Demotivating outcome of asymmetrical Nucleus Accumbens disconnection for cocaine related disorder: a translational point of view. / Desmotivadora evolución de la desconexión asimétrica del Núcleo Accumbens en el trastorno por consumo de cocaína: un punto de vista traslacional.

Letter to the editor.

Carta al editor.

Comprehensive surgical management of cocaine-induced midline destructive lesions.

PURPOSE: This article presents a review of the literature and proposes a protocol for managing acute and chronic midfacial cocaine-induced injuries. MATERIALS AND METHODS: This report describes a series of 4 patients affected by cocaine-induced midline destructive lesions. Three patients came to the authors' attention after 18 months of drug withdrawal and underwent surgical treatments to restore nasal and palatal morphology and function, and the fourth patient was referred because of acute cocaine-induced destructive lesions and was treated by aggressive debridement. An 18-month drug-free period is planned before beginning any reconstructive procedures in this latter patient. RESULTS: Long-term follow-up showed stable results without relapse of palatal fistulas and good esthetic nasal appearance in all 3 patients undergoing reconstruction. The fourth patient did not show any disease progression and will be monitored for drug withdrawal. CONCLUSION: Chronic cocaine consumption may cause multiple types of damage to the soft and hard tissues of the midface. Acute lesions must be addressed with aggressive debridement. As a result of chronic injury, the palate and nose are deformed in a very complex way and the vascularity of the remaining local tissues may be compromised or inadequate for flap harvesting. Palatal and nasal reconstructions are very delicate operations and should be addressed separately to maximize the predictability of the result.

Versatility of the buccinator myomucosal flap in atypical palate reconstructions.

Initially described for the treatment of cleft palate, the anatomical bases of the buccinator myomucosal flap were described by Bozola et al. (1989). A meticulous search found several reports of its use for the correction of post-palatoplasty oronasal fistulas, with only a few reports of its use for other palate-related pathologies. A retrospective analysis was undertaken of patients treated by the Plastic Surgery Units at the Rio de Janeiro Federal University Hospital (HU-UFRJ) and the São Paulo University Hospital (HC-USP), suffering from palatal lesions not associated with a cleft palate and treated through the use of buccinator myomucosal flaps. The average age was 47 years, with 70% of the patients being male. Assorted aetiologies were noted for palatal defects. When there was significant damage to the soft palate, a superior base pharyngeal flap was used. Of this total, in 71% of the cases only the buccinator myomucosal flap was used. In all cases, the flaps were unilateral, adequately covering the defects in question. The buccinator myomucosal flap is a good option for reconstructing medium to large palate defects, as it is a flap with good vascularization and dimension, in addition to an ample arc of rotation, with primary closure of the donor site, without adding significant morbidity.

Diagnostic considerations and prosthetic rehabilitation of a cocaine-induced midline destructive lesion: A clinical report.

The intranasal inhalation of cocaine has numerous complications. In addition to its systemic effects, cocaine can cause extensive destruction of the osteocartilaginous midline structures of the palate, nose, and sinuses. Without an accurate social and clinical history, a cocaine-induced midline destructive lesion can cause diagnostic difficulties, because its clinical presentation closely mimics other diseases. This clinical report describes an oronasal defect caused by cocaine use, the diagnostic considerations of these lesions, and prosthetic management of the defect.

Adrenalectomy prevents behavioural sensitisation of mice to cocaine in a genotype-dependent manner.

The objective of the present study was to investigate the contribution of adrenal stress hormones to strain differences in cocaine sensitivity. For this purpose, we have studied sensitisation to the locomotor stimulant effect of cocaine and, in parallel, cocaine-induced corticosterone secretion in two inbred mouse strains: C57BL/6 and DBA/2. Adrenalectomy ('ADX': surgical removal of the adrenal glands) was performed in a subset of animals to investigate the contribution of the adrenals. ADX and SHAM operated mice were subjected to repeated injections of cocaine (15.0mg/kg) or saline for nine consecutive days, followed by a 5-day withdrawal interval and a saline challenge on day 14. All animals were challenged with 7.5mg/kg cocaine on day 15. We report that repeated cocaine exposure induced locomotor sensitisation in both strains, while endocrine sensitisation was only observed in the DBA/2 strain. By contrast, cocaine attenuated corticosterone responses in C57BL/6 mice throughout the sensitisation paradigm. We have therefore identified one strain, the DBA/2 strain, that displays parallel sensitisation of cocaine-induced locomotion and -corticosterone secretion. Most interestingly, ADX prevented locomotor sensitisation only in DBA/2 mice, suggesting that behavioural sensitisation depends on the integrity of adrenal function and on secretion of adrenal glucocorticoids in this strain. The present results demonstrate that adrenal stress hormones facilitate behavioural sensitisation to cocaine in a genotype-dependent manner and suggest that glucocorticoids contribute to strain differences in psychostimulant sensitivity.

Palatal and nasal necrosis resulting from cocaine misuse.

The potential social and economic harm caused by cocaine addiction is well known. The wider health risks and potential nasal complications of septal perforation and nasal collapse are also recognised. We report a case of oro-nasal fistula secondary to cocaine misuse and discuss the aetiology, management and potential methods of repair.

Siderobezoar gástrico em doente psiquiátrico / Gastric iron foreign body

Pica é um tipo específico de transtorno alimentar caracterizada pela ingestão persistente de substâncias inadequadas a nutrição e que não fazem parte de uma prática aceita culturalmente. Geralmente ocorrem em crianças, adolescentes e doentes com distúrbios psiquiátricos. O objetivo do presente relato é apresentar homem de 36 anos, usuário de cocaína, em surto psicótico, que procurou atendimento médico em virtude de dor abdominal após ter ingerido objetos metálicos. A radiografia simples do abdômen confirmou a presença de estruturas metálicas no interior do estômago (faca, colher média, dois parafusos de grandes proporções, talhadeira, boca perfuratriz, estilete de uso odontológico e fragmento de serra metálica). A endoscopia digestiva alta revelou a presença dos objetos metálicos na luz do estômago que em virtude das suas características não foram passíveis de remoção endoscópica. Os objetos foram removidos cirurgicamente através de gastrotomia anterior. A recuperação pós-operatória se fez sem intercorrências e o doente encaminhado para acompanhamento psiquiátrico.

Pica is a specific type of alimentary disturbance characterized by the persistent ingestion of substances that are inappropriate for nutrition and do not form part of culturally acceptable practices. It generally occurs among children, adolescents and patientswith psychiatric disturbances. The objective of the present reportis to present here the case of a 36-year-old man who was a cocaine user and had a psychotic attack due to abstinence. He sought medical assistance because of abdominal pain after ingesting metal objects. Simple radiography of the stomach showed the presence of metallic structures inside the stomach (knife, dessert spoon, two large screws, chisel, drill bit, a probe for dental use and a fragment of a metal saw blade). Endoscopy of the upper digestive tract confirmed the presence of the metal objects in the lumen of the stomach. Because of their physical characteristics, they could not be removed by means of endoscopy. The patient was submitted to laparotomy andthe objects were removed by means of anterior gastrotomy of small dimensions. The postoperative recovery took place without intercurrences and the patient was referred for psychiatric follow-up.

[Analysis of vascular complications in intra-venous drug addicts after puncture of femoral vessels]. / Untersuchung von Gefässkomplikationen nach Punktion der Femoralgefässe bei intravenösem Drogenabusus.

BACKGROUND: Intravenous drug abuse is a global social and health care problem. Vascular complications following intravascular inguinal self-injection of addictive drugs are rarely seen. An efficient therapeutic concept is needed because, besides the risk of vascular injuries, infections ranging up to systemic inflammatory response syndrome or sepsis might occur. METHODS: This was a single center retrospective analysis of vascular complications in drug addicts from 1994 to 2002 in an university hospital. A systematic literature review in MEDLINE was performed with the following key words: 1 vascular, 2 complications, 3 drugs, 4 addicts, 5 mycotic aneurysms. RESULTS: 10 patients with a long lasting history of i. v. drug abuse (median: 16.1 years, range: 10-28 years) and vascular complications were included in this study. The mean age was 40.2 years (range 32-50 years). 5 patients showed pain and tumescence of the inguinal region at the time of admission. 7/10 patients had a poor general health and nutritional status. 2 patients had a hepatitis-B- and C-infection, 7 patients were hepatitis C Ag positive. All patients were HIV negative. 1 patient had an older deep venous leg thrombosis that was treated conservatively. In six cases, we saw an intraoperative arterial bleeding; in five cases pseudoaneurysms. The patients were treated with 5 venous interpositions, 4 venous patch plastics, 1 end-to-end anastomosis and 2 prosthetic grafts. 3 thrombectomies were performed. One time we performed a ligation of the pseudoaneurysm without reconstruction. Six reconstructions were covered with a biological seal. One thigh amputation was necessary; no patient died. In 2 patients with severe problems, we performed 11 operative revisions. The systematic literature review in MEDLINE showed no evidenced based therapy regimen. CONCLUSION: We favour the resection of the aneurysm including a radical debridement of the wound with secondary wound healing. In the case of an isolated aneurysm of the arteria femoralis superficialis or the arteria profunda femoris, a ligation or excision without reconstruction is possible with a low risk of postoperative complications. A reconstruction with autologous material is necessary in the case of aneurysms of the common femoral artery or its bifurcation. The reconstructed vessel should be covered with a biological seal, e. g. omentum majus. If there is no autologous material available for the reconstruction, we recommend the ligation without reconstruction, because the results after implantation of artificial vascular prostheses are not satisfying.

The surgical abdomen associated with cocaine abuse.

Cocaine use is common and is associated with gastrointestinal complications that can present as a surgical abdomen. We report a case of a previously healthy 25-year-old man who presented to the Emergency Department with severe abdominal pain and vomiting after using IV cocaine. Exploratory celiotomy revealed massive free intraperitoneal (IP) clotted blood with no evidence of underlying pathology. This unusual case underscores the possibility of life-threatening hemorrhage in cocaine consumers.

Cocaine-induced oronasal fistulas with external nasal erosion but without palate involvement.

The effects of chronic cocaine abuse have been widely described in the literature. Common complications include nasal septal perforation, saddle-nose deformity, and palatal perforation. Erosion of the external structures of the face has not been as extensively described, nor have oronasal fistulas that involve structures other than the hard or soft palate. In this article, we present the first reported case of cocaine-induced external nasal erosion that included multiple oronasal fistulas in the anterior gingival sulcus but did not involve the hard or soft palate. We stress the importance of a thorough history in such patients and consideration of all possible diagnoses, including drug abuse.

[Ischemic colitis induced by cocaine. Clinical case]. / Colitis isquémica inducida por cocaína. Caso clínico.

We report a 29 years old male, with a history of cocaine abuse and excessive alcohol intake, who was admitted to the hospital with an acute peritonitis. The patient was operated and multiple perforations of the cecum were found. A right hemicolectomy was performed and the pathological study of the surgical piece showed an ischemic colitis. A literature review reveals 22 reported cases of ischemic colitis associated to cocaine abuse.

Necrotizing granulomatous vasculitis associated with cocaine use.

Cocaine abuse may be associated with a destructive nasal and pharyngeal process felt to be due to ischemia secondary to vasoconstriction. This report is the first to document a necrotizing granulomatous vasculitis associated with nasal destruction and an oronasal fistula in a chronic cocaine user. Cocaine is an environmental insult that may play a role in triggering cerebral and non-cerebral vasculitis including a necrotizing granulomatous vasculitis of the respiratory tract.

Cocaine-induced intramural hematoma of the ascending aorta.

We report the case of a 35-year-old man who presented at our institution with intramural aortic hematoma shortly after inhaling cocaine and smoking crack cocaine. To our knowledge, such a case has not previously been reported in the English medical literature. Problems of diagnosis and the mechanisms of intramural hematoma and aortic dissection are discussed.