Additive antiproteinuric effect of combination therapy with ACE inhibitor and angiotensin II receptor antagonist: differential short-term response between IgA nephropathy and diabetic nephropathy.

In previous studies, the synergistic antiproteinuric effect of the combination therapy of ACE inhibitors and angiotensin II receptor antagonists (ATRAs) has been inconsistent in relation to underlying renal diseases. The influence from the blood pressure (BP) - reducing effect in some studies might also contribute to this inconclusiveness. To examine the possibility of the benefit being different according to underlying renal diseases, we undertook a crossover therapeutic trial of the combination therapy in two selected homogenous groups of patients with diabetic and non-diabetic renal diseases. The BP-reducing effect was excluded during the study. Nineteen biopsy-proven IgA nephropathy, as examples of non-diabetic renal diseases, and 24 type 2 diabetic nephropathy patients were selected as the study subjects. The subjects had to meet the follow criteria: a creatinine clearance (Ccr) between 25 - 90 ml/min/1.73 m2, 24-hr urinary protein excretion rate over 1.0 g/day and a BP maintained at less than 130/80 mmHg, with more than six-month therapy of ramipril, (5.7 +/- 0.4 mg/day, 13 +/- 2 month). The baseline data between the two groups showed no significantly differences. After a 12-week stabilization period (control period), 4 mg, once daily, dose of candesartan (combination period) followed by a placebo (placebo period), or vice versa, were administered in addition to the ramipril, for 12 weeks. The combination, with candesartan, did not change the Ccr, BP, serum and urinary electrolytes or the urea. The 24 hour urinary protein excretion rate was significantly reduced by the combination therapy in the patients with IgA nephropathy (3.1 +/- 0.3 g/day in combination, 4.2 +/- 0.3 in control, and 4.3 +/- 0.2 in placebo; p < 0.05). However, the patients with diabetic nephropathy showed no reduction in their proteinuria with the combination therapy (3.8 +/- 0.2 g/day in combination, 3.9 +/- 0.3 in control, and 4.1 +/- 0.3 in placebo; p=NS). The changes in proteinuria showed no relationship with the changes in the BP in IgA nephropathy. In conclusions, the benefit of combination therapy of its antiproteinuric effect was different between IgA and diabetic nephropathy over the 12-week trial. The difference in the pathophysiological role, and the importance of the renin- angiotensin system, between the two diseases might contribute to the discrepancy in the result. We suggest the discrimination of the underlying renal diseases in the study subjects is an important prerequisite for future studies on this issue.

Foreign body-induced actinomycosis mimicking bronchogenic carcinoma.

Actinomycosis is a slowly progressive infectious disease caused by an anaerobic and microaerophilic bacteria that colonizes the face, neck, lung, pleura and the ileocecal region. There have been a few cases of this disease which have involved in the lung but one very rare case has been reported. We report a case of foreign body-induced endobronchial actinomycosis mimicking bronchogenic carcinoma in a 69-year-old man. On admission, the patient presented with weight loss, cough and hemoptysis. The fiberoptic bronchoscopy revealed a soft tissue mass, with a partial occlusion of the left upper bronchus, which resembled bronchogenic carcinoma. Contrary to the first impression, the biopsy of the bronchus revealed the mass lesion to be an actinomycotic infection involving the bronchus. After the confirmation of the lesion, treatment with penicillin was initiated. The follow-up bronchoscopy revealed an aspirated fish bone at the site of infection. The foreign body was safely removed.

Early dipyridamole stress myocardial SPECT to detect residual stenosis of infarct related artery: comparison with coronary angiography and fractional flow reserve.

BACKGROUND: The detection of residual stenosis of infarct related artery (IRA) at early stage after acute myocardial infarction (AMI) is crucial in clinical decision making for interventional revascularization. The aim of this study was to evaluate the relevancy of early dipyridamole stress myocardial SPECT to detect functionally and luminologically significant residual stenosis of IRA after AMI. METHODS: Twenty five consecutive patients (M:F = 19:6, age: 56 +/- 13 yrs) with AMI underwent SPECT and coronary angiography within 5 days of the attack. Infarct related arteries with FFR < 0.75 and diameter stenosis (DST) > 70% were regarded to have functionally and morphologically significant residual stenosis. Reversible perfusion defect was defined if there was improvement of the perfusion score more than one grade in infarct segments on rest images of SPECT compared with stress images. RESULTS: Mean FFR and DST were 0.76 +/- 0.14 and 74 +/- 15%. SPECT showed no significant correlation with both FFR and DST with Kendall's coefficiency of 0.28 (p = 0.05) and 0.13 (p = 0.35). The sensitivity and specificity of SPECT to detect functionally and morphologically significant residual stenosis were 92%, 31% and 83%, 29%. CONCLUSION: The early dipyridamole stress myocardial SPECT after AMI does not seem to be a useful non-invasive test for the detection of functionally and luminologically significant residual stenosis of IRA.