Do oropharyngeal throat packs prevent fluid ingestion during orthognathic surgery?

The oropharyngeal throat pack is commonly used in oral and maxillofacial surgery despite debated evidence regarding its barrier function. The study objectives were to investigate whether the oropharyngeal pack reduces blood ingestion and to evaluate its relationship with postoperative nausea and vomiting (PONV) and throat pain. This was a single-center, parallel group, single-blind randomized controlled trial. Participants undergoing orthognathic surgery, age ≥16 years, were included in the study. After intubation and prior to surgery start, the treatment group received oropharyngeal packing; the control group received no packing. Outcome variables were the quality of gastric contents aspirated by nasogastric tube (bloody or not bloody), PONV, and throat pain (visual analog scale). Thirty patients (treatment n = 15; control n = 15) were randomized and analyzed. There was no difference between the groups in quality of gastric contents (P = 1.00) or incidence of PONV at 2 hours and 24 hours (P = 1.00). Throat pain incidence and severity at 2 hours were both higher in the treatment group, but this was not statistically significant (P = 0.128, P = 0.223). The results indicate that the oropharyngeal pack is not an effective barrier against blood ingestion. Oropharyngeal packs do not improve or worsen PONV, but may increase throat pain.

Hyponatremia and activation of vasopressin secretion are both independently associated with 30-day mortality: results of a multicenter, observational study

BACKGROUND

Hyponatremia is a common feature of acute illness and associated with increased mortality. This may be explained by a stress-mediated activation of the vasopressin system with an increase in free-water reabsorption.

OBJECTIVES

To investigate whether the association between hyponatremia and mortality could be explained by activation of the vasopressin system.

METHODS

We prospectively enrolled adult, medical patients seeking emergency care in three centres in Switzerland, France and the United States. We investigated associations between admission plasma sodium and copeptin, a stable portion of the vasopressin-precursor peptide, with 30-day mortality. We performed uni- and multivariate regression analysis.

RESULTS

Of 6962 included patients, 18% had hyponatremia (sodium ≤135 mmol L^-1 ), which doubled their risk for mortality compared to patients with normonatremia (8.3% vs. 3.8%). This association was confirmed in a multivariate-adjusted logistic regression analysis [adjusted odds ratio (OR) 1.47, 95% CI 1.12-1.93, P = 0.005]. Vasopressin levels, mirrored by copeptin, were also increased in nonsurvivors and strongly associated with mortality (adjusted OR 3.42, 95% CI 2.76-4.25, P < 0.001). The association between hyponatremia and mortality remained unchanged when adding copeptin levels to the regression model (fully adjusted OR 1.53, 95% CI 1.16-2.00, P = 0.002).

CONCLUSION

This prospective study including medical patients upon emergency room admission found hyponatremia as well as an activation of the vasopressin system to be independently associated with mortality. This suggests that stress- and vasopressin-independent mechanisms are responsible for the association of low sodium levels with mortality.

The association of admission hyperglycaemia and adverse clinical outcome in medical emergencies: the multinational, prospective, observational TRIAGE study

AIMS

The clinical relevance of hyperglycaemia in an emergency department population remains incompletely understood. We investigated the association between admission blood glucose levels and adverse clinical outcomes in a large emergency department cohort.

METHODS

We prospectively enrolled 7132 adult medical patients seeking emergency department care in three tertiary care hospitals in Switzerland, France and the USA. We used adjusted multivariable logistic regression models to examine the association between admission blood glucose levels and 30-day mortality, as well as adverse clinical course stratified by pre-existing diabetes and principal medical diagnoses.

RESULTS

In 6044 people without diabetes (84.7%), severe hyperglycaemia, defined as a glucose level of > 11.1 mmol/l (200 mg/dl), was associated with a doubling in the risk of 30-day mortality [adjusted odds ratio (OR) 1.9; 95% confidence interval (95% CI), 1.1 to 3.3; P = 0.018] and a three-fold increase in the risk of intensive care unit admission (adjusted OR 3.0; 95% CI, 1.9 to 4.9; P < 0.001). These associations were similar among different diagnoses. In the population with diabetes (n = 1088), no association with 30-day mortality was found (adjusted OR 1.0; 95% CI, 0.6 to 1.8; P for interaction = 0.001), whereas the association with intensive care unit admission was weaker (adjusted OR 2.4; 95% CI, 1.5 to 4.1; P for interaction = 0.011). Overall 30-day mortality was higher in those with diabetes than in those without (6.1 vs. 4.4%, P = 0.015).

CONCLUSIONS

In this large medical emergency department patient cohort, admission hyperglycaemia was strongly associated with adverse clinical course in people without diabetes. (Clinical Trial Registry No: NCT01768494).

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

Elevated Intracranial Pressure Diagnosis with Emergency Department Bedside Ocular Ultrasound

Bedside sonographic measurement of optic nerve sheath diameter can aid in the diagnosis of elevated intracranial pressure in the emergency department. This case report describes a 21-year-old female presenting with 4 months of mild headache and 2 weeks of recurrent, transient binocular vision loss. Though limited by patient discomfort, fundoscopic examination suggested the presence of blurred optic disc margins. Bedside ocular ultrasound (BOUS) revealed wide optic nerve sheath diameters and bulging optic discs bilaterally. Lumbar puncture demonstrated a cerebrospinal fluid (CSF) opening pressure of 54 cm H2O supporting the suspected diagnosis of idiopathic intracranial hypertension. Accurate fundoscopy can be vital to the appropriate diagnosis and treatment of patients with suspected elevated intracranial pressure, but it is often technically difficult or poorly tolerated by the photophobic patient. BOUS is a quick and easily learned tool to supplement the emergency physician's fundoscopic examination and help identify patients with elevated intracranial pressure.

Influence of procalcitonin on decision to start antibiotic treatment in patients with a lower respiratory tract infection: insight from the observational multicentric ProREAL surveillance

Procalcitonin (PCT)-guided antibiotic stewardship is a successful strategy to decrease antibiotic use. We assessed if clinical judgement affected compliance with a PCT-algorithm for antibiotic prescribing in a multicenter surveillance of patients with lower respiratory tract infections (LRTI). Initiation and duration of antibiotic therapy, adherence to a PCT algorithm and outcome were monitored in consecutive adults with LRTI who were enrolled in a prospective observational quality control. We correlated initial clinical judgment of the treating physician with algorithm compliance and assessed the influence of PCT on the final decision to initiate antibiotic therapy. PCT levels correlated with physicians' estimates of the likelihood of bacterial infection (p for trend <0.02). PCT influenced the post-test probability of antibiotic initiation with a greater effect in patients with non-pneumonia LRTI (e.g., for bronchitis: -23 % if PCT ≤ 0.25 μg/L and +31 % if PCT > 0.25 μg/L), in European centers (e.g., in France -22 % if PCT ≤ 0.25 μg/L and +13 % if PCT > 0.25 μg/L) and in centers, which had previous experience with the PCT-algorithm (-16 % if PCT ≤ 0.25 μg/L and +19 % if PCT > 0.25 μg/L). Algorithm non-compliance, i.e. antibiotic prescribing despite low PCT-levels, was independently predicted by the likelihood of a bacterial infection as judged by the treating physician. Compliance was significantly associated with identification of a bacterial etiology (p = 0.01). Compliance with PCT-guided antibiotic stewardship was affected by geographically and culturally-influenced subjective clinical judgment. Initiation of antibiotic therapy was altered by PCT levels. Differential compliance with antibiotic stewardship efforts contributes to geographical differences in antibiotic prescribing habits and potentially influences antibiotic resistance rates.

Effect of a very late antigen-4 receptor antagonist on allergen-induced airway responses and inflammation in asthma

BACKGROUND

Very late antigen-4 (VLA(4)) plays a key role in the recruitment of eosinophils in allergic responses in animal studies.

OBJECTIVE

We investigated whether pretreatment with multiple doses of a VLA(4) receptor antagonist, HMR 1031, protects against allergen-induced airway responses and airway inflammation in humans.

METHODS

Fourteen asthmatics (7F/7M), 18-49 years, PC(20) forced expiratory volume in 1 s (FEV(1)) methacholine (M) (<8 mg/mL; FEV(1) 82.3-116.1% predicted) with dual responses to inhaled allergen participated in a double-blind, placebo-controlled, cross-over study. Each treatment period consisted of 9 days, separated by >or=2 weeks. Exhaled nitric oxide (eNO), PC(20)FEV(1)(M) and hypertonic saline-induced sputum was obtained on Days 1, 7 and 9. Subjects inhaled HMR 1031 (20 mg b.i.d.) or placebo (P) on Days 1--8. On Day 8, an allergen bronchoprovocation test was performed, the airway response was measured by FEV(1), and expressed as %fall from baseline. Data from 12 evaluable subjects are presented here.

RESULTS

Both treatments were well tolerated. There was no significant difference between HMR 1031 and P in the early asthamatic response: mean AUC (0-3 h)+/-SEM (%fall h): 26.01+/-4.26 and 17.41+/-4.26, respectively (P=0.18), nor in the late response: mean AUC (3-9 h)+/-SEM (%fall h): 97.09+/-8.63 and 97.61+/-8.63, respectively, P=0.97. This corresponded to the absence of significant allergen-induced changes in PC(20)FEV(1)(M), eNO, sputum eosinophils and soluble inflammation markers between both treatment periods.

CONCLUSIONS

Treatment with multiple inhaled doses of the VLA(4) antagonist, HMR 1031, did not result in detectable protection against allergen-induced airway responses or airway inflammation in asthma.

Delivery of pediatric after-hours care by call centers: a multicenter study of parental perceptions and compliance

BACKGROUND

Despite the rapid growth of centralized call centers to provide after-hours triage to patients of multiple providers, little is known about the perceptions of parents regarding this type of care and their compliance with triage disposition recommendations.

DESIGN/METHODS

From August through September 1999, randomized samples of after-hours calls were selected each day from computerized records at 4 pediatric call centers at 1) Children's Hospital, Denver, Colorado; 2) Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; 3) Rainbow Babies and Children's Hospital, Cleveland, Ohio; and 4) All Children's Hospital, St Petersburg, Florida. All participating call centers use the same triage software. Calls were randomly selected to yield at least 250 callers with nonurgent dispositions and 100 with urgent dispositions from each site. Telephone surveys to callers were conducted by an external survey unit 3 to 7 days after the call to the call center.

RESULTS

Surveys were completed for 70.5% of those sampled (N = 1561). Parents indicated they were very satisfied or satisfied with aspects of care received from 92.6% (waiting time) to 99.4% (nurse courteousness) of the time. Satisfaction did not differ by site or by recommended disposition of the index call. Most parents (65.2%) reported no preference about speaking with a physician or nonphysician for after-hours care, whereas 27.7% preferred to speak with a physician. Usually speaking with a physician during office hours (odds ratio [OR]: 1.48), feeling it was important that provider knows child's medical history (OR: 3.47), and respondent having an educational level of college graduate or higher (OR: 1.30) were significant predictors of preferring to speak with a physician. Of the 37.0% (N = 723) of parents who reported any change in their relationship with their primary provider as a result of the after-hours call center, 95.7% (N = 691) assessed the change to be positive. Reported compliance with the call center disposition recommendation was 83.3% for urgent referral, 41.0% for next day, 4.5% for visit at a later time, and 78.2% for home care. The major reason given by parents for noncompliance was reporting that they heard a different disposition (76.9% for urgent to 100% for visit at a later time).

CONCLUSIONS

Parental satisfaction with pediatric call centers was uniformly high in 4 different geographic locations, and almost all parents who reported any effect on their relationship with their primary provider assessed it as positive. Compliance with recommendations for urgent evaluation or home care was relatively high but for intermediary dispositions was low. In most cases in which noncompliance occurred, parents reported hearing a different disposition. Additional study is needed to clarify whether noncompliance, especially in cases in which an urgent recommendations was made, is attributable to poor nurse communication of the recommended disposition, parental misinterpretation, or parental difference of opinion.

Breast cancer risk factors in two distinct ethnic groups: Indian and Pakistani vs. American premenopausal women

Asian Indians from the Indian subcontinent have low rates of breast cancer, but studies on breast cancer risk factors in Indian and Pakistani women living in the United States are lacking. This study contrasted breast cancer risk factors [serum total 17 beta-estradiol (E2), sex hormone-binding globulin-bound E2, available E2, estrone (E1), and dehydroepiandrosterone sulfate, reproductive history, family history of cancer, body composition/size, dietary intake, physical activity, and excretion of isoflavones] between two distinct ethnic groups of premenopausal women residing in the United States. We also determined the contribution of these and other factors to the variability of each sex hormone. Distributions of values for serum total E2, available E2, and sex hormone-binding globulin-bound E2 (%) were greater (p < 0.005) in American (n = 47) than in Indian and Pakistani (n = 47) women. Multiple regression analysis indicated that 26% of the variability (p < or = 0.0001) in serum E2 was accounted for by the ratio of total cholesterol to high-density-lipoprotein cholesterol, length of time in the United States, and saturated fat intake, whereas less (17%) variability was accounted for by available E2 (representing free E2 + albumin-bound E2), contributed by the ratio of total cholesterol to high-density-lipoprotein cholesterol and saturated fat intake. Five variables accounted for 31% of the variability (p < or = 0.0001) in E1. The major finding of this study was that circulating sex hormone concentrations were determined more by environmental factors than by ethnicity, which was not a significant contributor to any of the serum hormones.

Ptc1, a type 2C Ser/Thr phosphatase, inactivates the HOG pathway by dephosphorylating the mitogen-activated protein kinase Hog1

The HOG (high-osmolarity glycerol) mitogen-activated protein kinase (MAPK) pathway regulates the osmotic stress response in the yeast Saccharomyces cerevisiae. Three type 2C Ser/Thr phosphatases (PTCs), Ptc1, Ptc2, and Ptc3, have been isolated as negative regulators of this pathway. Previously, multicopy expression of PTC1 and PTC3 was shown to suppress lethality of the sln1Delta strain due to hyperactivation of the HOG pathway. In this work, we show that PTC2 also suppresses sln1Delta lethality. Furthermore, the phosphatase activity of these PTCs was needed for suppression, as mutation of a conserved Asp residue, likely to coordinate a metal ion, inactivated PTCs. Further analysis of Ptc1 function in vivo showed that it inactivates the MAPK, Hog1, but not the MEK, Pbs2. In the wild type, Hog1 kinase activity increased transiently, approximately 12-fold in response to osmotic stress, while overexpression of PTC1 limited activation to approximately 3-fold. In contrast, overexpression of PTC1 did not inhibit phosphorylation of Hog1 Tyr in the phosphorylation lip, suggesting that Ptc1 does not act on Pbs2. Deletion of PTC1 also strongly affected Hog1, leading to high basal Hog1 activity and sustained Hog1 activity in response to osmotic stress, the latter being consistent with a role for Ptc1 in adaptation. In vitro, Ptc1 but not the metal binding site mutant, Ptc1D58N, inactivated Hog1 by dephosphorylating the phosphothreonine but not the phosphotyrosine residue in the phosphorylation lip. Consistent with its role as a negative regulator of Hog1, which accumulates in the nucleus upon activation, Ptc1 was found in both the nucleus and the cytoplasm. Thus, one function of Ptc1 is to inactivate Hog1.

Myocardial bridging of left circumflex coronary artery associated with acute myocardial infarction

Myocardial bridging of coronary arteries has been associated with myocardial infarction (MI), conduction disturbances, and sudden cardiac death. There are several reports on MI in association with myocardial bridging of the left anterior descending coronary artery. Here we present a case report of acute MI associated with myocardial bridging of the left circumflex coronary artery.

Treatment of photosensitive epilepsy using coloured glasses

A recently introduced optometric technique, colorimetry, enables the perceptual effects of ophthalmic tints to be evaluated subjectively, optimized, and then prescribed in tinted spectacles. The new technique is beneficial in reducing visual stress in patients with dyslexia and migraine. We describe an open trial designed to ascertain: (1) whether the colorimetry assessment, as it is now given, is safe for the investigation of photosensitive patients in optometry clinics where colorimetry equipment is most readily available, but where EEG control is not practical; (2) what proportion of patients with photosensitive epilepsy is likely to benefit to the extent already described in individual cases; (3) whether a tint selected by colorimetry could be shown to reduce the incidence of paroxysmal epileptiform EEG activity in response to flicker and patterns, thereby validating the subjective methods and corroborating the reported seizure reduction. Twenty-four females and nine males (aged 12-43 years) took part. All the patients had suffered visually-provoked seizures, had exhibited a photoparoxysmal response on at least one previous EEG recording, and had received a diagnosis of photosensitive epilepsy. Twenty-two were currently experiencing seizures. A further EEG was recorded in all except seven cases: a routine resting record, followed by hyperventilation. Colorimetry was performed after hyperventilation and before photic stimulation. Twenty-three (70%) reported beneficial effects during colorimetry and were prescribed glasses. There was a preponderance of lenses with a rose or purple colour, in contrast to patients with dyslexia. Seventeen of the 23 patients were available at follow-up, an average of 2.4 years later. Thirteen (57%) reported benefits, and said they were still using the lenses. In six of the 13 the benefits were pronounced, including a reduction of dizziness from fluorescent lighting, elimination of aura when using computer screens etc. Only in three cases was there a reduction in seizures that could reasonably be attributed to the use of lenses; in two of these cases no medications were prescribed, and in the third the medications remained unchanged for four years, two before and two after the introduction of the glasses. In an additional four cases a reduction in seizures was observed but medication had been changed. There was a modest reduction in EEG photosensitivity with the coloured lenses but also to an equivalent or lesser extent with grey in all of the eight patients examined in this way. One patient had seizures during colorimetry, but the seizures were not accompanied by scalp EEG changes.

Effects of dexmedetomidine on isoflurane requirements in healthy volunteers. 1: Pharmacodynamic and pharmacokinetic interactions

Dexmedetomidine is a highly selective alpha 2-adrenoceptor agonist with anaesthetic-sparing effects. We have determined the pharmacodynamic and pharmacokinetic interactions between dexmedetomidine and isoflurane in volunteers. Nine male subjects were allocated randomly to receive isoflurane anaesthesia preceded by infusion of dexmedetomidine on three separate occasions, 2 weeks apart. Dexmedetomidine target plasma concentrations were 0.0 (placebo), 0.3 ng ml-1 (low-dex) and 0.6 ng ml-1 (high-dex). End-tidal isoflurane concentrations at which gross purposeful movement and response to verbal commands occurred were identified. In the recovery period, sedation scores and digit symbol substitution tests were recorded. Venous blood samples were obtained before, during and after anaesthesia at predetermined intervals for measurement of plasma concentrations of dexmedetomidine and calculation of standard pharmacokinetic indices (AUC, Cl, Vss, T1/2 alpha, T1/2 beta). The end-tidal isoflurane concentration at which 50% of subjects first responded to the tetanic stimulus was 1.05% in the placebo group, 0.72% in the low-dex group and 0.52% in the high-dex group. We conclude that dexmedetomidine decreased isoflurane requirements in a dose-dependent manner and reduced heart rate, systolic and diastolic arterial pressures. Sedation and slight impairment of cognitive function persisted for several hours after anaesthesia and the end of infusion of dexmedetomidine. Isoflurane did not appear to influence the pharmacokinetics of dexmedetomidine.

Restenosis following angioplasty in the swine coronary artery is inhibited by an orally active PDGF-receptor tyrosine kinase inhibitor, RPR101511A

BACKGROUND

Platelet-derived growth factor (PDGF), a purported mediator of arterial response to injury, stimulates proliferation, chemotaxis, and matrix production by activation of its membrane receptor tyrosine kinase. Because these activities underlie restenosis, inhibition of the PDGF-receptor tyrosine kinase (PDGFr-TK) is postulated to decrease restenosis.

METHODS AND RESULTS

RPR101511A is a novel compound which selectively and potently inhibits the cell-free and in situ PDGFr-TK and PDGFr-dependent proliferation and chemotaxis in vascular smooth muscle cells (VSMC). To evaluate the effect of RPR101511A (30 mg. kg-1. d-1 BID for 28 days following PTCA) on coronary restenosis, PTCA was performed in hypercholesterolemic minipigs whose left anterior descending (LAD) coronary artery had been injured by overdilation and denudation, yielding a previously existing lesion. Angiographically determined prePTCA minimal lumen diameters (MLD) were similar in vehicle and RPR101511A-treated pigs (1.98+/-0.09 versus 2.01+/-0.08 mm) and increased to the same extent in the 2 groups following successful PTCA (2.30+/-0.06 versus 2.52+/-0.13). At termination, there was an average 50% loss of gain in the vehicle-treated group but no loss of gain with RPR101511A (2.16+/-0. 05 versus 2.59+/-0.11, P<0.001). Morphometric analysis of the LAD showed that RPR101511A caused a significant decrease in total intimal/medial ratio (0.96+/-0.58 versus 0.67+/-0.09, P<0.05).

CONCLUSIONS

RPR101511A, which acts by inhibition of the PDGFr-TK, completely prevented angiographic loss of gain following PTCA and significantly reduced histological intimal hyperplasia.

Subjective gastrointestinal tolerability of acetylsalicylic acid and paracetamol after single dose treatment

A prospective, randomised, double-blind, parallel group, two center, single-dose study was conducted to evaluate and compare the incidence of upper gastrointestinal complaints of acetylsalicylic acid and paracetamol. 600 healthy volunteers received acetylsalicylic acid (2 effervescent tablets of 400 mg), paracetamol (2 effervescent tablets of 500 mg) or placebo (2 effervescent tablets) in three treatment groups. Subjects filled in a questionnaire at 0.5, 1, 2, 3 and 4 h after dosing to evaluate eight upper gastrointestinal symptoms, which were stomach pain, burning sensation, nausea, heartburn, gas, burping, indigestion and upset stomach. The primary study objective was to show equivalence between acetylsalicylic acid and paracetamol.

RESULTS

The absolute number of subjects reporting gastrointestinal intolerance were 50 of 200 in the placebo group, 46 of 200 in the paracetamol group and 56 of 201 in the acetylsalicylic acid group. The statistical test showed equivalence between both active substances.

CONCLUSION

The rate of gastrointestinal intolerance following a single dose of two effervescent tablets of acetylsalicylic acid is equivalent to that of paracetamol and not different from gastrointestinal intolerance of placebo.

A novel endothelial-derived lipase that modulates HDL metabolism

High-density lipoprotein (HDL) cholesterol levels are inversely associated with risk of atherosclerotic cardiovascular disease. At least 50% of the variation in HDL cholesterol levels is genetically determined, but the genes responsible for variation in HDL levels have not been fully elucidated. Lipoprotein lipase (LPL) and hepatic lipase (HL), two members of the triacylglyerol (TG) lipase family, both influence HDL metabolism and the HL (LIPC) locus has been associated with variation in HDL cholesterol levels in humans. We describe here the cloning and in vivo functional analysis of a new member of the TG lipase family. In contrast to other family members, this new lipase is synthesized by endothelial cells in vitro and thus has been termed endothelial lipase (encoded by the LIPG gene). EL is expressed in vivo in organs including liver, lung, kidney and placenta, but not in skeletal muscle. In contrast to LPL and HL, EL has a lid of only 19 residues. EL has substantial phospholipase activity, but less triglyceride lipase activity. Overexpression of EL in mice reduced plasma concentrations of HDL cholesterol and its major protein apolipoprotein A-I. The endothelial expression, enzymatic profile and in vivo effects of EL suggest that it may have a role in lipoprotein metabolism and vascular biology.

Cardiovascular disease risk factors in 2 distinct ethnic groups: Indian and Pakistani compared with American premenopausal women

BACKGROUND

Although people from the Indian subcontinent have high rates of cardiovascular disease (CVD), studies of such in Indian and Pakistani women living in the United States are lacking.

OBJECTIVE

This study accounted for variability in serum lipid (total cholesterol and triacylglycerol) and lipoprotein [LDL cholesterol, lipoprotein(a), and HDL cholesterol] concentrations in Indian and Pakistani compared with American premenopausal women in the United States. Body composition, regional fat distribution, dietary intake, and energy expenditure were compared between groups.

DESIGN

The 2 groups were 47 Indian and Pakistani and 47 American women. Health was assessed via medical history, physical activity, body composition (via anthropometry and dual-energy X-ray absorptiometry), dietary intake (via 7-d food records), and serum lipids.

RESULTS

Serum total cholesterol, triacylglycerol, LDL cholesterol, lipoprotein(a), the ratio of total to HDL cholesterol, and the ratio of LDL to HDL cholesterol were greater (P <0.03), whereas HDL-cholesterol values were lower (P = 0.011) in Indians and Pakistanis than in Americans. Multiple regression analysis indicated that approximately 18% of the variance in total cholesterol (P = 0.0010) and LDL cholesterol (P = 0.0009) was accounted for by ethnicity, energy expenditure, and the ratio of the sum of central to the sum of peripheral skinfold thicknesses. Ethnicity, sum of central skinfold thicknesses, ratio of polyunsaturated to saturated fat, and monounsaturated fat intake accounted for approximately 43% of the variance in triacylglycerol concentration (P < 0.0001). Monounsaturated fat, percentage body fat, and alcohol intake accounted for approximately 26% of variance in HDL cholesterol. Ethnicity contributed approximately 22% of the 25% overall variance in lipoprotein(a).

CONCLUSIONS

Results suggest that these Indian and Pakistani women are at higher CVD risk than their American counterparts, but that increasing their physical activity is likely to decrease overall and regional adiposity, thereby improving their serum lipid profiles.

Safety and preliminary findings with the intravascular contrast agent NC100150 injection for MR coronary angiography

In this Phase I clinical study, a novel ultrasmall superparamagnetic iron oxide contrast agent, NC100150 Injection (Nycomed Imaging, Oslo, Norway, a part of Nycomed Amersham), was used in two-dimensional magnetic resonance coronary angiography (MRCA). Safety and imaging data were acquired from 18 healthy male volunteers at both 0.5 and 1.5 T, before and after the administration of NC100150 Injection. Through-plane and in-plane images of the right coronary artery were analyzed. The postcontrast imaging sequences used prepulses and a high flip angle, to introduce T1 weighting. At 1.5 T (TE 2.6 msec), the through-plane coronary artery signal-to-noise ratio (SNR) (P = 0.04), coronary artery-to-fat signal difference-to-noise ratio (SDNR) (P = 0.001), coronary artery-to-myocardium SDNR (P<0.001), and coronary artery delineation (P<0.001) were improved by the administration of NC100150 Injection. For in-plane imaging, coronary artery delineation improved, but there were no significant changes in the SNR and SDNR. At 0.5 T, with the longer TE (6.7 msec) imaging sequence used, there was a reduction in the SNR (P = 0.01), the fat SDNR (through-plane P = 0.02; in-plane P = 0.25), and the coronary artery diameter (P<0.01 in both imaging planes). There was a trend toward improvement in the myocardial SDNR and coronary artery delineation. In conclusion, NC 100150 Injection was given safely to 18 healthy subjects, with no major adverse reactions. Coronary artery delineation was improved in both imaging planes at 1.5 T, with a trend toward improvement at 0.5 T. At 1.5 T, with a short TE imaging sequence, the marked T1 shortening effects of NC100150 Injection were dominant, leading to an improvement in the quantitative parameters for the through-plane images. At 0.5 T, with a longer TE imaging sequence, the T2* effects of the contrast agent played a role in reducing the quantitative image parameters. With further optimization of imaging sequences, to take advantage of the long-lived intravascular T1 shortening effect of NC100150 Injection, further improvements in MRCA will be possible.

Phase I safety and pharmacokinetic profile of an intercellular adhesion molecule-1 antisense oligodeoxynucleotide (ISIS 2302)

Healthy male volunteers received single or multiple intravenous infusions of an intercellular adhesion molecule-1 antisense phosphorothioate oligodeoxynucleotide, ISIS 2302, in a rising-dose (0.06-2.00 mg/kg infused over 2 hr), double-blind, placebo-controlled trial. Brief, dose-related increases in activated partial thromboplastin time were seen at the time of peak plasma concentration (C(max)). Clinically insignificant increases in C3a were seen after higher, repeated doses, but C5a, blood pressure and pulse were unaffected. No adverse events or other laboratory abnormalities were related to treatment with the drug. ISIS 2302 C(max) was linearly related to dose and occurred at the end of infusion. Plasma half-life for intact drug (53-54 min) and total oligonucleotide (67-74 min) were similar at the two doses (0.5 and 2.0 mg/kg) at which extensive pharmacokinetic data were collected. Nonlinear changes in area under the plasma concentration/time curve and steady-state volume of distribution with increasing dose suggested a saturable component to disposition. Metabolites co-migrating with n-1, n-2 and n-3 chain-shortened versions of ISIS 2302 appeared very rapidly in plasma, and disposition and metabolism appeared unaltered by repeated dosing. ISIS 2302 was well tolerated and behaved reproducibly with respect to plasma pharmacokinetics and expected side effects.

RPR 107393, a potent squalene synthase inhibitor and orally effective cholesterol-lowering agent: comparison with inhibitors of HMG-CoA reductase

Squalene synthase catalyzes the reductive dimerization of two molecules of farnesyl pyrophosphate to form squalene and is the first committed step in sterol synthesis. A specific inhibitor of squalene synthase would inhibit cholesterol biosynthesis but not prevent the formation of other products of the isoprenoid pathway, such as dolichol and ubiquinone. RPR 107393 [3-hydroxy-3-[4-(quinolin-6-yl)phenyl]-1-azabicyclo[2-2-2]octane dihydrochloride] and its R and S enantiomers are potent inhibitors of rat liver microsomal squalene synthase, with IC50 values of 0.6 to 0.9 nM. One hour after oral administration to rats, RPR 107393 inhibited de novo [14C]cholesterol biosynthesis from [14C]mevalonate in the liver with an ED50 value of 5 mg/kg. Diacid metabolites of [14C]farnesyl pyrophosphate were identified after acid treatment of the livers of these animals. These results support in vitro data demonstrating that these compounds are inhibitors of squalene synthase. In rats, RPR 107393 (30 mg/kg p.o. b.i.d. for 2 days) reduced total serum cholesterol by < or = 51%. In the same paradigm, the HMG-CoA reductase inhibitor lovastatin failed to lower serum cholesterol in rats. In marmosets, RPR 107393 (20 mg/kg b.i.d.) reduced plasma cholesterol concentration by 50% after 1 week of administration; this was greater than the reduction observed with lovastatin or pravastatin, neither of which produced > 31% reduction in plasma cholesterol when administered for 1 week at a dose of 50 mg/kg b.i.d. The R and S enantiomers of RPR 107393 (20 mg/kg p.o. q.d. for 7 days) reduced plasma low density lipoprotein cholesterol by 50% and 43%, respectively, whereas high density lipoprotein cholesterol was unchanged. In summary, RPR 107393 is a potent inhibitor of squalene synthase. It is an orally effective hypocholesterolemic agent in rats and marmosets that has greater efficacy than lovastatin or pravastatin in the marmoset.

1-Hydroxy-3-(methylpentylamino)-propylidene-1,1-bisphosphonic acid as a potent inhibitor of squalene synthase

Squalene synthase, the first committed enzyme for sterol synthesis, converts farnesyl pyrophosphate to squalene with presqualene pyrophosphate as an intermediate. It was discovered that BM 21.0955 (1-hydroxy-3-(methylpentylamino)-propylidene-1,1-bisphosphon ic acid), in development for the treatment of bone disorders, inhibited rat liver microsomal squalene synthase (K(i) = nmol/l). BM 21.0955 also inhibited sterol biosynthesis from mevalonate (IC50 = 42 nmol/l), and cholesterol biosynthesis in J774 cells (IC50 = mumol/l). Structural modifications on this molecule to make it more lipophilic may result in a new class of cholesterol-lowering agents.

Dietary soybean protein prevents bone loss in an ovariectomized rat model of osteoporosis

The purpose of this study was to examine whether soybean protein isolate prevents bone loss induced by ovarian hormone deficiency. Thirty-two 95-d-old Sprague-Dawley rats were randomly assigned to four treatment groups [sham-operated (sham); ovariectomized (ovx); ovx+soybean; ovx + 17 beta-estradiol (E2)] and killed after 30 d. Rats in the sham, ovx and ovx + 17 beta-estradiol groups were fed a casein-based diet, and the soybean group was fed soybean protein isolate instead of casein; the diets were otherwise comparable. Rats in the ovx group had significantly lower densities of the right femur (P < 0.001) and the fourth lumbar vertebra (P < 0.05) than rats in the sham group. These lower bone densities were not observed in animals receiving 17 beta-estradiol or fed soybean. The ovx group also had significantly (P < 0.01) greater serum concentrations of 1,25-dihydroxycholecalciferol than the other three groups. Our findings suggest that dietary soybean protein is effective in preventing bone loss due to ovarian hormone deficiency. Because serum activities of both alkaline phosphatase and tartrate-resistant acid phosphatase were significantly greater in the ovx group and in the ovx + soybean group but not in the group receiving 17 beta-estradiol, compared with sham animals, this confirms that ovariectomy enhances and 17 beta-estradiol suppresses the rate of bone turnover. Despite the higher rate of bone turnover in the soybean-fed animals, the vertebral and femoral bone densities of these rats were significantly greater than those of rats in the ovx group, suggesting that formation exceeded resorption. Further studies are needed to clarify whether this protective effect on bone is due to the protein itself or to the presence of isoflavones in soybean protein.

RPR 101821, a new potent cholesterol-lowering agent: inhibition of squalene synthase and 7-dehydrocholesterol reductase

RPR 101821 (trans-2-[4-(benzoxazol-2-yl)-phenylmethoxy] amino cyclohexane hydrochloride) is a potent cholesterol-lowering agent in rodents and marmoset. The compound inhibited rat liver microsomal squalene synthase (IC50 = 1 nM) and 7-dehydrocholesterol (7DHC) reductase (IC50 = 1 microM; Lewis et al. 1995). When RPR 101821 (10 mg/kg), the 7DHC reductase inhibitor BM 15.766 (4[2-[4-(4-chlorocinnamyl)piperazine-1-yl]ethyl] benzoic acid; 10 mg/kg) or the HMG-CoA reductase inhibitor lovastatin (30 mg/kg) was given orally to rats at -29 h, -21 h and -5 h, serum cholesterol was reduced by 56%, 46% or 15%, respectively. The reduction in cholesterol with RPR 101821 was associated with an accumulation of 7DHC in serum, suggesting an inhibition of 7DHC reductase. In the presence of BM 15.766, RPR 101821 reduced the serum accumulation of 7DHC in a dose-dependent manner, with complete inhibition at 30 mg/kg, p.o. In Balb-cJ mice, RPR 101821 and lovastatin (50 mg/kg, b.i.d., p.o., for 14 days) lowered serum cholesterol by 67% and 2%, respectively. In marmosets, RPR 101821 and lovastatin (both at a dose of 10 mg/kg, p.o., b.i.d., for 7 days) reduced cholesterol by 28% and 19%, respectively. In summary, RPR 101821 is an orally effective potent cholesterol-lowering agent in rodents and a small primate species. The suggested mechanism of hypocholesterolemic effect is the inhibition of squalene synthase and 7DHC reductase.

Enzyme inhibition during the conversion of squalene to cholesterol

Two separate enzymatic assays were developed in order to test the selectivity of inhibitors in cholesterol biosynthesis. One assay detects inhibition of delta 5.7-sterol delta 7-reductase, the enzyme involved in the conversion of 7-dehydrocholesterol to cholesterol. Delta 5.7-Sterol delta 7-reductase was inhibited by both RPR 101821, a protonated cyclohexylamine, and BM 15.766, a piperazine derivative, with IC50 values of 1 microM. The second assay detects accumulation of any of five intermediates (squalene oxide, squalene dioxide, lanosterol, desmosterol, and 7-dehydrocholesterol) upon inhibition of enzymes catalyzing reactions in the conversion of squalene to cholesterol. In this assay, inhibition data were most accurate when control assays exhibited a conversion of squalene to cholesterol in the order of 50%. The time required to attain 50% conversion of squalene to cholesterol was 6 h. Given a high inhibitor to substrate concentration ratio and the possible values of Ki, kon, and koff for the reaction between enzymes and inhibitor to form enzyme-inhibitor complexes, it was predicted that in the presence of inhibitors, intermediate accumulation could still be observed after 6 h incubation. The experimental results were in agreement with this prediction.

Growth hormone-releasing activity of hexarelin in humans. A dose-response study

Hexarelin is a new hexapeptide (His-D-2-methyl-Trp-Ala-Trp-D-Phe-Lys-NH2) that stimulates the release of growth hormone both in vitro and in vivo. In this double-blind, placebo-controlled, rising-dose study we evaluated the growth hormone releasing activity of hexarelin in healthy human subjects. Twelve adult male volunteers received single intravenous boluses of 0.5, 1 and 2.micrograms.kg-1 hexarelin as well as placebo. For safety, drug doses were given in a rising-dose fashion with placebo randomly inserted into the sequence. Plasma growth hormone concentrations increased dose-dependently after the injection of the peptide, peaking at about 30 min and then decreasing to baseline values within 240 min with a half-life of about 55 min. The mean peak plasma growth hormone concentrations (Cmax) were 3.9, 26.9, 52.3, 55.0 ng.ml-1 after 0, 0.5, 1 and 2 micrograms.kg-1, respectively. The corresponding areas under the curve of growth hormone plasma levels from drug injection to 180 min (AUC0-180) were 0.135, 1.412, 2.918 and 3.695 micrograms.min.ml-1. The theoretical maximum response (Emax) and the dose that produces half of the maximum response (ED50) were estimated using logistic regression. The calculated ED50 values were 0.50 and 0.64 microgram.kg-1 for Cmax and AUC0-180, respectively. The corresponding Emaxs were 55.1 ng.ml-1 and 3936 ng.min.ml-1, thus indicating that the effect after the 2 micrograms.kg-1 dose is very close to the maximal response.(ABSTRACT TRUNCATED AT 250 WORDS)

Compliance and contact lens care: a new assessment method

We propose a new method for assessing and quantifying compliance with contact lens care regimens. We recommend two separate procedures: one in which trained interviewers examine the actual lens care techniques used by typical, experienced patients and another in which clinicians rate each step in a lens care regimen as to the level of risk to the patient's comfort and safety if noncompliance with that step occurs. When combined, these steps quantify compliance with the regimen under investigation. The method can be used to assess the incidence of compliance with the regimen in question, and to compare compliance across dissimilar care systems. In our investigation, we applied the method to a multi-purpose solution regimen which has been marketed as being simple to use and, therefore, the correct care procedures are more likely to be complied with. However, we found that patient compliance with this regimen was equivalent to that found in an earlier study of an oxidative (hydrogen peroxide) care system, with noncompliance posing significant risks to both safety and comfort. The results indicate that 91% of patients were noncompliant with one or more of the steps in the lens care regimen that were judged to be clinically significant safety risk factors. Factors which posed significant risks to comfort were less likely to induce noncompliance. Only 34% of patients failed to follow one or more of the steps judged to provide clinically significant risks to comfort. The authors conclude that multi-purpose or simplified regimens are not acceptable substitutes for careful patient training and frequent follow-up.

RG 12561 (dalvastatin): a novel synthetic inhibitor of HMG-CoA reductase and cholesterol-lowering agent

RG 12561 (dalvastatin) is a prodrug which converts to its open hydroxyacid form in the body. The Na salt of RG 12561 (RG 12561-Na) is a potent inhibitor of 3-hydroxy-3-methyl-glutaryl-coenzyme A (HMG-CoA) reductase, the rate-limiting enzyme in the cholesterol biosynthetic pathway. It competitively inhibits rat liver HMG-CoA reductase with an IC50 value of 3.4 nmol/l. In the same assay, the IC50 values for other potent HMG-CoA reductase inhibitors, lovastatin-Na and pravastatin, were 2.3 and 8.9 nmol/l, respectively. In Hep G2 liver cells, RG 12561-Na, lovastatin-Na and pravastatin inhibited cholesterol biosynthesis from radiolabeled octanoate with IC50 values of 4 and 5 nmol/l and 1.1 mumol/l, respectively. In a rat ex vivo assay, orally administered RG 12561, lovastatin and pravastatin inhibited cholesterol biosynthesis in liver slices with ED50 values of 0.9, 0.5 and 12 mg/kg, respectively. In cholestyramine-fed hamsters, RG 12561 (0.1% in food for 18 days) reduced LDL cholesterol, whereas HDL was slightly increased. The reductions in the LDL/HDL ratio for RG 12561, RG 12561-Na, lovastatin and lovastatin-Na were 35, 76, 88 and 88%, respectively. At a higher dose, RG 12561 (0.4% in food) reduced serum cholesterol, LDL and LDL/HDL by 84, 97 and 91%, respectively. In WHHL rabbits, RG 12561 and lovastatin (5 mg/kg, b.i.d., 12 days) reduced serum cholesterol by 17 and 16%, respectively. These results demonstrate that RG 12561 is a potent cholesterol-lowering agent.

Bisphosphonates used for the treatment of bone disorders inhibit squalene synthase and cholesterol biosynthesis

Some bisphosphonates used for the treatment of bone disorders are also potent inhibitors of squalene synthase, a critical enzyme for sterol biosynthesis. Among seven drugs tested, YM 175 (cycloheptylaminomethylene-1,1-bisphosphonic acid) was the most potent inhibitor of rat liver microsomal squalene synthase (Ki = 57 nM) and sterol biosynthesis from [14C]mevalonate in rat liver homogenate (IC50 = 17 nM). EB 1053 (3-(1-pyrolidino)-1-hydroxypropylidene-1,1-bisphosphonic acid) and PHPBP (3-(1-piperidino)-1-hydroxypropylidene-1,1-bisphosphonic acid) were less potent inhibitors in both these assays. Pamidronate and alendronate were poor inhibitors of squalene synthase (IC50 > 10 microM) but were potent inhibitors of sterol biosynthesis from mevalonate (IC50 = 420 and 168 nM, respectively), suggesting that the latter two agents may have inhibited other enzymes involved in the synthesis of farnesyl pyrophosphate from mevalonate. Etidronate and clodronate were inactive in both these assays. YM 175 also inhibited sterol biosynthesis in mouse macrophage J774 cells (IC50 = 64 microM) and in rats, when administered acutely, it inhibited cholesterol biosynthesis in the liver (ED50 = 30 mg/kg, s.c.). Structural modifications on YM 175 to enhance cell permeability may result in a new class of cholesterol-lowering agents.

Effects of pentoxifylline on hemodynamics, oxygen transport, and tissue metabolism in experimental, severe hemorrhagic shock

BACKGROUND AND METHODS

It is hypothesized that pentoxifylline may be beneficial during shock states by improving tissue oxygenation. To test this hypothesis, we examined the effect of pentoxifylline on hemodynamics, oxygen delivery (DO2), and tissue metabolism during severe hemorrhagic shock. We conducted a placebo-controlled, randomized trial using anesthetized, mechanically ventilated dogs in hemorrhagic shock maintained at a mean arterial pressure of 45 to 50 mm Hg. Six animals were treated with a 10-mg/kg bolus of iv pentoxifylline followed by a continuous infusion at 5 mg/kg.hr. The controls consisted of six animals treated with saline.

RESULTS

There were no significant differences between the groups before treatment. During 150 mins of posttreatment, repeated measurements of the control and pentoxifylline groups showed no significant differences in heart rate (HR), cardiac output, systemic and pulmonary vascular resistances, DO2, or blood lactate concentration (repeated-measures analysis of variance).

CONCLUSIONS

In this acute, nonresuscitated, canine hemorrhagic shock model, pentoxifylline did not act as a vasodilator, or have any significant effect on HR, cardiac output, oxygen transport, or lactic acidosis.

Visual evoked potentials in Alzheimer's disease: correlations with age and severity

Flash and pattern reversal visually evoked potentials were recorded in 25 patients fulfilling NINCDS-ADRDA criteria for 'probable' Alzheimer's disease (AD). Results were compared with those obtained from groups of normal elderly subjects and patients with mild memory impairment not amounting to dementia. The P2 component of the flash VEP was significantly delayed in AD patients of 74 years or less and correlated with severity whereas the P100 component of the pattern reversal VEP remained relatively unchanged. The latency difference between the P2 and the P100 proved to be a valid discriminator between demented and non-demented subjects only in the younger age group. This limits its usefulness as a diagnostic test of dementia in patients over the age of 75.

Histopathology of human keratorefractive lenticules

Eight human corneal lenticules (three from keratophakia, two from hypermetropic keratomileusis, and three from myopic keratomileusis) were examined by light and electron microscopy. The keratophakic lenticules were removed for optical reasons 3, 3.5, and 6 months after surgery. Microscopically, all displayed hypocellularity, mature collagen fibrils and microfibrils, keratocyte ghosts, and keratocytic debris. The hypermetropic keratomileusis specimens were removed at 13 and 14 months postoperatively, the first because of opacities from enzymatic digestion of the cornea, and the second due to contact lens-induced erosion of Bowman's layer and decreased lacrimal secretion. Ultrastructurally, both lenticules exhibited fractures in Bowman's layer, and the 14-month specimen showed multilayered squamous epithelia. The myopic keratomileusis specimens were removed at 4, 8, and 48 months postoperatively due to opacification of the interface caused by delayed epithelial healing, detergent trauma, and previous epithelization, respectively. Electron microscopy revealed fractures in Bowman's layer, subepithelial fibrocellular growth, sparse keratocyte populations of the anterior stroma, porous collagen bundles, keratocytic debris, and regions of epithelial ingrowth.

Distribution of temporal spikes in relation to the sphenoidal electrode

Sphenoidal EEG recordings were performed in 111 patients with epilepsy, who showed antero-mesial temporal epileptiform discharges. In 6, a multipolar sphenoidal electrode showed a shallow potential gradient between the standard sphenoidal site and the surface. In 17 patients a superficial electrode at the site of entry of the sphenoidal wire recorded all discharges seen at the sphenoidal. Out of 165 foci, in only 2 instances were less than 90% of sphenoidal discharges recognisable on the surface. In 39 patients who underwent surgery, lesions confined to mesial temporal structures were found to be associated with inter-ictal discharges maximal at the sphenoidal electrode. A mid-temporal maximum was always associated with diffuse non-specific, or lateral temporal pathology. It is concluded that sphenoidal recording offers no advantage over suitably placed scalp contacts for detecting inter-ictal epileptiform discharges. It may be of some value for differentiating between mesial and lateral temporal foci.

Lisinopril for severe congestive heart failure

Lisinopril, a new converting enzyme inhibitor, was studied hemodynamically in 55 patients. The response to 2.5-, 5- and 10-mg doses showed significant increases in cardiac index and significant reductions in pulmonary artery wedge, right atrial, pulmonary arterial and systemic arterial pressures, as well as in systemic vascular resistance. Significant changes in most parameters were present at 24 hours. A dose-response relation for most parameters was noted. Over a 3-month period, 47 patients were followed up, with improvement in functional capacity and symptomatic status. Metabolic parameters did not change over time, although 26% showed evidence of reversible renal dysfunction. Only 3 patients (6.4%) required discontinuation because of adverse effects. A subgroup of patients reassessed at 3 months demonstrated maintenance of hemodynamic effects. The present study demonstrates that (1) the hemodynamic effects of lisinopril are of relatively long duration; (2) within certain limits, a dose-response relation can be defined; and (3) the drug has an acceptable long-term tolerability profile.

Lovastatin is hypertriglyceridemic in Syrian golden hamsters

The effects of a potent HMG CoA reductase inhibitor, lovastatin, was studied in male Syrian Golden hamsters. Lovastatin (0.1% in food for 6 days) increased hamster serum triglycerides by 12-fold with 2.4-fold increase in serum cholesterol. On continuous treatment serum triglyceride and cholesterol levels gradually decreased to below control values by 12-18 days. When hamsters were fed a mixture of lovastatin and Na-mevalonate no increase in serum triglyceride was observed. [14C]Cholesterol synthesis was increased by 266-fold in livers of hamsters fed lovastatin for 6 days. The increased synthesis of endogenous mevalonate metabolites may be a reason for the decrease in triglyceride levels after 6 days in our studies. The present study suggests that a mevalonate metabolite(s) is necessary for normal triglyceride metabolism in hamsters.

Modulation of hemodynamic effects with a converting enzyme inhibitor: acute hemodynamic dose-response relationship of a new angiotensin converting enzyme inhibitor, lisinopril, with observations on long-term clinical, functional, and biochemical responses

The hemodynamic effects of varying oral doses of the long-acting converting enzyme inhibitor lisinopril were studied in an acute, single-blind, parallel fashion in 55 patients with moderate to severe congestive heart failure. Doses of 2.5, 5.0, and 10 mg produced a significant increase in cardiac index and significant reductions in pulmonary capillary wedge, right atrial, pulmonary arterial, and systemic arterial pressures and systemic vascular resistance. The changes were present up to 24 hours after dosing for most parameters. There was a clear-cut dose-response relationship observed. Forty-seven patients were followed over a 3-month period, during which functional status and exercise tolerance improved. Although 26% showed some evidence of renal dysfunction with lisinopril, these changes could be normalized by decreasing either the lisinopril or the diuretic dose. These data demonstrate that the hemodynamic changes with the long-acting converting enzyme inhibitor lisinopril can be modulated with dose adjustment in patients with congestive heart failure. They also suggest that renal function changes may be normalized by adjustment of either the dose of lisinopril or the diuretic dose.