International guidelines and educational experiences in an out-patient clinic for asthma

In June 1989, an out-patient clinic for asthma was instituted at Crema Hospital, Italy. Up to November 1994, 430 adult asthmatics were recruited, classified and managed according to the recommendations of the international guidelines. The aims of this study are to verify: 1) whether the organization of the clinic could maintain asthma under control and reduce hospital admissions; and 2) whether the traditional educational approach could be implemented by lessons in the school of asthma to improve the control of asthma symptoms and/or admissions. The data reported refer to the first 360 asthmatics attending the clinic between 1989 and 1994: 53, 45 and 2% of them were suffering from extrinsic, intrinsic and occupational asthma, respectively. On recruitment, forced expiratory volume in one second (FEV1) was < 80% of predicted in 170 patients, and arterial oxygen tension (Pa,O2) 8.0 kPa (< 60 mmHg) in 27 patients. After the admission visit, 190 patients (53%) were classified as mild, 97 (27%) as moderate, and 73 (20%) as severe asthmatics. In May 1993, a school of asthma was organized. Forty four patients were recruited, stratified according to the severity of their asthma and randomized into two groups: 22 patients attended the school, and 22 patients did not. Each group consisted of 5, 10 and 7 patients with mild, moderate and severe asthma, respectively. The school comprised four lessons twice a week. One year after the end of the school, we could find no differences between the two groups (school versus controls) with regard to the number of urgent care visits (9 vs 9), scheduled visits (22 vs 21) and hospital admissions (2 vs 2).

Presentation of synthetic peptide antigen encoded by the MAGE-1 gene by granulocyte/macrophage-colony-stimulating-factor-cultured macrophages from HLA-A1 melanoma patients

The recent identification of the sequences of the peptides derived from a number of human melanoma-associated antigens has presented opportunities for developing a specific-peptide-based vaccine in this form of cancer. Since antigen-presenting cells (APC) play a crucial role in the induction of the T-cell-mediated immune response, we examined whether or not ex vivo cultured APC, bearing the appropriate MHC restricting elements, when pulsed with a relevant melanoma-specific cytotoxic-T-lymphocyte (CTL)-determined peptide, can present the peptide to the CTL. Here we show that a population of cells, derived from the monocyte/macrophage lineage from peripheral blood and grown in granulocyte/macrophage-colony-stimulating factor, exhibit many essential characteristics of "professional" APC (dendritic-type morphology with a proportion of the population, the B7 molecule, and high levels of MHC class I and class II molecules, CD11b and CD54 molecules) and are capable of efficiently presenting the nonapeptide, EADPTGHSY, encoded by the melanoma antigen MAGE-1 gene, to the MAGE-1-specific CTL clone, 82/30. These results suggest that this type of autologous ex vivo cultured population of professional APC, when pulsed with the relevant-CTL-determined peptide, can serve as a novel type of candidate vaccine for active specific immunization against HLA-A1-positive patients with melanoma expressing the MAGE-1 antigen.

Heterozygosity for homocysteinuria: a detectable and reversible risk factor for pulmonary thromboembolism

Heterozygosity for homocysteinuria is a common, inherited autosomal condition that has recently been considered as an independent cardiovascular risk factor. In vitro and in vivo results suggest that this condition, like the homozygous form, is also a risk factor for deep-venous thrombosis and pulmonary thromboembolism. We report a case of recurrent pulmonary thromboembolism in a young woman with familial hyperhomocysteinaemia. The relative frequency of this condition, as well as its simple and harmless cure, make testing for heterozygosity for homocysteinuria useful and profitable in the prevention of pulmonary thromboembolism, above all in younger subjects with a significant case history.

[Atenolol i.v. in the acute phase of AMI: the indications, contraindications and interactions with thrombolytic drugs in the GISSI-2 study. The GISSI-2 Researchers. Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto Miocardico]

BACKGROUND

In the pre-thrombolytic era, several studies showed the effectiveness of beta-blocker administration in the treatment of patients (pts) with acute Myocardial Infarction (MI). Results from the ISIS-1 and GISSI trials suggested that the combined administration of beta-blocker and of thrombolytic drugs in the acute phase of infarction could lead to a better prognosis. The possibility of synergic effects from the associated administration of these drugs was confirmed by small clinical trials. In GISSI-2 study a large number of patients treated with thrombolytic drugs were given i.v. atenolol (10 mg) as recommended therapy, not following a randomized study design.

AIM

We reviewed the data of the GISSI-2 study population in order to evaluate: 1) the number of pts treated with i.v. atenolol; 2) the anamnestic and clinical characteristics of treated und untreated pts; 3) the causes of exclusion from the beta-blocker therapy; 4) the causes of scheduled dose withdrawal and the incidence of side effects related to atenolol administration; 5) the interaction between atenolol and streptokinase (SK) and rtPA; 6) the incidence of relevant clinical events and the causes of death during the in-hospital period.

RESULTS

Among 12377 evaluated pts, 5616 (45.4%) were given atenolol i.v., 2772 received SK (49.5%) and 2844 (50.5%) rtPA. Mean age was 59.5 +/- 11.3 yrs in atenolol treated pts vs 63.4 +/- 10.9 yrs in untreated pts (p < 0.001); 34.1% of pts aged > 70 yrs vs 48.6% of younger pts (p < 0.00001) and 42.1% of females vs 46.2% of males (p < 0.003) received atenolol. Pts with previous MI received less frequently atenolol than those without MI (17.5% vs 13.5%, p < 0.00001). 88.5% of the treated pts was in Killip class I at entry (untreated 69.5%, p < 0.00001); anterior and lateral site, non-Q type and > or = 5 electrocardiographic leads with ST segment elevation were more frequently found in atenolol treated pts, inferior and unknown site in untreated pts. Among 6761 untreated pts, 32% did not receive atenolol for the occurrence of bradycardia, 15.2% for hypotension, 14.1% for heart failure, 7.2% for bronchospasm or history of asthma, 6.2% for bradycardia and hypotension, 0.3% for death; in 25% of the untreated pts, none of the above-mentioned causes was detectable. 1064 pts (18.9%) did not complete the scheduled dose of atenolol for the occurrence of bradycardia or atrioventricular block > or = II degree (7.3%), hypotension (7%), bradycardia and hypotension (1.8%), heart failure (0.7%), death (0.03%), other causes (1.9%). Transient hypotension was found more frequently in pts treated with SK than in those receiving rtPA (9.3% vs 4.8%, p < 0.0001), but the rate of persistent hypotension was not different in both groups (4.6%). During the hospital phase a higher incidence of advanced atrioventricular block (12.3% vs 4.3%), need of temporary or permanent pacing (5.6% vs 1.9%), sustained ventricular tachycardia (4.5% vs 2.8%), heart failure (12% vs 7.1%), ventricular fibrillation (8% vs 4.9%) and death (11.9% vs 5.1%) were shown in pts that were not given i.v. atenolol. Heart failure was the main cause of death in both groups (untreated 2.3% vs 2.2%); ventricular fibrillation (0.2% vs 0.48%), cardiac rupture (0.5% vs 1.4%), and electromechanical dissociation (0.9% vs 1.9%) were less frequent in treated pts.

CONCLUSIONS

The absence of randomized design of atenolol administration limits the value of the differences found in the clinical outcome of the two groups of pts. In spite of that, the low incidence of death and side effects in treated pts, and the high percentage of pts who completed the scheduled dose of atenolol, confirm that the iv. administration of beta-blockers in the acute phase of the myocardial infarction is safe, well tolerated and suitable in almost an half of the patients submitted to thrombolytic therapy with SK or rtPA.(ABSTRACT TRUNCATED AT 400 WORDS)

[The evolution of hospital mortality due to acute myocardial infarct in the first 2 GISSI studies. Participants in the GISSI 1 and GISSI 2 studies. Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto Miocardico]

During the short while of 5 years, between 1984 and 1985, two large clinical trials have been performed in Italy concerning fibrinolytic therapy in Acute Myocardial Infarction: GISSI 1 and GISSI 2. They made possible to evaluate the evolution of demographic and clinical features, the in-hospital mortality rate, and the causes of death of a huge number of patients admitted to CCU throughout the whole country. Out of 31,826 patients with acute myocardial infarction admitted to 176 CCU participating to the GISSI 1 16.9% were 75 years old and 24.7% were females; 21.8% and 26.4% were the percentages in the 38,086 patients admitted to the 223 CCU participating in the GISSI 2. Despite the higher prevalence of the two demographic characteristic with the worse prognosis, the in-hospital mortality rates were respectively 12.2% in the GISSI 1 and 10.0% in the GISSI 2 studies, with a statistically significant decrease (RR 0.84; C.L. 0.80-0.88). The significant decrease in the in-hospital mortality concerns also the patients populations selected according to the same criteria of inclusion in the two trials (within 6 hours from the onset of symptoms and with only ST elevation at the ECG of admission) and to the treatment with fibrinolytic drug (SK or rtPA). As a matter of fact 468 patients died of the 4,696 (10.0%) treated with SK in the GISSI 1 against 1,092 patients of 12,381 (8.8%) enrolled in the GISSI 2 and treated with SK or rtPA (RR 0.87; L.C. 0.78-0.98). The reduction of in-hospital mortality may be explained by some differences in the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Lung changes in rheumatoid arthritis: CT findings

PURPOSE

To evaluate lung changes in rheumatoid arthritis (RA).

MATERIALS AND METHODS

The authors reviewed the computed tomographic (CT) scans from 84 patients with RA with a mean articular disease duration (+/- standard deviation) of 12 years +/- 8 (range, 0.3-45 years). Fifteen patients underwent sequential CT evaluation during 5-65-month follow-up (mean, 18 months).

RESULTS

Thirty-eight patients (49%) had abnormal CT scans showing the following abnormalities: (a) bronchiectasis and/or bronchiolectasis (n = 23, 30%), (b) pulmonary nodules (n = 17, 22%), (c) subpleural micronodules and/or pseudoplaques (n = 13, 17%), (d) nonseptal linear attenuation (n = 14, 18%), (e) areas of ground-glass attenuation (n = 11, 14%), and (f) honeycombing (n = 8, 10%). Abnormal CT examinations were recorded in 11 of 38 asymptomatic patients (29%) and 27 of 39 symptomatic patients (69%). The following CT abnormalities were found with a significantly higher frequency among patients with respiratory symptoms: (a) bronchiectasis and/or bronchiolectasis, (b) rounded areas of attenuation, (c) areas of ground-glass attenuation, and (d) honeycombing.

CONCLUSION

CT may be a useful noninvasive tool for recognition of RA-associated lung disease with special emphasis on bronchial and bronchiolar changes.

A simple electrocardiographic predictor of the outcome of patients with acute myocardial infarction treated with a thrombolytic agent. A Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI-2)-Derived Analysis

OBJECTIVES

This analysis aimed to evaluate in a large patient cohort the relation between ST segment alterations after fibrinolytic therapy for acute myocardial infarction and 1) the combined end point of in-hospital mortality plus clinical congestive heart failure or extensive left ventricular damage, and 2) mortality 30 and 180 days after randomization.

BACKGROUND

Angina relief, enzyme release acceleration and ST segment normalization are related to coronary artery reperfusion and prognosis. Electrocardiographic (ECG) evaluation before and after fibrinolytic drug administration has been used to predict short- and long-term clinical outcome in acute myocardial infarction.

METHODS

Patients enrolled in the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI-2) trial underwent a standard ECG on admission and after 4 h of alteplase or streptokinase therapy; 7,426 recordings were suitable for ST segment analysis. A decrease > or = 50% in the sum of ST segment elevation in all ECG leads was adopted as the cutoff for predicting coronary artery patency. Recanalization was deemed to have occurred in 4,951 patients (group A) versus 2,475 patients without reperfusion (group B).

RESULTS

Group A patients experienced a lower incidence of the combined end point than did group B patients (16.2% vs. 22.9%, respectively), as well as of all its components (death, clinical heart failure, ejection fraction < 35%, injured myocardial segment > 45%, QRS score > 10). Thirty- and 180-day mortality rates were lower in group A than group B (3.5% and 5.7% vs. 7.4% and 9.9%, respectively); relative risk (Cox) was 0.46 (95% confidence interval [CI] 0.37 to 0.57) for 30-day and 0.58 (95% CI 0.48 to 0.70) for 180-day mortality. Patients in group A had significantly less ventricular fibrillation and sustained ventricular tachycardia but more ischemic episodes (early recurrent angina plus myocardial infarction recurrence).

CONCLUSIONS

A simple, inexpensive instrumental evaluation, unaffected by different epidemiologic and clinical characteristics of the population analyzed, can allow early assessment of the effectiveness of fibrinolytic treatment with respect to the main clinical outcomes.

Predictors of nonfatal reinfarction in survivors of myocardial infarction after thrombolysis. Results of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI-2) Data Base

OBJECTIVES

This study was designed to reassess the prediction of recurrent nonfatal myocardial infarction in patients recovering from acute myocardial infarction after thrombolysis.

BACKGROUND

Recurrent nonfatal myocardial infarction is a strong and independent predictor of subsequent mortality. Current knowledge of risk factors for nonfatal reinfarction is still largely based on data gathered before the advent of thrombolysis. Thus, this prospective study was planned to identify harbinger of nonfatal reinfarction in the postinfarction patients of the multicenter Grouppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI-2) trial.

METHODS

Predictors of nonfatal reinfarction at 6 months were analyzed by multivariate technique (Cox model) in 8,907 GISSI-2 survivors of myocardial infarction with clinical follow-up, relying on a set of prespecified variables reflecting residual ischemia, left ventricular failure or dysfunction, complex ventricular arrhythmias, comorbidity as well as demographic and historical factors.

RESULTS

The postdischarge to 6-month incidence rate of nonfatal reinfarction was 2.5%. Independent predictors of nonfatal reinfarction were cardiac ineligibility for exercise test (relative risk 2.97, 95% confidence interval [CI] 1.98 to 4.45), previous myocardial infarction (relative risk 1.70, 95% CI 1.22 to 2.36) and angina at follow-up (relative risk 1.50, 95% CI 1.10 to 2.04). On further multivariate analysis, performed in 6,580 patients with both echocardiographic and electrocardiographic monitoring data available, a history of angina emerged as an additional risk predictor (relative risk 1.58, 95% CI 1.10 to 2.25).

CONCLUSIONS

The 6-month incidence of nonfatal reinfarction is rather low in survivors of myocardial infarction after thrombolysis. Cardiac ineligibility for exercise testing and a history of coronary artery disease are risk predictors. Recurrent nonfatal infarction is not predictable by qualitative variables reflecting residual ischemia, except by postdischarge angina. Prediction of nonfatal reinfarction appears less accurate than prediction of mortality, as almost 50% of reinfarctions occur in patients without any of the identified risk factors.

[Clinical and instrumental elements predictive of left ventricular insufficiency in acute myocardial infarct: multivariate analysis in patients treated with thrombolytic therapy]

BACKGROUNDS

During the course of acute myocardial infarction (AMI), the appearance of signs of left ventricular failure (LVF) (cardiogenic shock, acute pulmonary edema, congestive heart failure) is a prognostically negative event which is still relatively frequent even in patients receiving fibrinolytic therapy. The early identification of patients exposed to such a risk would allow adequate diagnostic and therapeutic preventive measures to be taken.

AIM

To evaluate, in a population of AMI patients undergoing thrombolysis and without any serious complications at the moment of hospitalisation, which anamnestic, clinical and instrumental data obtained within the first 24 hours best identify those who will subsequently develop full-blown LVF. Secondary aim is to evaluate the role that extension of coronary disease plays in determining the occurrence of LVF.

METHODS

The study involved 104 consecutive patients aged < 75 years admitted to hospital for AMI with ST-segment elevation, within 12 hours of the onset of symptoms, in Killip class 1-2 upon entry to the CCU, and treated with thrombolytic therapy. The study design included the collection of anamnestic and clinical data upon admission to the CCU; an enzymatic curve during the first 4 days; the ECG at entry, and 4 and 24 hours after the beginning of fibrinolysis; the chest X-ray, the 2D-echocardiography (2D-echo) and the hemodynamic measurements within the first 24 hours; a coronary angiography on the tenth day (or earlier if clinically necessary).

RESULTS

Seventeen patients (16%) presented signs of LVF; 8 (7.6%) with cardiogenic shock, 9 with congestive heart failure: 3 died (3%), all for shock. Univariate analysis correlated LVF with: 1) the indices of the extension of ischemic/necrotic damage: number of derivations with ST elevation (p < 0.04) and Q waves (p < 0.05) at first ECG, maximum peak of myocardial enzyme (p < 0.02), wall motion score index (p < 0.001), percentage extension of asynergy (p < 0.001), presence of remote asynergy (p < 0.001), left ventricular (LV) end-systolic (p < 0.001) and end-diastolic volume (p < 0.01), and LV ejection fraction (EF) (p < 0.001) at 2D-echo; 2) the indices of hemodynamic involvement: Killip class 2 at entry (p < 0.02), pulmonary venous flow diversion at chest X-ray (p < 0.001), systolic (p < 0.05), diastolic (p < 0.01) and mean (p < 0.01) pulmonary pressure, capillary wedge pressure (p < 0.01), and the LV systolic work index (p < 0.05). Multivariate analysis showed that the only independent variable predictive of LVF was the EF at 2D-echo (p < 0.001): the sensitivity and specificity of EF was respectively 36% and 97% at cut-off value of 0.30, and 93% and 69% at cut-off value of 0.45. Multivessel coronary disease was found more frequently in patients who developed LVF (p < 0.05) and was correlated with 2D-echo LV involvement: presence of remote asynergies (p < 0.0001), lower EF (p < 0.01), higher wall motion score index (p < 0.001) and percentage extension of asynergy (p < 0.01).

CONCLUSIONS

The incidence of LVF in patients with AMI, without serious complications at onset, is still relatively high (16%) even if they are treated with thrombolysis. Of all evaluated clinical and instrumental indices, multivariate analysis showed that EF at 2D-echo was the only independent variable predictive of LVF. Extension of coronary disease correlated with development of LVF. Moreover, worse LV performance and greater regional contractility involvement at 2D-echo correlated with extension of coronary disease. Consequently, echocardiography would appear to be bed-side, simple, reliable and accurate mean of establishing a prognosis from the moment a patient with AMI is admitted to a CCU.

Age-related increase in mortality among patients with first myocardial infarctions treated with thrombolysis. The Investigators of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI-2)

BACKGROUND

The overall rate of mortality due to ischemic heart disease is known to increase progressively with age. We evaluated the relation between the mortality rate and age in patients with first myocardial infarctions treated with thrombolytic therapy.

METHODS

We studied 9720 patients with first infarctions who had been enrolled in the GISSI-2 trial. (This trial compared the efficacy of tissue plasminogen activator with that of streptokinase in patients with myocardial infarction.) Of these, only 35 percent had a history of angina. The relation between age and mortality during hospitalization and during the six months after discharge was determined by unadjusted and adjusted analyses.

RESULTS

The in-hospital mortality rate was 1.9 percent among patients 40 years old or younger, but it increased to 31.9 percent among those more than 80 years old; however, values for indicators of infarct size did not increase with age. Autopsies were performed in 20 percent of the 772 patients who died in the hospital; the findings showed that the frequency of cardiac rupture increased from 19 percent among patients 60 years old or younger to 86 percent among those more than 70 years old. The mortality rate for the first six months after hospital discharge also increased significantly with age. After adjustment for confounding variables, older age continued to be significantly associated with a higher risk of in-hospital and post-discharge death. When age was introduced into a multivariate model as a continuous variable, the risk of death was estimated to increase by about 6 percent per year for both in-hospital and six-month mortality rates.

CONCLUSIONS

In patients with first myocardial infarctions who received thrombolytic therapy, age was a powerful independent predictor of both in-hospital and post-discharge mortality rates. The exponential, age-related increase in the mortality rate did not appear to be explained by larger infarcts.

Determinants of 6-month mortality in survivors of myocardial infarction after thrombolysis. Results of the GISSI-2 data base. The Ad hoc Working Group of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI)-2 Data Base

BACKGROUND

Current knowledge of risk assessment in survivors of myocardial infarction is largely based on data gathered before the advent of thrombolysis. It must be determined whether and to what extent available information and proposed criteria of prognostication are applicable in the thrombolytic era.

METHODS AND RESULTS

We reassessed risk prediction in the 10,219 survivors of myocardial infarction with follow-up data available (ie, 98% of the total) who had been enrolled in the GISSI-2 trial, relying on a set of prespecified variables. The 3.5% 6-month all-cause mortality rate of these patients compared with the higher value of 4.6% found in the corresponding GISSI-1 cohort, originally allocated to streptokinase therapy, indicates a 24% reduction in postdischarge 6-month mortality. On multivariate analysis (Cox model), the following variables were predictors of 6-month all-cause mortality: ineligibility for exercise test for both cardiac (relative risk [RR], 3.30; 95% confidence interval [CI], 2.36-4.62) and noncardiac reasons (RR, 3.28; 95% CI, 2.23-4.72), early left ventricular failure (RR, 2.41; 95% CI, 1.87-3.09), echocardiographic evidence of recovery phase left ventricular dysfunction (RR, 2.30; 95% CI, 1.78-2.98), advanced (more than 70 years) age (RR, 1.81; 95% CI, 1.43-2.30), electrical instability (ie, frequent and/or complex ventricular arrhythmias) (RR, 1.70; 95% CI, 1.32-2.19), late left ventricular failure (RR, 1.54; 95% CI, 1.17-2.03), previous myocardial infarction (RR, 1.47; 95% CI, 1.14-1.89), and a history of treated hypertension (RR, 1.32; 95% CI, 1.05-1.65). Early post-myocardial infarction angina, a positive exercise test, female sex, history of angina, history of insulin-dependent diabetes, and anterior site of myocardial infarction were not risk predictors. On further multivariate analysis, performed on 8315 patients with the echocardiographic indicator of left ventricular dysfunction available, only previous myocardial infarction was not retained as an independent risk predictor.

CONCLUSIONS

A decline in 6-month mortality of myocardial infarction survivors, seen within 6 hours of symptom onset, has been observed in recent years. Ineligibility for exercise test, early left ventricular failure, and recovery-phase left ventricular dysfunction are the most powerful (RR, > 2) predictors of 6-month mortality among patients recovering from myocardial infarction after thrombolysis. Qualitative variables reflecting residual myocardial ischemia do not appear to be risk predictors. The lack of an independent adverse influence of early post-myocardial infarction angina on 6-month survival represents a major difference between this study and those of the prethrombolytic era.

[The resolution of right atrial thrombosis of recent onset during the intravenous infusion of rtPA: a report of 3 cases with continuous echocardiographic monitoring]

We performed continuous echocardiographic examination during the i.v. administration of rtPA in three patients with recent-onset, mobile right atrial thrombosis, in order to assess both the timing and mode of thrombus resolution. In all these cases, right atrial thrombus disappeared before the scheduled dose (100 mg i.v. within three hours) was completed: 60 mg of rtPA were required in the first patient, and 50 mg in the other two. In the first case, the thrombus divided into numerous smaller fragments chaotically moving in the right chambers before disappearing; in the second, the echo reflectivity of the thrombus gradually diminished and the mass showed multiple echo-lucent cavities before disappearing; in last case, the atrial mass migrated from the right atrium to the right ventricle before disappearing. None of the patients experienced any symptoms at the dissolving of the thrombus; bleeding complications occurred in all three (in one, at the site of previous PTCA; in another, at the site of arterial and venous puncture; in the third the haematoma was localized at the site of a previous orthopedic operation) but only two required blood transfusion. In patients with right atrial thrombosis, continuous echocardiographic examination allows us to identify both the timing and mode of thrombus resolution, and the occurrence of new-onset peripheral pulmonary embolization. This information can help in optimizing the dosage of the drug in patients in whom bleeding complications can be suspected to occur after thrombolytic therapy.

Histoplasmosis in an HIV-negative Italian man with mycosis fungoides

The authors deal with a case of Histoplasmosis in a 50 yr old Italian man without any history of risk exposure to HIV infection and suffering from mycosis fungoides. Although this infection is rare in Europe and particularly in Italy, this case suggests the possibility that soils capable of supporting the saprophytic fungus growth are present even out of the endemic areas.

[Severe bronchial spasm crises induced by topical administration of eyedrops with timolol base, a non-selective beta blocking agent]

Since their introduction in clinical practice beta-blocker drugs are known to be able to induce bronchospasm. However, this adverse effect may develop only in subjects with asthma, chronic bronchitis and/or airways hyper-reactivity. Although this potentially adverse effect of beta-blockers on the airways has long been recognized, its mechanism in inducing bronchospasm remains unclear. The Authors report a case of severe bronchoconstrictive episodes with respiratory failure following the administration of a timolol ophthalmic solution in a 51 yr old woman. Pharmacokinetics, preventive and therapeutic aspects of timolol eyedrop-induced bronchospasm are discussed.

Amino acid sequence of a globin from the sea cucumber Caudina (Molpadia) arenicola

Coelomic cells from the sea cucumber Caudina (Molpadia) arenicola contain four major globins, A, B, C and D. The hemoglobins from this organism show unusual ligand-linked dissociation properties. The complete amino acid sequence of the D globin has been established. It is N-acetylated, consists of 158 residues and has a 10 amino acid N-terminal extension similar to that found in some other invertebrate globins. The C. arenicola D globin has an equal sequence identity (28%) with both alpha and beta human globins and as anticipated, is more closely related to these vertebrate proteins than are molluscan globins. The C. arenicola D globin shows a 59% identity with the globin I from the sea cucumber Paracaudina chilensis. The availability of the C. arenicola D globin sequence will aid the X-ray analysis of this protein and facilitate an understanding of the changes in subunit interactions that occur with cooperative ligand binding.

Usefulness of color Doppler in the diagnosis of ventricular septal rupture after myocardial infarction

Ten consecutive patients with ventricular septal rupture complicating acute myocardial infarction were studied by means of Doppler echocardiography (including two-dimensional, conventional and color Doppler techniques) and bedside right heart catheterization using a Swan-Ganz catheter. One patient died before an operation could be performed. Seven critically ill patients underwent emergency cardiac surgery without preoperative cardiac catheterization, while in two patients it was also possible to undertake coronary angiography before surgery. Two-dimensional echocardiography diagnosed post-infarction ventricular septal rupture in 6 out of 10 patients. Color Doppler revealed the presence and the location of septal rupture in all 10 patients. The color Doppler diagnosis was confirmed either by surgery or necropsy. The estimates of pulmonary artery pressure, obtained by color Doppler-guided continuous wave Doppler beam, were very close to those measured by simultaneous right heart catheterization. In 3 patients, patch leakage occurred 3 days, 15 days and 1 year after the operation. Two-dimensional echocardiography revealed the patch leakage in only one of 3 patients while its location was visualized by color Doppler in all 3 patients. In one patient the color Doppler diagnosis was confirmed at necropsy. In the remaining 2 patients, a small left-to-right shunt was demonstrated by radionuclide studies. Color Doppler echocardiography is a highly sensitive and rapid technique in the diagnosis of postinfarction ventricular septal rupture. In critically ill patients it offers relevant information and may obviate the need for any invasive preoperate investigation.