Reliable outcomes and survivorship of unicompartmental knee arthroplasty for isolated compartment osteonecrosis.

Aims: Primary (or spontaneous) and secondary osteonecrosis of the knee can lead to severe joint degeneration, for which either total or unicompartmental arthroplasty may be considered. However, there are limited studies analyzing outcomes of unicompartmental knee arthroplasties (UKAs) for osteonecrosis involving an isolated compartment of the knee. The aims of this study were to analyze outcomes of UKAs for osteonecrosis with specific focus on 1) survivorship free of any revision or reoperation, 2) risk factors for failure, 3) clinical outcomes, and 4) complications. Patients and Methods: A total of 45 patients underwent 46 UKAs for knee osteonecrosis between 2002 and 2014 at our institution (The Mayo Clinic, Rochester, Minnesota). Twenty patients (44%) were female; the mean age of the patients was 66 years, and mean body mass index (BMI) was 31 kg/m2. Of the 46 UKAs, 44 (96%) were medial UKAs, and 35 (76%) were fixed-bearing design. Mean mechanical axis postoperatively was 1.5° varus (0° to 5° varus); 41 UKAs (89%) were performed for primary osteonecrosis. Mean follow-up was five years (2 to 12). Results: Survivorship free of any revision in the cohort was 89% (95% CI 77 to 99) and 76% (95% CI 53 to 99) at five and ten years, respectively. In patients undergoing UKA for primary osteonecrosis survivorship free of any revision was 93% (95% CI 83 to 100)at both five and ten years. Secondary osteonecrosis was a significant risk factor for poorer survivorship free of any revision or reoperation (hazard ratio 7.7, p = 0.03). Three medial UKAs (6.5%) were converted to total knee arthroplasties (TKAs): two for lateral compartment degeneration and one for development of lateral osteonecrosis. No implants were revised for loosening, fracture, or wear. Knee Society scores improved from a mean of 60 (44 to 72) preoperatively to a mean of 94 postoperatively (82 to 100) (p < 0.001). There were no surgical complications. Conclusion: When done for primary osteonecrosis of the knee, UKA resulted in reliable clinical improvement, minimal complications, and durable estimated implant survivorship free of revision at ten years. UKA done for secondary osteonecrosis was substantially less durable at mid-term follow-up. Progression of knee degeneration, rather than implant failure or loosening, was most common indication for conversion to TKA. Cite this article: Bone Joint J 2018;100-B:450-4.

Nano-indentation and laser-induced damage testing in optical multilayer-dielectric gratings.

We demonstrate how a nanomechanical test identifies areas of mechanical field concentration as being comparable to areas where optical fields are known to be concentrated, in the special context of laser-induced damage testing (LIDT) of diffractive gratings of silica deposited on optical multilayers. The nano-indentation response of the diffraction gratings is measured in a new mode that allows for the extraction of a measurable metric characterizing the brittleness of the gratings, as well as their ductility. We show that lower LIDTs are positively correlated with an increased grating brittleness, and therefore identify a nanomechanical approach to describe LIDTs. We present extensive numerical simulations of nano-indentation tests and identify different deformation modes including stretching, shear concentration, and bending as precursors to mechanical failure in the nano-indentation test. The effects of geometrical inhomogeneities on enhanced stress generation in these gratings are specifically examined and addressed, and we show the agreement between nanomechanical testing and analytical interpretation of these inhomogeneities.

Nano-indentation of single-layer optical oxide thin films grown by electron-beam deposition.

Mechanical characterization of optical oxide thin films is performed using nano-indentation, and the results are explained based on the deposition conditions used. These oxide films are generally deposited to have a porous microstructure that optimizes laser induced damage thresholds, but changes in deposition conditions lead to varying degrees of porosity, density, and possibly the microstructure of the thin film. This can directly explain the differences in the mechanical properties of the film studied here and those reported in literature. Of the four single-layer thin films tested, alumina was observed to demonstrate the highest values of nano-indentation hardness and elastic modulus. This is likely a result of the dense microstructure of the thin film arising from the particular deposition conditions used.

Fracture mechanics of delamination defects in multilayer dielectric coatings.

During the fabrication of multilayer-dielectric (MLD) thin-film-coated optics, such as the diffraction gratings used in OMEGA EP's pulse compressors, acid piranha cleaning can lead to the formation of chemically induced delamination defects. We investigate the causes of these defects and describe a mechanism for the deformation and failure of the MLD coating in response to hydrogen peroxide in the cleaning solution. A fracture mechanics model is developed and used to calculate the crack path that maximizes the energy-release rate, which is found to be consistent with the characteristic fracture pattern observed in MLD coating delamination defects.

Maximum likelihood estimation for longitudinal data with truncated observations.

We obtain maximum likelihood estimates of the parameters when the observations on the response variable in a repeated measures design are truncated above a cutpoint. The maximum likelihood equations are solved iteratively using an EM-like procedure. It is observed that these estimates have smaller mean squared error than recently proposed iterative weighted least-squares estimates. The results are applied to data arising from a study of dioxin elimination in Air Force veterans. Published in 2000 by John Wiley & Sons, Ltd.

Adaptive linkage crossover.

Problem-specific knowledge is often implemented in search algorithms using heuristics to determine which search paths are to be explored at any given instant. As in other search methods, utilizing this knowledge will more quickly lead a genetic algorithm (GA) towards better results. In many problems, crucial knowledge is not found in individual components, but in the interrelations between those components. For such problems, we develop an interrelation (linkage) based crossover operator that has the advantage of liberating GAs from the constraints imposed by the fixed representations generally chosen for problems. The strength of linkages between components of a chromosomal structure can be explicitly represented in a linkage matrix and used in the reproduction step to generate new individuals. For some problems, such a linkage matrix is known a priori from the nature of the problem. In other cases, the linkage matrix may be learned by successive minor adaptations during the execution of the evolutionary algorithm. This paper demonstrates the success of such an approach for several problems.

Ontogeny of adenosine deaminase in developing trophoblast and decidual cells of rat and hamster.

The enzyme adenosine deaminase (ADA) is expressed at high level in the tissue of foeto-maternal interface during early pregnancy. As the main constituents of this interface are trophoblast (TR) and decidual cells (DC), the enzyme was estimated in isolated TR and DC to determine the extent of contribution by the respective cells. The enzyme level was estimated in cytosolic fraction, cell lysate and in conditioned media of these cells in rat and hamster. In both species the concentration of ADA was found to be markedly high in cytosolic fraction over to the cell lysate and the conditioned media in both TR and DC. Species-wise, it was higher in hamster. Cell-wise, the enzyme activity was significantly higher in TR than DC in rat but equal in hamster. In the conditioned medium, also, the enzyme activity was higher in TR in both species. The inference drawn from the results are: 1) the maximum enzyme activity in cytosolic fraction of TR and DC of both species clearly indicates equal involvement of the cells that constitute foeto-maternal unit, 2) the enhanced level of enzyme in TR and DC of hamster over to those of rat is possibly due to the higher proliferative activity in the cells of this species because of shorter gestation (16-17 days in hamster and 22-23 days in rats).

Effect of a carbon dioxide laser on periodontally involved root surfaces.

BACKGROUND: The purpose of this in vitro study was to evaluate the effect of CO2 laser on the periodontally involved root surface, and to compare its efficacy with citric acid, EDTA and hydrogen peroxide in removal of root surface smear layer after root planing. METHODS: The study was conducted on 50 periodontally involved single rooted human teeth with poor prognosis. Immediately after extraction the teeth were scaled and root planed with Gracey curets; 50 specimens were obtained from the proximal side of each tooth which were assigned randomly to 1 of the 4 groups. Group A (35 specimens) was divided into 7 subgroups of 5 specimens each and irradiated with CO2 laser using a defocused mode at 3-watt power for 0.2, 0.4, 0.6, 0.8, 1.0, 1.2, or 1.4 seconds, respectively. Groups B, C, and D (5 specimens each) were treated with 6% hydrogen peroxide, EDTA solution (pH 7.4), or saturated citric acid solution (pH 1), respectively for 3 minutes. The specimens were then fixed and scanned using SEM. RESULTS: It was observed that surface smear layer was present on root surfaces of teeth that were root planed; the CO2 laser was not able to remove the smear layer on the sites that were irradiated for 0.2, 0.4 or 0.6 seconds at 3W power. Irradiation time of 0.8 seconds at 3W power was able to remove the smear layer, but the dentinal tubules were partially exposed. The surface irradiated for 1 second showed a flat appearance with many clear orifice of dentinal tubules. No change in diameter of exposed dentinal tubules was observed and their diameter was nearly equal that of normal dentinal tubules. Irradiation time of 1.2 and 1.4 seconds produced surface charring and carbonization and was totally ineffective in exposing the dentinal tubules; 6% hydrogen peroxide did not remove the smear layer completely and the exposed dentinal tubules orifice was not clear. EDTA (pH 7.4) and citric acid (pH 1) were found to be effective in removing the smear layer and exposing the dentinal tubules, which showed funnel shaped widening. CONCLUSIONS: Surface smear layer was present on root surfaces of teeth that were root planed. Laser irradiation of 1 second at 3W completely removed the smear layer with minimal change in the diameter of the dentinal tubules. EDTA and citric acid were also effective in removing smear layer, but the exposed dentinal tubules showed funnel-shaped widening.

Hypophysectomy and/or peroxisome proliferators strongly influence the levels of phase II xenobiotic metabolizing enzymes in rat testis.

The objectives of the present work were to determine the influence of hypophysectomy and/or peroxisome proliferators (PP) on certain xenobiotic-metabolizing enzyme activities, i.e. glutathione transferases (GST), glutathione peroxidase (GPX), phenol sulphotransferases (pSULT), phenol UDP-glucuronosyl transferases (pUGT), catalase, NADP(H) quinone oxidoreductase (QR) and epoxide hydrolases (EH) in the rat testes. Adult male rats, hypophysectomized and their sham-operated controls, were treated for 10 days with clofibrate (0.5%), perfluorooctanoic acid (0.05%, PFOA), acetylsalicylic acid (1%, ASA) and di(2-ethylhexyl)phthalate (2%, DEHP) in their diet. The results show that, in addition to both body and testis weight, hypophysectomy caused dramatic changes in most of the xenobiotic-metabolizing enzyme activities, which have been measured here. The most pronounced effects were seen in cytosolic QR (2.2-fold increase), pUGT (95% reduction), pSULT (75% reduction), mitochondrial catalase (75% reduction), microsomal EH (70% reduction) and microsomal GST (55% reduction). Treatment with PP, i.e. perfluorooctanoic acid (PFOA), clofibrate, acetyl salicylic acid (ASA) and di(2-ethylhexyl)phthalate (DEHP) showed varied effects on the xenobiotic-metabolizing enzyme activities, the highest effects (10-60% reduction) were seen in sham-operated animals. These effects were not so pronounced or were not seen in hypophysectomized rats except for the case of PFOA treatment, which caused increases of enzyme activities. The highest increases were seen with microsomal GST (70%), GPX (75%) and cytosolic EH (75%). It is concluded from these experiments that the regulation of several xenobiotic-metabolizing enzymes in the rat testis is affected by the pituitary and/or pituitary hormones and that different peroxisome proliferators have variable effects on the levels of these xenobiotic-metabolizing enzymes. The general trend of reduction in enzyme activities implies that the testis is less protected under conditions that can perturb hormonal status.

Hormonal response to orthostasis in elderly people with systemic systolic hypertension.

BACKGROUND: Orthostatic hypotension is a common phenomenon in the elderly. Hormonal changes during orthostatic stress have been described in elderly normotensive people and in those with essential hypertension. However, the hormonal response in elderly people who have systolic hypertension during orthostasis has not yet been quantified. METHODS: In this study we investigated 14 non-diabetic men, aged 60 to 75 years, with untreated systolic hypertension who were subjected to 45 degrees passive head-up incline on a tilt table for 15 min. Their hormonal profile and hemodynamic changes were analyzed before and after the stress. RESULTS: In the supine position, plasma levels of norepinephrine, atrial natriuretic peptide and aldosterone were in the normal range, while the plasma renin activity was low. Immediately upon tilt the systolic blood pressure fell but it reverted to baseline values after 15 min of orthostasis. At that time the cardiac output decreased while the systemic vascular resistance and the plasma norepinephrine concentration rose. The atrial natriuretic peptide appeared to fall, and the renin-aldosterone level did not change. CONCLUSION: The physiologic response to orthostatic stress in elderly people with systolic hypertension is comparable to that of elderly normotensive people and those with essential hypertension, i.e. a decrease in cardiac output and an increase in plasma norepinephrine levels. The atrial natriuretic peptide appeared to fall appropriately. The response of the renin-aldosterone system mimicked that in elderly patients with low renin essential isolated hypertension. These observations may have a bearing on the management of elderly people with systolic hypertension who also have orthostatic symptoms; they may not require a different approach from that needed for others of the same age group.

Effects of peroxisome proliferators and/or hypothyroidism on xenobiotic-metabolizing enzymes in rat testis.

The objectives of the present work were to study the effects of certain peroxisome proliferators on xenobiotic-metabolizing enzyme activities in the testes of normal and hypothyroid rats, i.e. phenol sulfotransferases (pST), phenol UDP-glucuronosyl transferases (pUDPGT), glutathione transferases (GST), catalase, epoxide hydrolase (EH), glutathione peroxidase (GPX) and NAD(P)H quinone oxidoreductase (QR). Adult male rats (normal and hypothyroid) were treated for 10 days with clofibrate (0.5%), perfluorooctanoic acid (0.5%, PFOA), acetylsalisylic acid (1%, ASA) and di(2-ethylhexyl)phthalate (2%, DEHP) in their diet. The results show that treatment of normal rats with peroxisome proliferators dramatically affects the activities of xenobiotic-metabolizing enzymes (40-60% reduction). The highest effects are seen in catalase activity (50-60% with PFOA and ASA), pUDPGT (55% with PFOA), pST (55% with PFOA) and QR (50% with DEHP). These effects are not seen or are weaker after induction of hypothyroidism. Taken together, it is concluded that different classes of peroxisome proliferators have different effects on rat testicular xenobiotic-metabolizing enzymes.

Stage-specific apoptosis in the rat seminiferous epithelium: quantification of irradiation effects.

The effects of 3 Gy local X-irradiation on the adult rat testis were studied together with exact determination of the radiation dose distribution in the testis. Seminiferous tubule segments were isolated 8-66 hours postirradiation (p.i.), squashed between a microscope slide and a coverslip, and the exact stage of the seminiferous epithelial cycle was identified under a phase-contrast microscope. The squash preparations were subjected to in situ end labeling (ISEL) for visualization and quantification of apoptotic cells. In controls, the highest numbers of apoptotic cells were scored in stages XII-XIV and I. In situ end-label staining of cells was observed in A3-A4 spermatogonia, spermatocytes at zygotene, pachytene, and meiotic division phases, as well as in early spermatids. In irradiated testes, from 8 hours p.i. and onward, intermediate- and B-type spermatogonia were sensitive at stages II-VI. At 42 hours, in stage I, elevated numbers of degenerating spermatocytes were seen. Most of them had not undergone meiotic divisions at stage XIV and showed an apoptotic type of degeneration at stage I. At the time of irradiation, the cells were in stage XIII, suggesting that diakinetic spermatocytes are particularly sensitive to irradiation. Also, preleptotene-zygotene spermatocytes in stages VII-XII were sensitive to irradiation. Apoptotic-type of cell degeneration was confirmed by living cell squash preparations, electron microscopy, and DNA electrophoresis. In conclusion, irradiation may provide a useful model system for studying apoptosis, and its control in spermatogonia and meiotically dividing cells.

Studies on the effect of sulfite on benzo[a]pyrene-7,8-dihydrodiol activation to reactive intermediates in human polymorphonuclear leukocytes.

Sodium sulfite, a hydrolysis product of the environmental pollutant sulfur dioxide increased the activation of (-)-trans-7,8-dihydroxy-7,8-dihydrobenzo[a]pyrene (BP-7,8-diol) to the (+)-anti-enantiomer of trans-7,8-dihydroxy-9,10-epoxy-7,8,9,10-tetrahydrobenzo[a]pyrene (BPDE) in phorbol myristate acetate (PMA)-stimulated human polymorphonuclear leukocytes (PMNs). This effect was potentiated in the presence of DMSO. No significant effect of sulfite on BP-7,8-diol activation was observed in resting leukocytes. As revealed by the 32P-postlabelling technique the dominant adduct in both intracellular DNA and to DNA added to the leukocytes was (+)-anti-BPDE bound to the exocyclic nitrogen of deoxyguanosine. The mechanism underlying the stimulatory effect of sulfite on diol epoxide production and increased DNA-binding probably involves one-electron oxidation of sulfite to a sulfur trioxide radical anion and subsequent reaction with molecular oxygen to form the corresponding peroxyl radical. This step obviously requires PMA-initiated oxidative burst and thus, production of superoxide radical anions (O2-.).

Efficient classification for multiclass problems using modular neural networks.

The rate of convergence of net output error is very low when training feedforward neural networks for multiclass problems using the backpropagation algorithm. While backpropagation will reduce the Euclidean distance between the actual and desired output vectors, the differences between some of the components of these vectors increase in the first iteration. Furthermore, the magnitudes of subsequent weight changes in each iteration are very small, so that many iterations are required to compensate for the increased error in some components in the initial iterations. Our approach is to use a modular network architecture, reducing a K-class problem to a set of K two-class problems, with a separately trained network for each of the simpler problems. Speedups of one order of magnitude have been obtained experimentally, and in some cases convergence was possible using the modular approach but not using a nonmodular network.

Stimulatory effects of sulfur and nitrogen oxides on carcinogen activation in human polymorphonuclear leukocytes.

The occurrence of inflammatory processes and of cancer in the human respiratory tract is intimately associated. One of the major factors in this is probably the recruitment of and stimulated activity of polymorphonuclear leukocytes (PML) in conjunction with the ability of these cells to convert various carcinogens to their ultimate active metabolites. In this study, we demonstrate that nitrite and sulfite, the major dissolution products of the environmental pollutants nitrogen dioxide and sulfur dioxide in water enhance the metabolic activation of trans-7,8-dihydroxy-7,8-dihydrobenzo[a]pyrene (BP-7,8-dihydrodiol), the proximal carcinogen of benzo[a]pyrene, to trans-7,8-dihydroxy-9,10-epoxy-7,8,9,10-tetrahydrobenzo[a]pyrene (BPDE) and tetraols, the corresponding hydrolysis products, in human PML prestimulated with 12-O-tetradecanoylphorbol-13-acetate. Nitrite was more efficient than sulfite in stimulating the formation of reactive intermediates of BP-7,8-dihydrodiol in PML that covalently bind to extracellular DNA and, in particular, to intracellular proteins. The mechanism by which sulfite stimulates the metabolism of BP-7,8-dihydrodiol most probably involves the intermediate formation of a sulfur trioxide radical anion (SO3.-) the subsequent formation of the corresponding sulfur peroxyl radical anion (.OOSO3-) in the presence of oxygen. The mechanism underlying the stimulatory action of nitrite is less clear but the major pathway seems to involve myeloperoxidase. These results offer an explanation for the increased incidence of lung cancer in cigarette smokers living in urban areas. The major glutathione transferase (GST) isoenzyme in human PML is GST P1-1, a Pi-class form. The GST activity of PML was found to be inversely correlated with the extent of binding of BP-7,8-dihydrodiol products to exogenous DNA. These results suggest that individuals exhibiting high GST-activity in the PML may be better protected against the type of carcinogenic dealt with in this study.

Nitrite-stimulated DNA-binding of carcinogenic diol epoxides from benzo[a]pyrene-7,8-dihydrodiol in human polymorphonuclear leukocytes.

Human polymorphonuclear leukocytes (PMNs) previously treated with 12-O-tetradecanoyl phorbolmyristate-13-acetate (PMA) to initiate the oxidative burst activate (-)-trans-7,8-dihydroxy-7,8- dihydrobenzo[a]pyrene [(-)-BP-7,8-diol)] to DNA-binding intermediates. The 32P-postlabelling technique and HPLC-analysis of enzyme-digested DNA were employed for identification of DNA-adducts following incubation of (-)-BP-7,8-diol in PMNs. The results are consistent with the formation of (+)-anti-BPDE, the ultimate carcinogen of BP, bound via trans-addition of the C-10 position in the diol epoxide molecule to the exocyclic nitrogen of deoxyguanosine (BPDE-N2-dG adduct). Addition of nitrite, the major aqueous dissolution product of NO2, stimulated the formation of (+)-anti-BPDE and subsequent binding to both nuclear DNA in PMNs (about twofold) and to DNA present outside the cells (two- to fourfold). Preliminary experiments suggest that nitrite stimulates the metabolism of (-)-BP-7,8-diol by direct interaction with myeloperoxidase and hydrogen peroxide. Consistent with previous work by us and others, the covalent binding of (+)-anti-BDPE to extracellular targets demonstrate that these reactive products, expected to be formed intracellularly, can be released from the leukocytes. Measurement of hydroxyl radical-induced DNA damage by estimating the formation of 8-hydroxydeoxyguanosine (8-OH-dG) in resting PMNs revealed low amounts of adducts (1 adduct/10(6) dG-1 adduct/10(5) dG). Pretreating the cells with PMA or PMA in conjunction with nitrite had no significant effect on 8-OH-dG adduct formation.

Alternative pathways of sulfite oxidation in human polymorphonuclear leukocytes.

Sodium sulfite is metabolized by human polymorphonuclear leukocytes by two alternative pathways, one enzymatic route dependent on sulfite oxidase and one non-enzymatic which involves intermediate formation of sulfur trioxide anion radicals. Initiation of the oxidative burst by phorbol myristate acetate significantly stimulates sulfate formation through the second pathway. The activity of sulfite oxidase in polymorphonuclear leukocytes varies greatly among individuals, a variation consistent with the suggested polymorphic distribution of sulfite oxidase in the human population.

Baroreflex function during 45-degree passive head-up tilt before and after long-term thiazide therapy in the elderly with systolic systemic hypertension.

The ratio of the 30th to the 15th cardiac cycle duration on an electrocardiogram (30:15 ratio) immediately after active standing from the supine position has been used as one of the markers of baroreflex function. A ratio of < or = 1.0 has been suggested to indicate baroreflex dysfunction. Blood pressure (BP) changes were measured and the 30:15 ratio was calculated after standing and during 45-degree passive head-up tilt from the supine position in 10 nondiabetic men (mean age +/- SE 70.1 +/- 1.05 years, and BP < 150/90 mm Hg). After tilt the decrease in systolic BP (from 132 +/- 4.8 to 117 +/- 6.3 mm Hg; p < 0.001) appeared to be larger than that after standing (from 132 +/- 4.6 to 123 +/- 5.8 mm Hg; p < 0.01), whereas the 30:15 ratios were 0.965 +/- 0.006 and 0.970 +/- 0.014, respectively, which suggested baroreflex dysfunction. Although the mean of the 2 ratios did not differ, the variance appeared to be less during tilting than after standing. Thus, the 45-degree passive head-up tilt appeared to be a better and more uniform inducer of orthostatic stress than active standing. Therefore, 45-degree head-up tilt was used in a group of 10 nondiabetic male patients (aged 70 +/- 1.46 years) with isolated systolic hypertension (systolic BP > 160 mm Hg, diastolic BP of < 90 mm Hg) to assess their baroreflex function. Upon tilting, their systolic BP decreased from 190 +/- 5.5 to 179 +/- 5.8 mm Hg (p < 0.05) and their 30:15 ratio was 0.985 +/- 0.011.(ABSTRACT TRUNCATED AT 250 WORDS)

Hemodynamic response to orthostatic stress in the elderly with systolic systemic hypertension before and after long-term thiazide therapy.

The hemodynamic effects of orthostatic stress in elderly subjects with systolic hypertension were studied before and after long-term hydrochlorothiazide therapy (50 mg daily). Sixteen nondiabetic men aged 70 +/- 1 (SE) years participated in the study initially, and 12 completed 1 year of therapy. Patients underwent 45 degrees head-up incline on a tilt table before, after 1 month and after 1 year of therapy. Hemodynamic variables were measured in the following situations: (1) the supine position, (2) immediately after completion of passive 45 degrees head-up position at 0 minute, (3) at 15 minutes in the tilted state while patients performed intermittent foot movements to minimize gravitational pooling and simulate the standing position outside the laboratory, and (4) after returning to the supine position. Systolic and diastolic blood pressure (BP) decreased significantly after 1 month of therapy, and this reduction was maintained up to 1 year in all aforementioned body positions, with the exception of diastolic BP at 0 minute of tilt, which was significant at 1 year only. Before therapy was begun, there was a significant reduction in systolic BP immediately after completion of tilting; however, this was statistically insignificant both at 1 month and 1 year of therapy. Thus, the data may help dispel the concern of exacerbating the hypotensive response to orthostatic stress in patients with systolic hypertension after long-term thiazide diuretic therapy.