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Background: Pneumothorax is one of the respiratory toxic effects of cocaine inhalation. The literature counts several cases, some associated to other respiratory conditions such as pneumomediastinum, haemoptysis and others not requiring surgical treatment., Aim: We present a series of nonHIV cocaine-inhaler subjects who underwent video-assisted thoracoscopic surgery (VATS) for isolated spontaneous pneumothorax., Design: Nine subjects, with a mean age of 24 ± 4 years, admitting cocaine inhalation, developed spontaneous pneumothorax and underwent 10 surgical treatments by means of VATS, at our Institution., Results: Previous pneumothorax occurred in six cases episodes ranged from 0 to 5 (mean 1.6 ± 1.6). Chest computed tomography (CT) scan showed abnormalities in seven cases. All subjects underwent lung apicectomy, apical pleurectomy and mechanical pleurodesis. Seven subjects had also bullectomy. In all cases the visceral pleura was partially covered by fibrinous exudate. Histology of the lung showed small foreign body granulomatous inflammation in fibrotic and/or emphysematous pulmonary parenchyma. Relapse of pneumothorax occurred in one subject at 60 days and it was surgically treated. Mean follow-up was 150 ± 38 months (range 120-239). All subjects are now well, with no evidence of pneumothorax., Conclusions: Spontaneous pneumothorax in cocaine-inhaler subjects is a reality of which physicians need to be aware. Chest CT scan might not reveal abnormalities. Macroscopically the lung might presents bullae and/or peculiar visceral pleura. Foreign body granulomas observed in the specimens suggest that the particulate component of inhaled substances can injure the lung. Surgical treatment of the bullous disease and mechanical pleurodesis can provide a long-term follow-up without relapse of pneumothorax., (© The Author(s) 2019. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Aim: To estimate the prevalence of drug and polydrug use among drunk-drivers during the driving license regranting program, in order to assess the inclusion of toxicological tests on hair and urine samples in the systematic methodology in this category of subjects., Short Summary: A total of 2160 drunk-drivers were tested for alcohol and drugs during driving license regranting. Thirty-one subjects showed alcohol use, 212 illicit drug use and, among these, 131 were polydrug users. Nineteen different patterns of drug and polydrug use were found. Cocaine was detected in 165 subjects., Methods: The study was performed on 2160 drunk-drivers examined at Legal Medicine and Toxicology Unit of the University of Padova, in a 3-year-period (2014-2017). The positivity for one or more illicit drugs in hair or urine samples was confirmed by LC/MS and GC/MS methods. Chi-square test, Fischer's exact test and Cochran-Armitage Trend test were used to study the correlation between general characteristics of the examined sample and the presence of drug/polydrug use., Results: Thirty-one subjects showed alcohol use, 212 illicit drug use and, among these, 131 were polydrug users. Nineteen different patterns of drug and polydrug use were found. Cocaine was detected in 165 subjects in whom 122 showed a concurrent use of alcohol and cocaine, identified through the detection of cocaethylene in hair samples. No significant association and/or trends between drug/polydrug use and the general characteristics of the sample were detected., Conclusions: The results show that drug and polydrug use among drunk-drivers should be subjected to toxicological as well as alcohological monitoring, especially in the regranting procedure. The implementation of this procedure could improve the knowledge of dimensions of the issue, providing a powerful means for the reduction of phenomenon of driving under the influence of alcohol and drugs.

Background: Cocaine addiction is associated with either ischaemic or non-ischaemic cardiac complications. The prevalence of myocardial damage in asymptomatic addicts has never been evaluated by cardiovascular magnetic resonance (CMR), which allows non-invasive detection of myocardial oedema and fibrosis., Objective: To prospectively evaluate the prevalence of myocardial damage in cocaine addicts with no history of cardiac disease by CMR., Methods: Thirty consecutive subjects (25 men, mean age 39 ± 7 years), with no history of cardiac symptoms/disease were evaluated 48 h after the withdrawal of cocaine by a comprehensive humoral, clinical and instrumental assessment, including B-type natriuretic peptide and troponin I assay, echocardiography, exercise stress test and 24 h ECG recording, as well as CMR examination. The CMR study was performed using a 1.5 Tesla scanner. Myocardial oedema was evaluated by a T2-weighted STIR sequence and fibrosis using the late gadolinium enhancement technique., Results: Biohumoral markers of cardiac involvement were negative in all subjects except one. Fifteen subjects had subtle abnormalities at resting ECG, while exercise stress testing and Holter studies were negative for ischaemic or arrhythmic events. Echocardiography provided evidence of wall motion abnormalities in 12 subjects. At CMR evaluation, myocardial involvement was detected in 25 subjects (83%), oedema in 14 (47%) and fibrosis in 22 (73%). Eleven subjects (37%) showed both myocardial oedema and fibrosis with similar localisations in nine. Seven subjects had ischaemic patterns of fibrosis and 15 had non-ischaemic patterns of fibrosis., Conclusions: A high prevalence of cardiac damage in asymptomatic cocaine addicts can be found by CMR examination.

In driver licence regranting, subjects with a history of cocaine use are requested to undergo laboratory testing to verify both current and past abstinence from the drug. Identification of cocaine use based only on urinalysis may miss some cases because of the short elimination half-life of the drug. Moreover, many abusers know how to time their cocaine consumption in such a way that they can "beat" the urinalysis, having a series of negative urine tests. We report on the use of hair testing to disclose sporadic cocaine consumption in seven subjects attending the Local Medical Commission to reobtain driver licence, with constant negative urinalysis. Even with one or two weekly negative urine screens along several months, all the subjects were positive using hair testing for cocaine and benzoylecgonine, above the internationally recommended limit of quantification: 0.5 ng/mg and 0.05 ng/mg for cocaine and benzoylecgonine, respectively (concentration range for cocaine: 0.51-2.23 ng/mg hair; concentration range for benzoylecgonine: 0.08-1.70 ng/mg hair). The obtained results support strongly the use of hair testing for cocaine in drug addicts and occasional abusers applying for regranting of driver licence in order to minimize social risk behaviours.

Background: Several studies indicate a specific relationship between bipolar disorder and stimulant use and abuse. It has generally been assumed that cocaine use represents self-enhancement or attempts to optimize one's level of hypomania, cyclothymia or hyperthymia. This topic required further examination among heroin abusers because cocaine abuse is commonly comorbid with heroin abuse., Methods: Cocaine abuse by bipolar subjects was investigated in a group of 1090 treatment-seeking heroin addicts enrolled between 1994 and 2005. We collected data with 1) the Drug Addiction History Rating Scale; and 2) the Semi-structured Interview for Depression, which inquires systematically among others, about hypomania, cyclothymia, hyperthymia and depressive temperament. Subjects were aged 29+/-6 years, and predominantly male (76.2%)., Results: Univariate and multivariate analyses provided correlations in favour of a link between current cocaine abuse and double diagnosis, with special relevance to the bipolar spectrum, as well as psychotic disorders (p<0.0001)., Limitation: The modality of access to cocaine in different communities and the difficulty to distinguish cocaine use from abuse by the rating scale administered may have limited the interpretation of results., Conclusions: If cocaine abuse precedes that of heroin or is concomitant, heroin may hypothetically serve as a "mood balancer" which transiently dampens subthreshold excitatory states and mood swings. Our data further suggest the need for a more complex model linking cocaine and bipolarity: subthreshold bipolarity, including hyperthymic and cyclothymic temperaments, seems to predispose to heroin addiction, but craving for the suppressed hypomania in turn could lead to cocaine abuse, which eventually unmasks a frank bipolar disorder - in some cases leading to mixed state, severe mania, as well as psychosis beyond mania. Prospective observations would shed further insight on this complex interface of major clinical and public health importance.

Mental health and addiction services have traditionally evolved separately in many European countries, with policy reflecting this. Differences in severity profiles between users of the community addiction services with comorbidities of mental illness and substance misuse and those with substance misuse only were studied using a matched case-control study design, with regard to the main substance (opiates or cocaine) patients were dependent on. Patterns of substance abuse and diagnostic features were evaluated according to the Addiction Severity Index (ASI) and DSM-IV. Mentally ill substance abusers are significantly more likely to have used amphetamines, inhalants and having been polydrug users. They are particularly impaired in medical and family/social relationships ASI composite scores, but less in drug use. Severity profiles and needs of dually diagnosed patients require assessment and treatment skills that should be provided through adequate links with mental health system., (Copyright 2006 S. Karger AG, Basel.)

Background: Cocaine-induced lesions may cause extensive destruction of the osteocartilaginous structures of the nose, sinuses, and palate that mimics the clinical picture of other diseases., Methods: From January 1991 to September 2001 25 patients with cocaine-induced midline destructive lesions were observed at the Department of Otorhinolaryngology of the University of Brescia. The diagnosis was based on physical and endoscopic evaluation, routine blood and urine analysis, radiological findings, and repeated biopsies of the nasal mucosa. Serum was analyzed by the antineutrophilic cytoplasmic antibody (ANCA) test using indirect immunofluorescence and by enzyme-linked immunosorbent assay for antibodies against proteinase 3 and myeloperoxidase., Results: Septal perforation was present in all 25 patients, 16 of which (68%) also had partial destruction of the inferior turbinate. Hard palate reabsorption was observed in only six patients (24%); in two of these patients, the lesion also extended to the soft palate. Fourteen patients (56%) were positive by the immunofluorescence test (nine patients had a P-ANCA and five patients a C-ANCA pattern). Four patients (16%) with the P-ANCA pattern and all patients with the C-ANCA pattern also tested positive for anti-proteinase 3 antibodies., Conclusion: Any sinonasal inflammation involving the midline that persists or remains refractory to treatment may be the first manifestation of potentially lethal drug addiction. Cocaine abuse should be considered in the differential diagnosis of destructive lesions of the nasal cavity even in the presence of a positive ANCA test.

Diagnosis of drug exposure is strongly supported by analysis of hair samples. In the province of Brescia, Italy, for regranting driving license to drug addicts or occasional abusers, a control programme was adopted including analysis of illicit drugs in two hair segments (0-3 and 3-6 cm) and in urine. From January 1998 to April 1999, upon request of the Local Medical Commission, 697 hair samples were tested in our laboratory. One hundred and eighty subjects resulted positive in hair for one or two of the controlled drug classes (73.3% for cocaine, 10% for opiates, 16.7% for both). Positive subjects were classified by residence, age, sex and license category. Seventy-two subjects were called back after 6-12 months and submitted to a second hair and urine analysis: in 34 cases the result of the first analysis was confirmed (19 negatives, 15 positives for one or both drug classes). Another 37 cases tested positive at the first control and negative at the second, suggesting the hypothesis that a strict control may have a significant deterrent function. The high percentage of negative results at the second control may be explained by the prevalence of cocaine users in the examined population. Our results allow us to conclude that the strict application of control rules lead to a decrease of social risk behaviours.

The present paper describes an integrated diagnostic strategy to check the physical fitness of subjects, formerly users of illicit drugs, to obtain a driving license, after having quit their addiction. According to the Italian law, applicants for a driving license with a history of drug abuse must give evidence to have quit this behaviour and to show no risk of relapse in the future. To prove this, at our institute, they undergo medical examination, hair analysis and a urinalysis program on eight seriate samples, collected over about 40 days. About 700 subjects per year are investigated with this strategy. The hair samples are screened for opiates (morphine), cocaine and ecstasy, the most abused illicit substances in our region, by using commercial radioimmunoassays adopting cut-off levels of 0.1 ng/mg. All positive samples and about 10% of negatives are confirmed by high-performance liquid chromatography. Further confirmation of results can be carried out by capillary electrophoresis (and/or GC/MS or MS/MS). In 1998, the prevalence of positives for morphine, cocaine and ecstasy was 4.8, 11.3 and 2.6%, respectively. In this year, for the first time, the percentage of hair samples positive for cocaine was greater than that for opiates. The results of this integrated diagnostic strategy are presented and discussed, with particular emphasis on the comparison between hair analysis on a single sample and seriate urinalyses (on eight samples).