Dual blockade of the renin-angiotensin system in type 1 patients with diabetic nephropathy.

BACKGROUND: Albuminuria and hypertension are predictors of poor renal and cardiovascular outcome in patients with diabetes. Approximately 30% of type 1 patients with diabetic nephropathy (DN) have albuminuria >1 g/day, and blood pressure >135 and/or >85 mmHg despite antihypertensive therapy with recommended doses of ACE inhibitor (ACEI) and diuretics. We tested the effect of dual blockade of the renin-angiotensin system (RAS) in these patients. METHODS: We performed a randomised double blind crossover trial with 2 months treatment with Irbesartan 300 mg o.d. and placebo added on top of previous antihypertensive treatment. We included 21 type 1 patients with DN responding insufficiently to ACEI and diuretics, as defined above. At the end of each treatment period, albuminuria, 24-h blood pressure and glomerular filtration rate (GFR) were measured. RESULTS: Addition of 300 mg Irbesartan to the patients' usual antihypertensive therapy induced a mean reduction in albuminuria of 37% (95% CI 20-49, P<0.001); from 1574 mg/24 h (95% CI 1162-2132) to 996 mg/24 h (95% CI 699-1419), a reduction in 24-h blood pressure of 8 mmHg systolic (95% CI -2 to 18) and 5 mmHg diastolic (95% CI 1-9) (P=0.11 and 0.01, respectively) (from placebo, mean (SE) 146 (4)/80 (2) mmHg). GFR remained unchanged. Serum potassium increased (mean 4.3 to 4.6 mmol/l, P=0.02). Intervention to reduce serum potassium was needed in two patients with GFR <35 ml/min/1.73 m(2). Otherwise the dual blockade with Irbesartan was safe and well tolerated. CONCLUSIONS: Dual blockade of the RAS may offer additional renal and cardiovascular protection in type 1 patients with DN responding insufficiently to conventional antihypertensive therapy, including recommended doses of ACEI and diuretics.     

Radiation exposure to angiographers under different fluoroscopic imaging conditions

Radiation levels near an imaging chain commonly used in angiography were measured with both a 100- and a 200-mm-thick scatter phantom. The scatter was measured in lines parallel in space to the central ray of the x-ray beam, at lateral distances of 300, 500, and 800 mm. The effects of fluoroscopic kilovoltage and image intensifier magnification mode were also measured. The results indicate that the highest scattered radiation levels occur near the surface of the patient where the x-ray beam enters. Exposure rates were measured in both anteroposterior (AP) and posteroanterior (PA) geometries on a U-arm system. In PA geometry, the highest radiation levels occur below the angiographer's waist, an area well protected by the lead apron. The AP geometry increases the exposure rate to the neck, head, and upper extremities, areas where apron shielding is less effective.     

Changes in bladder function in the one year spontaneously diabetic BB rat.

Micturition characteristics and in vitro urinary bladder function were investigated in insulin-treated spontaneously diabetic BB rats and age-matched non-diabetic controls one year after the onset of diabetes. BB rats weighed less than controls and were hyperglycemic. Diabetic rats consumed larger volumes of water and excreted larger volumes of urine than controls. The frequency of micturitions and the mean volumes of urine excreted per micturition were significantly increased in BB rats compared to age-matched controls. Associated with the micturition changes in the BB rats were significant increases in bladder body mass. Contractile responses of strips from bladder bodies and bases were measured in response to nerve stimulation, carbachol, phenylephrine, ATP, and KCl. No significant differences between controls and diabetics were found in the absolute contractile responses of bladder body strips to nerve stimulation, carbachol, ATP, or KCl. However, if the data were transformed to correct for the increases in tissue mass in the diabetics, there were significant decreases in the responses of bladder body strips from BB rats to carbachol, ATP, and KCl, but not to nerve stimulation. Even after transformation, there were no differences in the responses of bladder base strips to carbachol, phenylephrine, or KCl. The data indicate that significant changes in micturition characteristics are evident one year after the onset of diabetes in the spontaneously diabetic BB rat. These changes are slow in development, since they are absent six months after the onset of diabetes. The changes in micturition and bladder strip contractility are qualitatively similar to, but quantitatively modest in comparison with those caused by streptozotocin-induced diabetes mellitus. The quantitative differences are probably attributable to an ameliorative effect of the insulin received by the BB rat.     

An Empirical Evaluation of Eye Movement Desensitization and Reprocessing (EMDR) with Survivors of a Natural Disaster

Controlled studies of treatments effective with victims of natural disasters are almost nonexistent. This is a small study conducted under difficult conditions to test the effectiveness of Eye Movement Desensitization and Reprocessing (EMDR) in treating trauma related reactions following Hurricane Andrew. The results were positive in that EMDR produced significant improvement over wail list controls in perceived posttraumatic avoidance behaviors and thoughts as measured by changes in the Impact of Event Scale and significant improvement in subjective aversive reactions to representative experiences of the hurricane. These results suggest and support other studies that EMDR can be an effective therapeutic intervention for trauma reactions.     

Tropical pyomyositis in a temperate climate in an immunocompetent adult.

Tropical pyomyositis, though common in Africa, South America, and the South Pacific, is relatively rare in North America. Reported is the case of a patient who developed chest wall muscle abscesses after sustaining minor chest wall muscle trauma and presented to the emergency department appearing acutely ill. He was treated surgically with irrigation and debridement of the abscesses as well as with antibiotics and recovered fully over a seven-month course. This case illustrates important aspects of tropical pyomyositis with a discussion of the natural history of this disease as well as diagnostic modalities and treatment options for this virulent infectious process that is usually caused by penicillin-resistant Staphylococcus aureus.     

Maternal renal insufficiency: A cause of congenital rickets and secondary hyperparathyroidism

We present a case of a newborn with congenital rickets and radiographic evidence of secondary hyperparathyroidism in which the infant's mother had severe, longstanding untreated renal insufficiency.     

Dose-dependent headache response and dilatation of limb and extracranial arteries after three doses of 5-isosorbide-mononitrate

Summary The aim of the present study was to compare the ability of different doses of isosorbide-5-mononitrate (5-ISMN) to cause dilatation of medium sized and small arteries, and to examine the intensity and duration of any headache produced. Ten healthy volunteers each received 3 doses of 5-ISMN and placebo on separate days. The diameters of the radial and superficial temporal arteries were repeatedly measured with high frequency ultrasound and pain was scored using a 10 point verbal scale.A clear dose-relationship was found for plasma concentrations and headache, and for changes in the diameter of the temporal artery, but not for the radial artery.It is concluded that headache after 5-ISMN is caused by arterial dilatation or by mechanisms responsible for the arterial dilatation. Ultrasound monitoring of arterial diameters is an important and sensitive tool in the evaluation of nitrates and other vasodilators.