Heroin-piracetam mixture: suggested mechanisms of action and risks of misinterpretation for drug users

Piracetam is a positive allosteric modulator of the α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor that has been frequently used in the treatment of cognitive disorders. Press and internet reports indicate that the use of piracetam, as a heroin adulterant, has spread rapidly in some countries, especially in Asia and Europe. Its use, as adulterant, is believed to produce more profound desirable effects, while decreasing hangover. Recent surveys demonstrated that piracetam protects neurons from heroin-induced apoptosis. The protective role of this adulterating substance may be related to restoration of beta-endorphin levels and to its neuroprotective effects. The aim of this paper is to review the relevant literature and suggest the main hypothetical mechanisms that justify its use as a heroin adulterant, try to understand if its use could help people who want to come off heroin by reducing withdrawal symptoms and, finally, give useful information that permit us to understand why drug trafficking organisations started to use piracetam as heroin adulterant

A proposed role for sepsis in the pathogenesis of myocardial calcification

Myocardial calcification is a rare and life-threatening condition that is a recognised complication of ischaemic heart disease, cardiac surgery, rheumatic fever and myocarditis. It is distinct from coronary artery or valvular calcification, and can be seen in patients with abnormal calcium metabolism1 . Its presence in the context of sepsis is less well recognised and the mechanisms responsible are poorly understood. We review the relevant literature and propose a mechanistic theory for its pathogenesi

Ventricular androgenic-anabolic steroid-related remodeling: an immunohistochemical study

Background: Several fatal cases of bodybuilders, following a myocardial infarction after long exposure to androgenicanabolic steroids (AAS), are reported. In recent years, evidence has emerged of cases of heart failure related to AAS consumption, with no signs of coronary or aorta atherosclerosis. This study aims to further investigate the pathogenesis of the ventricular AAS-related remodeling performing immunohistochemistry (IHC). Method: In order to examine innate immunity activity and myocytes and endothelial cell apoptosis, IHC analyses were performed on heart tissue of two cases of bodybuilders who died after years of supratherapeutic use of metelonone and nandrolone and where no atherosclerosis or thrombosis were found, using the following antibodies: anti-CD68, anti-iNOS, anti-CD163, anti-CD 15, anti-CD8, anti-CD4, anti-HIF1 α, and in situ TUNEL staining. Results: Results confirm the experimental findings of recent research that, in the absence of other pathological factors, if intensive training is combined with AAS abuse, myocytes and endothelial cells undergo apoptotic alterations. The absence of inflammatory reactions and the presence of an increased number of M2 macrophages in the areas of fibrotic remodeling confirm that the fibrotic changes in the heart are apoptosisrelated and not necrosis-related. Conclusions In conclusion, the study indicates that, in very young subjects with chronic hypoxia-related alterations of the heart, signs of a heart failure in the other organs and a history of AAS abuse, death can be ascribed to progressive heart failure due to the direct apoptotic cardiac and endothelial changes produced by AAS

An atypical death from Rapunzel syndrome: a case report

Trichotillomania is a psychiatric disorder characterized by recurring urges to pulling out hairs, eyelashes, or down in other parts of the body. Trichophagia, which is the urge to ingesting the pulled-out hairs, can cause Rapunzel syndrome, an unusual disorder where gastric trichobezoars can be found in the small intestine. Trichobezoars, amorphous masses composed of undigested food formed by hairs, can obstruct the gastrointestinal tract up to simulating symptoms typical of bowel obstruction. Rapunzel syndrome, named after Grimm's tale, may cause death, especially in the pediatric population, being it seldom over the age of 6; moreover, developing countries and environmental and familiar issues are listed as uncertain risk factors. The present case report deals with the death of a 4-year-old female occurred after lunch and following a series of vomit events; while no traumatic or pathological findings were revealed at the external examination, the autopsy revealed three large trichobezoars localized in the stomach and the small intestine. Despite death was due to gastrointestinal obstruction for multiple trichobezoars and collateral bronchoaspiration of dietary material, histological findings were totally non-specific, meaning that it is sometimes difficult to conclude that death is related to the primary pathological condition

Nonischemic left ventricular scar and cardiac sudden death in the young

Nonischemic Left Ventricular Scar (NLVS) is a pattern of myocardial injury characterized by midventricular and/or subepicardial gadolinium hyper enhancement at cardiac magnetic resonance, in absence of significant coronary artery disease. We aimed to evaluate the prevalence of NLVS in juvenile sudden cardiac death and to ascertain its aetiology at autopsy. We examined 281 consecutive cases of sudden death of subjects aged 1 to 35 years of age. NLVS was defined as a thin, grey rim of subepicardial and/or midmyocardial scar in the left ventricular free wall and/or the septum, in absence of significant stenosis of coronary arteries. NLVS was the most frequent finding (25%) in sudden deaths occurring during sports. Myocardial scar was localized most frequently within the left ventricular posterior wall, and affected the subepicardial myocardium, often extending to the midventricular layer. On histology it consisted of fibrous or fibro-adipose tissue. Right ventricular involvement was always present. Patchy lymphocytic infiltrates were frequent. Genetic and molecular analyses clarified the aetiology of NLVS in a subset of cases. ECG recordings were available in over half of subjects. The most frequent abnormality was the presence of low QRS voltages (< 0,5 mV) in limb leads. In serial ECG tracings, the decrease in QRS voltages appeared, in some way progressive. NLVS is the most frequent morphologic substrate of juvenile cardiac sudden death in sports. It can be suspected based on ECG findings. Autopsy study and clinical screening of family members are required to differentiate between Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia and chronic acquired myocarditis

Takotsubo cardiomyopathy and sepsis: a systematic review

Takotsubo cardiomyopathy (TTC) is characterized by a systolic dysfunction localized in the apical and medial aspect of the left ventricle. It is usually related to physical or emotional stress. Recent evidence highlighting the role of infection led us to analyze the links between TTC and sepsis. A systematic review of the literature was undertaken to assess any trends in clinical findings, diagnosis, and outcomes in such patients. We identified 23 selected papers reporting a total of 26 patients, having sepsis, in whom TTC occurred. For each case, we collected data identifying population characteristics, source of sepsis, clinical disease description, and the results of cardiovascular investigations. The majority of patients were females (n = 16), mean age was 62.8 (14.0 standard deviation) years, and clinical outcome was favorable in 92.3% of the cases once the management of sepsis was initiated. A better understanding of the mechanisms of sepsis-associated TTC may generate novel strategies to treat the complications of this cardiomyopathy and may even help predict and prevent its occurrence

medical prescription vs defensive medicine results of a questionnaire answered by members of the latina board of physicians surgeons and dentists

"Defensive Medicine" is intended as health practitioners' behaviour aimed at limiting any medical - legal disputes and in addition to limiting a doctor's responsibilities; specifically, DM is implemented by prescribing diagnostically useless tests, or by avoiding procedures that are potentially beneficial for the patient, but burdened by risk. The final effect of this medical conduct is to nullify the efficiency of health care, as well as increase times and costs. Our Group asked doctors registered with the Professional Board of Latina to answer a questionnaire aimed at investigating the perception of this issue and their behaviour in this regard, both in terms of prescriptions and insurance coverage. The results show a general attitude of distrust towards a disputed doctor and a series of behaviours aimed at avoiding such situations; the doctors interviewed asked for increased protection and less pressure in order to better carry out their work. ---------- Per "Medicina Difensiva" si intende una condotta, posta in essere dal personale sanitario, volta a limitare eventuali contenziosi medico – legali e finalizzata a limitare le responsabilità del medico; nello specifico, la MD si realizza attraverso prescrizione di esami inutili dal punto di vista diagnostico, ovvero tramite evitamento di procedure potenzialmente benefiche per il paziente, ma gravate da rischio. L'effetto finale di questa condotta medica è quello di vanificare l'efficienza dell'operato sanitario, aumentandone anche tempistiche e costi. Il Nostro Gruppo ha somministrato ai medici iscritti presso l'Ordine Professionale di Latina un questionario, volto ad indagare la percezione del problema esposto e il comportamento adottato a riguardo, sia in termini di prescrizioni che di copertura assicurativa. I risultati mostrano un atteggiamento generale di diffidenza nei confronti del contenzioso medico ed una serie di comportamenti volti ad evitare tali situazioni; i medici intervistati richiedevano una maggior tutela e una minore pressione, al fine di svolgere al meglio il proprio operato. ---------- "Medicina Defensiva" significa un comportamiento llevado a cabo por el personal de salud, dirigido a limitar cualquier disputa médicolegal y dirigido a limitar las responsabilidades del médico; específicamente, la MD se lleva a cabo prescribiendo pruebas innecesarias desde el punto de vista del diagnóstico, o evitando procedimientos que son potencialmente beneficiosos para el paciente, pero cargados por el riesgo. El efecto final de esta conducta médica es anular la eficacia de la atención médica, lo que también aumenta el tiempo y los costos. Nuestro Grupo ha entregado a los doctores inscritos en la Orden Profesional de Latina un cuestionario, dirigido a investigar la percepción del problema expuesto y el comportamiento adoptado al respecto, tanto en términos de prescripciones como de cobertura de seguro. Los resultados muestran una actitud general de desconfianza hacia el conflicto médico y una serie de comportamientos dirigidos a evitar tales situaciones; los médicos entrevistados requieren una mayor protección y menos presión, para realizar mejor su trabajo

Tanatologia forense

Il capitolo affronta le tematiche di maggiore interesse nello studio dei fenomeni tanatologici, siano esse di natura giuridica (accertamento, e diagnosi di morte) sia di natura medica (riscontro diagnostico ed autopsia giudiziaria). Viene dedicato ampio spazio alla determinazione dell'epoca della morte, che rappresentata l'argomento di maggiore interesse dal punto di vista forense, descrivendo i fenomeni tanatologici nella loro varia tipologia (consecutivi, trasformativi, et.). Un paragrafo specifico è dedicato alla morte improvvisa

I falsi invalidi: le "lacrime amare" della protezione sociale

L’Autore esamina un aspetto particolare dell’assistenza sociale rappresentato dai "falsi invalidi", che costituiscono l'aspetto deteriore di una degenerazione strutturale del welfare (l'assistenzialismo) che ha inquinato in modo capillare ed in profondità il settore, fino a richiedere provvedimenti straordinari di irrigidimento della normativa, spesso assunti in concorso e sull’onda di iniziative penali, nonché periodiche iniziative di revisione dei provvedimenti assistenziali di natura economica (assegno di invalidità, pensione di inabilità, indennità di accompagnamento) in essere. La degenerazione di questa componente del sistema della protezione sociale ha provocato un progressivo svuotamento dei contenuti propriamente medici del problema (accertamento e valutazione dell'invalidità), secondo una prospettiva aberrante, alimentata da una domanda tesa ad ottenere una distribuzione indiscriminata, "a pioggia", di benefici in origine concepiti per cittadini in condizioni di bisogno (invalidità “civile” in senso ontologico). Ne è derivato un deprecabile utilizzo di questi strumenti come "ammortizzatori sociali" di eventi estranei alla metodologia di accertamento, seppure rilevanti sul piano delle politiche istituzionali (la disoccupazione giovanile, il lavoro nero, l'assenza di strutture assistenziali e/o riabilitative, fra gli altri). L’analisi condotta evidenzia un panorama desolante attraverso la descrizione di meccanismi, procedure, modus operandi che, in varia misura combinati fra loro, possono concorrere a “drogare” il sistema della protezione dell’invalidità, creando i presupposti per quella grave degenerazione del settore