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.

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.

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).

[Clinico-laboratory evaluation a new sustained-release preparation of anhydrous theophylline]. / Valutazione clinico-laboratoristica di una nuova teofillina anidra a lento rilascio.

The clinical effectiveness and the pharmacokinetic parameters of a once-a-day sustained release preparation of anhydrous theophylline were studied in a trial carried out on 10 adult patients affected by bronchial asthma or chronic obstructive lung disease. Treatment with this new theophylline preparation allowed us to obtain mean serum concentrations within the therapeutic range (5-20 mcg/ml) which remained quite constant during 24 hours. All patients evidenced improvement of dyspnea and of the signs of bronchospasm. Tolerability was very good.

[Severe bronchial spasm crises induced by topical administration of eyedrops with timolol base, a non-selective beta blocking agent]. / Gravi crisi broncospastiche indotte da applicazione topica di gocce oculari a base di timololo, un beta bloccante non selettivo.

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.

Severe exacerbations of chronic obstructive pulmonary disease treated with BiPAP by nasal mask.

Bi-level pressure support ventilation via a nasal mask (NIPSV) was provided to 28 consecutive unselected patients with acute respiratory failure due to exacerbation of chronic obstructive pulmonary failure (COPD). If NIPSV improved gas exchange within 2 h, it was continued. Otherwise, patients would be promptly intubated. The patients median age was 68 years (minimum 56, maximum 82). The arterial blood gas drawn before initiating NIPSV showed (FiO2 21%) a mean PaO2 of 41.3 +/- 6 mm Hg, a mean PaCO2 of 66 +/- 15 mm Hg and a mean pH of 7.31. Upon admission the mean respiratory rate was 36 breaths/min and the median Apache II score was 20.5 (minimum 13, maximum 32). Despite oxygen administration all patients failed to improve their PaO2 and/or showed a consistent and dangerous hypercapnic response. NIPSV was performed with a median inspiratory positive airway pressure of 14 cm H2O (minimum 10, maximum 20) and a median expiratory positive airway pressure of 4 cm H2O (minimum 3, maximum 6). Eighteen patients (64%) were successfully ventilated with NIPSV, while in 10 (36%) NIPSV failed. A high Apache II score, but not admission blood gas exchange or respiratory rate, seems to be correlated with the failure to ventilate with NIPSV. The results of our preliminary experience suggest the use of NIPSV as an initial approach to acute respiratory failure due to exacerbation of COPD, particularly in patients with an Apache II score of less than 29.

Noninvasive mechanical ventilation improves the immediate and long-term outcome of COPD patients with acute respiratory failure.

Noninvasive positive pressure ventilation (NPPV) has been proposed in COPD patients with acute on chronic respiratory failure (ACRF) in order to avoid endotracheal intubation and to improve immediate outcome, but long-term outcome of this therapeutic approach is still undefined. We evaluated short- and long-term (1 year) outcome of early administration of NPPV in 24 patients with ACRF due to exacerbated COPD (Group A) in comparison with 24 matched historical-control patients treated conventionally (Group B). Patients of Group A were initially treated with NPPV via nasal mask in the presence of pH < or = 7.32, and/or Pa,O2 < 7.98 kPa, and/or Pa,CO2 > 7.18 kPa, plus signs of respiratory distress. In-hospital survival rate was not significantly different in Group A vs Group B, but the patients treated with NPPV showed an earlier improvement in blood gases and a better pH and respiratory rate at discharge. Only 2 patients of Group A needed endotracheal intubation as compared with 9 of Group B. Hospital stay was significantly reduced in survivors of Group A vs Group B. Further severe relapses of ACRF in Group A were treated using NPPV. The number and length of further hospitalizations for pulmonary exacerbations were significantly higher in Group B compared with Group A. The survival rate at 12 months was significantly lower in Group B than in Group A (50% vs 71%). In conclusion, NPPV administration in patients with ACRF due to exacerbated COPD improves not only immediate but also long-term outcome.

Histoplasmosis capsulati in Italy: autochthonous or imported?

Reports of a few apparently autochthonous cases of human histoplasmosis and results of epidemiological research suggested the autochthonous presence of the disease in Italy. Identifying two new histologically documented cases of Italian patients, who had never been abroad, and, the positive results of a histoplasmin reactivity survey carried out in the Province of Cremona, Italy confirmed this possibility.