Psychological aspects and treatment of patients with nasal septal perforation due to cocaine inhalation.

Use of cocaine, by inhalation, is currently increasing in Western Countries and its use is superseding heroin in the rising generation. Young people of the third millennium use narcotics to avoid the negative conditions of daily life and to escape on "unreal" trips, as happened in the '60s and '70s for the heroin-addicted. Today, on the contrary, people addicted to cocaine want to be more competitive and "winners" and believe that cocaine can help them to reach this goal. A series of 104 patients (75 male, 29 female), aged between 16 and 54 yrs, all habitual inhaling cocaine users (> or = 10 times per month) have been observed for 2 years. Among them, 11 (10.5%) had nasal septal perforation, which is frequently related to cocaine use. Of these 11 patients, 8 (72.7%) had nasal septal perforation of the quadrangular cartilage, while in the other 3 (27.3%) the perforation involved also the bony tract (vomer-perpendicular ethmoidal lamina). Psychological analysis of these 104 patients is reported: 62 patients (59.6%) answered that they inhaled cocaine to improve endurance and to feel stronger and less tired; 34 patients (32.7%) in order to enjoy themselves more during parties and to communicate more effectively with other people; 5 patients (4.8%) to gain confidence and to overcome their shyness, 2 patients (1.9%) to improve their sexual performance and 1 patient (1%) to drink more alcoholic drinks for a longer time without feeling sleepy. All the patients underwent psychotherapeutic treatment, but the lack of compliance and constantly missing the scheduled follow-up visits resulted in complete therapy being performed in only 16 patients (15.3%). All the patients with nasal septal perforation underwent rhino-endoscopy, at T0, with 0 degrees, 45 degrees endoscopes, computed tomography scan of nose and paranasal sinuses and biopsy. At the time of the observational period, none of the 11 patients who presented nasal septal perforation agreed to stop cocaine abuse; therefore, a temporary solution has been offered to all the patients (accepted by 3 of them), i.e., the positioning of a silicone button to close the perforation and, thus, improve the air flow in the nose and reduce progression of local necrosis. Together with the button, the positioning is described, under local anaesthesia, of two layers per septal side of hyaluronic acid, at different levels of esterification, kept in site by the button as a "sandwich" in order to obtain better re-growth of the mucosa and fewer scabs and bleeding.

Evaluation of ultrasound lung comets by hand-held echocardiography.

BACKGROUND: Ultrasound lung comets (ULCs) are a clinically useful sign of extravascular lung water. They require very limited technology (2 D-echo), and a short learning curve. The aim of the present study is to compare ULCs information obtained by experienced echocardiologists using a full feature echocardiographic platform and by inexperienced sonographers using a hand-held echocardiography system. METHODS: 20 consecutive in-hospital patients underwent, within 15' and in random order, 2 ultrasound examinations for ULCs by 2 observers with different specific expertise and different technology: 1) "high-tech veteran": ULCs assessment with full feature echocardiographic platform (HP Sonos 7500 Philips Medical Systems, Andover, MA, USA) by a trained echocardiologist, with > or =2 years expertise in ULCs assessment and accredited by the European Association of Echocardiography; 2) and a "low-tech beginner": ULCs assessment with hand-held echocardiography (Optigo; Philips, Andover, MA) by an echocardiographer with very limited (30') dedicated training on ULCs assessment. In each patient, ULC score was obtained by summing the number of comets from each of the scanning spaces in the anterior right and left hemithorax, from the second to the fifth intercostal space. RESULTS: There was a significant, tight correlation (r = .958, p < 0.001) between the 2 observations in the same patient by "high-tech veteran" and "low-tech beginner". CONCLUSION: ULCs are equally reliable in the hands of highly experienced echocardiologists using full feature echocardiographic platforms and in the hands of absolute beginners with miniaturized, compact, and battery-equipped echocardiographic systems. From the technological and expertise viewpoint, ULCs are the "kindergarten" of echocardiography, ideally suited for bedside evaluation of patients with both known or suspected heart failure.

The additive prognostic value of end-systolic pressure-volume relation in patients with diabetes mellitus having negative dobutamine stress echocardiography by wall motion criteria.

BACKGROUND/OBJECTIVE: The end-systolic pressure-volume relation (ESPVR) is a useful method to assess left ventricular contractility during stress providing prognostic information above and beyond regional wall motion. The aim of the study was to assess the prognostic value of ESPVR in patients with diabetes mellitus having negative dobutamine stress echocardiography by wall motion criteria. DESIGN: We enrolled 233 patients with diabetes mellitus (140 males; mean age 67 (SD 9); mean ejection fraction 52 (SD 10)) having negative dobutamine (up to 40 microg/kg/min with atropine 1 mg) stress echocardiography. In all, ESPVR was determined at rest and at the peak of stress as the ratio of peak systolic pressure and end-systolic volume (SP/ESV) index. SETTING: Adult patients with diabetes mellitus evaluated at a tertiary care centre. MAIN OUTCOME MEASURES: Death, non-fatal ST-elevation (STEMI), non-ST-elevation (NSTEMI) and late (>6 months) revascularisation. RESULTS: During a median of 18 months, 62 events occurred: 35 deaths, 4 STEMI, 5 NSTEMI and 18 late revascularisations. Event-free survival was lower (p = 0.006) in patients with peak SP/ESV index < or =28 mm Hg/ml/m(2), chosen with a receiver-operating characteristic curve. Multivariable indicators of future events were prior angioplasty (HR 2.10, 95% CI 1.17 to 3.77; p = 0.01), resting wall motion abnormality (HR 1.94, 95% CI 1.12 to 3.36; p = 0.02), and peak SP/ESV index < or =28 mm Hg/ml/m(2) (HR 2.28, 95% CI 1.08 to 4.81; p = 0.03). At incremental analysis, peak SP/ESV index < or =28 mm Hg/ml/m(2) added prognostic information to that of clinical and resting echo findings. CONCLUSIONS: Patients with diabetes mellitus having negative dobutamine stress echocardiography may still experience an adverse outcome, which can be identified by ESPRV, providing a prognostic stratification in addition to that supplied by regional wall motion abnormalities.