxicillin (AMPC)/clarithromycin (CAM) for eradication of Helicobacter pylori were studied in multicenter, double-blind fashion to evaluate the eradication rate of H. pylori and safety of eradiation treatment in Japanese patients with H. pylori-positive active gastric ulcers or duodenal ulcers. METHODS: Patients were randomly chosen for the control treatment of LPZ 30 mg twice a day (b.i.d.; Group A-LPZ-only) or the test treatments of LPZ 30 mg plus AMPC 750 mg and CAM 200 mg b.i.d. (Group B-LAC200) and LPZ 30 mg, AMPC 750 mg and CAM 400 mg b.i.d. (Group C-LAC400). All eradication treatments lasted for a period of 7 days. Successful eradication was assessed by culture and gastric histology 1 month after completion of the ulcer treatment. RESULTS: The eradication rates of H. pylori in the full analysis set were 0% in Group A-LPZ-only, 87.5% in Group B-LAC200 and 89.2% in Group C-LAC400 for gastric ulcer and, 4.4% in Group A-LPZ-only, 91.1% in Group B-LAC200 and 83.7% in Group C-LAC400 for duodenal ulcer. The eradication rates of Group B-LAC200 and Group C-LAC400 were 89.2% (95% CI: 84.8-93.7%) and 86.4% (95%CI: 81.5-91.3%) in total in the full analysis set, 89% (95% CI: 84.3-93.7%) and 85.3% (95%CI: 80.1-90.5%) in the per protocol set. The eradication rates in Groups B-LAC200 and group C-LAC400 were statistically significantly higher than the rate in Group A-LPZ-only for both gastric ulcer and duodenal ulcer patients (p <.0001 for both). CONCLUSION: A satisfactorily high H. pylori eradication rate was obtained in Japanese ulcer patients with the triple therapy regimen consisting of LPZ 30 mg, AMPC 750 mg, and CAM 200 mg b.i.d.

Brain interleukin-1 is involved in blood interleukin-6 response to immobilization stress in rats.

Interleukin (IL)-6, a cytokine for host defense responses to infection and inflammation, is known to be induced by non-invasive physical or psychological stress, too. To test possible involvement of brain IL-1 in the stress-induced IL-6 production, IL-1 mRNA expression in the hypothalamus, in parallel with blood IL-6 level, was examined in rats subjected to restriction of their movement (immobilization stress). When rats were immobilized, the hypothalamic IL-1 beta mRNA level was increased in 1 hr, followed by progressive rises in the serum IL-6 level. The immobilization-induced rise in serum IL-6 was mimicked by intracerebroventricular (icv) administration of IL-1 beta under normal conditions, whereas it was attenuated by icv injection of an IL-1 receptor antagonist. These results indicate that IL-1 in the hypothalamus plays a pivotal mediating role in the stress-induced peripheral IL-6 production.

Anorectic effect of leptin is mediated by hypothalamic corticotropin-releasing hormone, but not by urocortin, in rats.

Leptin is a key afferent signal that decreases food intake and increases energy expenditure by acting on the specific receptors in the hypothalamus. Corticotropin-releasing hormone (CRH) and its homologous peptide, urocortin, are also known to have a potent anorectic effect when given intracranially. To determine possible involvement of these two peptides in the leptin-induced anorexia, in the present study, food intake was measured in rats pretreated with antibodies against CRH and urocortin. In the control rats without antibody pretreatment, intracerebroventricular (icv) injection of leptin (0.1-1 microg/rat) suppressed nocturnal food intake. The anorectic effect of leptin was substantially attenuated in rats pretreated with icv injection of an anti-CRH antibody, but not with an anti-urocortin antibody. These results suggest that the anorectic effect of leptin is mediated by CRH, but not by urocortin, in the hypothalamus.

Optimization of atrioventricular delay and follow-up in a patient with congestive heart failure with an implanted DDD pacemaker: case report.

It has been reported that cardiac function can be improved by implanting a DDD pacemaker (PM) and setting a short atrioventricular (AV) delay in patients with impaired cardiac function. A previous report found that the critical AV delay that induces diastolic mitral regurgitation (MR) may represent the upper limit of the optimal AV delay. The optimal AV delay can be predicted by a simple method: slightly prolonged AV delay minus the interval between the end of the atrial kick and complete closure of the mitral valve (duration of diastolic MR) at the AV delay setting. The patient was a 84-year-old man with an old myocardial infarction. He had repeated admissions to hospital for congestive heart failure. ECG showed prolongation of the PQ interval (0.28 s) and complete left bundle branch block. Cardiac function was improved by AV sequential pacing when the AV delay was set at 120ms. After DDD-PM implantation, the cardiothoracic ratio decreased from 57 to 45% and cardiac function was improved from New York Heart Association class III to I. The AV delay was optimized during follow-up. Four years after PM implantation, the patient was in good condition without further hospital admission.

Nuclear transfer in cattle : effect of linoleic acid-albumin on freezing sensitivity of enucleated oocytes.

The effect of linoleic acid-albumin (LAA) supplementation to the media for IVM, enucleation, and activation on the developmental potential of bovine embryos produced by nuclear transfer (NT) into frozen-thawed cytoplasts was investigated. Blastomeres derived from morulae was placed in the perivitelline space of frozen-thawed cytoplasts, which were then fused by a DC pulse. The proportion of fused embryos was similar between groups with and without LAA (87 vs. 90%). The proportion of development to blastocysts of NT embryos derived from the media with LAA (14%) was higher than that without LAA (4%), indicating that LAA treatment of bovine oocytes during IVM, enucleation and activation can improve the ability of such cytoplasts after freezing and thawing to develop into blastocysts after NT.

Relationship between mutations in dihydropteroate synthase of Pneumocystis carinii f. sp. hominis isolates in Japan and resistance to sulfonamide therapy.

We examined mutations in the dihydropteroate synthase (DHPS) genes of Pneumocystis carinii f. sp. hominis (P. carinii) strains isolated from 24 patients with P. carinii pneumonia (PCP) in Japan. DHPS mutations were identified at amino acid positions 55 and/or 57 in isolates from 6 (25.0%) of 24 patients. The underlying diseases for these six patients were human immunodeficiency virus type 1 infection (n = 4) or malignant lymphoma (n = 2). This frequency was almost the same as those reported in Denmark and the United States. None of the six patients whose isolates had DHPS mutations were recently exposed to sulfa drugs before they developed the current episode of PCP, suggesting that DHPS mutations not only are selected by the pressure of sulfa agents but may be incidentally acquired. Co-trimoxazole treatment failed more frequently in patients whose isolates had DHPS mutations than in those whose isolates had wild-type DHPS (n = 4 [100%] versus n = 2 [11.1%]; P = 0.002). Our results thus suggest that DHPS mutations may contribute to failures of co-trimoxazole treatment for PCP.