Six deaths linked to concomitant use of buprenorphine and benzodiazepines.

AIMS: Buprenorphine at high dosage became available in 1996 for substitution treatment in France. This drug is considered particularly safe and has become widely available in general medical practice. We investigated the possible implication of a buprenorphine-benzodiazepine association in six deaths of known abusers. DESIGN: Full investigation of cause of death was conducted for six drug abusers. SETTING: The deaths occurred in two regions of France (Auvergne and Lorraine). Assays were carried out by the Institut de Medecine Legale at Strasbourg, France, one of the few French laboratories equipped to assay buprenorphine. MEASUREMENT: First, the blood and urine underwent triple exhaustive screening. Secondly, buprenorphine and norbuprenorphine were analysed in all the autopsy samples by HPLC/MS. FINDINGS: Benzodiazepine-buprenorphine associations were found in every case; no other substances that could account for the death were found. The tissue concentrations were markedly higher than the blood levels. CONCLUSION: If the number of deaths linked to such drug misuse proves high, it may be necessary to review how buprenorphine is dispensed.

An unusual death by zipeprol overdose.

Capillary gas chromatography coupled to mass spectrometry was employed to quantify zipeprol in biological fluids and tissues in a death attributed to oral zipeprol ingestion. The blood concentration of zipeprol was 6.69 mg/l. Hair analysis clearly indicated chronic drug abuse, with a concentration of 33.1 ng/mg. Results are discussed in the light of the existing literature.

[Diagnosis of left proximal coronary stenosis using 2-dimensional echocardiography]. / Diagnostic des sténoses coronariennes gauches proximales par échocardiographie bidimensionnelle.

The value of two-dimensional echocardiography (2DE) in the diagnosis of proximal left main coronary artery disease was assessed in 63 patients in whom 2DE was performed and interpreted before coronary angiography. The diagnosis of coronary artery disease depended on two groups of criteria, one group based on the lumen of the artery and the other, on the arterial wall. Eighty three pre cent of the investigations were interpretable. The bifurcation of the left main coronary artery was visualised in 23% of cases. 2DE was positive in 8 of the 10 cases (80%) in which coronary angiography showed stenosis of the left main coronary or the very proximal part of the left anterior descending arteries. There were two false negative results (20%). When coronary angiography did not show left main coronary stenosis (42 cases), 2DE was also negative in 39 cases (92%); there were 3 false positive results (7%), one due to calcification and other two to errors in appreciation of the criteria of stenosis. These results show that 2DE is useful before coronary angiography in identifying cases of possible left main stem or proximal left anterior descending disease providing the diagnostic criteria of coronary stenosis are strictly observed.

[Left auricular myxoma. Apropos of 9 cases. Study of echocardiographic and morphologic aspects. Familial inquiry]. / Le myxome auriculaire gauche. A propos de 9 cas - Etude des aspects échocardiographiques et morphologiques - Enquête familiale.

A study was made of 9 cases of left atrial myxoma with emphasis on the echocardiographic, haemodynamic and anatomical aspects and on the main clinical features. An epidemiological enquiry was made regarding the possibility of recurrences or familial cases. It was negative, suggesting that such cases are rare. The echocardiographic signs of left atrial myxoma are inconstant. The mitral diastolic EF slope is variable, the delay in appearance of the tumour echo behind the mitral valve in diastole is not constant, and the atrial "a" wave may be preserved. The echocardiographic features are a function of the size and shape of the myxoma, as well as the length and site of implantation of its pedicle.

[Unruptured aneurysms of the sinus of Valsalva disclosed by syncopal disorders of cardiac excitability. Apropos of 2 cases]. / Anévrysmes du sinus de Valsalva non rompus révélés par des troubles de l'excitabilité cardiaque syncopaux. A propos de deux observations.

Aneurysms of the sinus of Valsalva are rarely diagnosed before rupture into the cardiac cavities which usually leads to the appearance of a continuous murmur and cardiac failure. In the two cases described, the presenting symptom of the aneurysm was syncope due to cardiac hyperexcitability: ventricular tachycardia in the first and paroxysmal tachyarrhythmia in the second case. The presenting symptoms of unruptured aneurysms of the sinus of Valsalva were analysed. In general, they are: uncontinuous cardiac murmurs: either diastolic murmurs of aortic regurgitation, systolic murmurs of mitral or tricuspid regurgitation, or, as in our first case, of obstruction to right ventricular ejection; arrhythmias: the commonest are conduction defects, which can be syncopal; hyperexcitability (especially ventricular) seems to be very care. Echocardiography is a valuable tool for the diagnosis of sinus of Valsalva aneurysms. The appearances of unruptured aneurysms in our two patients are described. The presence of syncopal cardiac hyperexcitability, possibly associated with one of the preceding auscultatory abnormalities is an indication for echocardiography which may lead to the diagnosis of this condition.

[Cardiovascular manifestations of eosinophilia: clinical and echocardiographic presentation]. / Atteintes cardiaques au cours des hyperéosinophilies: une présentation clinique et échocardiographique polymorphe.

INTRODUCTION: Endomyocardial fibrosis with apical obliteration is the best known involvement among heart lesions induced by hypereosinophilia. However, hypereosinophilic heart disease may involve all three heart layers, with a polymorphic clinical and echocardiographic presentation. METHODS: Retrospective descriptive study of five patients highlighting the various manifestations of hypereosinophilic heart disease. RESULTS: We report five cases illustrating the variety of hypereosinophilic heart disease and review the pathophysiology of this potentially severe illness: cytotoxicity of eosinophils is mediated by the release of granular proteins that primarily damage the endocardium, leading to thrombosis and embolic complications, then to fibrosis and valvular complications; myocardial involvement may induce a dreadful acute eosinophilic myocarditis; finally, pericardial involvement may cause tamponade. CONCLUSION: These observations highlight the whole spectrum of the heart manifestations of hypereosinophilia, remind that the vital prognosis may be involved in the acute phase and underline that functional prognosis depends on early detection and treatment to reduce the risk of early thromboembolic and late fibrotic complications.