The combined strategy of successively more ambitious nurse-driven (computerised) insulin protocols and bedside glucose measurement resulted in acceptably low glucose levels with very few episodes of hypoglycaemia.

Melioidosis is an infectious disease caused by Burkholderia pseudomallei. It is endemic in South East Asia and tropical regions of Northern Australia. Sporadic cases have been described elsewhere. In this article we present a case of acute pulmonary melioidosis with fatal outcome imported from Brazil. The most common pathogen causing severe community-acquired pneumonia in Brazil is Streptococcus pneumoniae. Other possible pathogens include Legionella spp., Mycoplasma pneumonia, Gram-negative rods and viruses. There are few reports of melioidosis in the Americas. This article represents the second known human case of melioidosis from Brazil. Recognition of melioidosis as a possible cause of severe pneumonia, even if a patient has not been travelling in a highly endemic area, is important because of the therapeutic consequences. The epidemiology of melioidosis will be reviewed.

The aim of this study was to assess the social fate (work resumption) and long-term (four years) survival in 141 patients who completed a cardiac rehabilitation programme after a recent myocardial infarction. Out of the 100 patients who had been working up to recently before the myocardial infarction, 58 resumed their work. Of the predischarge evaluation (clinical data, resting radionuclide ventriculography, bicycle ergometry and 24-h ambulatory ECG monitoring) and bicycle ergometry after the rehabilitation, the only significant predictor of work resumption was a better exercise tolerance at discharge (P less than 0.02). Work was resumed by 68% of white-collar workers and by 52% of blue-collar workers. The four-year cardiac mortality in patients who completed the rehabilitation was 8.5% (N = 12). Four patients died during the first year. Clinical, ventriculographic and ergometric variables collected at hospital discharge, which were related to left ventricular dysfunction, were predictive of survival, while ventricular arrhythmias and markers of myocardial ischaemia were less predictive. The exercise testing performed after the rehabilitation programme was not useful for risk assessment. It is concluded that markers of left-ventricular dysfunction are predictive of a poor outcome; however, due to the low risk of patients who were referred to our rehabilitation unit and completed the rehabilitation programme, it seems reasonable for return to work to be based primarily on clinical information, exercise tolerance, and on psychological and social grounds. An additional extensive cardiological evaluation should be individually tailored for patients with specific symptoms.

Sir: Metastatic carcinoid tumours are frequently associated with carcinoid syndrome, which is characterised by episodic flushing of the head and neck and diarrhoea and reduced arterial-mixed venous oxygen saturation due to arterio-venous fistulae. Under certain circumstances profound hypotension or hypertension may occur, an event called ªcarcinoid crisisº.We report a patient who developed a carcinoid crisis during transesophageal echocardiography (TEE).Case report. In a 58-year-old man with a metastatic midgut carcinoid tumour with tricuspid valve stenosis and insufficiency a TEE was made in evaluation for possible surgical intervention. He was sedated with 1 mg of midazolam i. v. After approximately 15 min he developed shortness of breath and peripheral cyanosis, his oxygen saturation dropped to 80 %. His systolic arterial blood pressure dropped 25 mmHg. The echocardiographic examination was terminated. Physical examination showed acrocyanosis and decreased consciousness. He was tachypnoeic (60 breaths/min) with a heart rate of 118 beats/min and blood pressure of 80/50 mmHg. The liver was grossly enlarged and there were signs of ascites. The lower limbs showed pitting oedema. A blood gas analysis showed a PO 2 of 4.8 kPa and a PCO 2 of 3.4 kPa and an arterial oxygen saturation of 73 %. The

The aim of this study was to establish if angina pectoris and silent ST segment depression during pre-discharge exercise tests are predictive of 4 years survival after myocardial infarction. Accordingly, 377 consecutive hospital survivors of myocardial infarction underwent symptom-limited bicycle ergometry at hospital discharge. Sixty-eight patients had angina during exercise, 124 patients had silent ST segment depression and 184 had neither angina nor ST depression. The baseline demographic profile, exercise capacity during ergometry and radionuclide left ventricular ejection fraction were comparable in the three groups. The total mortality within 4 years in the three groups was 15%, 21% and 22%, and mortality due to reinfarction or sudden death was 10%, 17% and 14%. When patients on digitalis were excluded, the incidence of mortality due to reinfarction or sudden death in the group with painless ST segment depression was 11%. Coronary artery bypass grafting or percutaneous transluminal coronary angioplasty due to recurrent symptoms was performed in 41%, 20% and 18% respectively of the three groups. It is concluded that conditional upon modern treatment, including secondary prevention with beta-blockers and revascularization procedures in selected patients with symptoms refractory to medical therapy, exercise-induced angina and painless ST segment depression do not identify a group of patients at higher risk of sudden death or fatal reinfarction during the 4 years after myocardial infarction.