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BACKGROUND: Ehen refractory to optimal medical treatment cardiogenic pulmonary edema requires mechanical ventilation as a last therapeutic resource. In recent years an increasing number of authors reported their experience in the management of acute or subacute respiratory failure with non-invasive mechanical ventilation by nasal mask. MATERIALS AND METHODS: Encouraged by the first promising results reported in literature we experimented this new therapeutic tool in a first group of seven elderly patients (mean age: 76.57--range: 65-89); they all had been admitted for severe cardiogenic pulmonary edema unresponsive to maximal doses of the conventional drugs available for treating acute decompensated heart failure. The enrolled patients were treated with intermittent ventilation administered by nasal mask at selected values of inspiratory positive airway pressure (IPAP) that were comprised between 10 and 20 cm H2O. At the same time an expiratory positive airway pressure (EPAP) at values comprised between 3 and 8 cm H2O was applied. Ventilation was continued for variable periods of 3-24 hours until acceptable values of PaO2 and PaCO2 were obtained. The ventilation modality was spontaneous, spontaneous-time or timed depending on the patients' level of consciousness at starting time. RESULTS: A good short-term outcome was achieved in all the patients regardless of the ventilation modality applied. The main blood gas alteration was severe hypercapnia with acidosis in three patients, while the other four presented critical hypoxemia unresponsive to simple oxygen supply even if delivered by high-flow Venturi mask. Four of our seven patients were discharged from hospital in satisfactory haemodynamic conditions; the remaining three died during hospitalization from refractory heart failure. CONCLUSIONS: In this our preliminary experience the therapeutic approach with nasal positive pressure ventilation (NPPV) and EPAP proved to be very effective to improve the signs and symptoms of acute refractory cardiogenic pulmonary edema as it avoided the need of invasive mechanical ventilation. It was well tolerated by all our patients; besides it was not difficult to use or time-consuming for physician and nurses. On the other hand it didn't modify our patients' medium or long-time prognosis which was strictly related to their preexisting left ventricular pump derangement.

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The case is reported of a 69-year-old man with refractory heart failure due to ischemic cardiomyopathy. All other available treatments having failed and 250 mg doses of furosemide having been administered without success, dobutamine infusion was tried, at first with 72 hours of continuous infusion of 5 mcg/kg/min, followed by intermittent infusion at the same dosage, first with 12-h intervals, subsequently at the rate of 2-3 infusions weekly, and finally, after about 50 days, with a single weekly infusion. Clinical and hemodynamic results were brilliant with the patient passing from grade IV NYHA to grade II and from ejection fraction 21% (Teichholz M-mode measurement) to 55%, 14 months after the start of dobutamine treatment. Discussing the possible mechanisms of this favourable result, the authors stress the possible improvement of the contractility of the "stunned" or "hibernating" myocardial segments. On the basis of their experience and of data in the literature the authors underline the validity of a therapeutic protocol of intermittent dobutamine infusion for severe heart failure.

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The authors describe two recently observed cases of silent angina with ST segment elevation. The patients, both 80-years old, were submitted to 24-hour Holter examination to account for recurrent episodes of dizziness. The examination revealed silent angina with ST elevation concentrated mainly in the late evening and morning hours, accompanied by accelerated heart rate. Treatment with low diltiazem doses was completely successful.

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As echocardiography is being used more often, its value and accuracy are becoming more fully appreciated, especially for identifying normal anatomic variants and their possible erroneous interpretation as pathologic states. We report the echocardiographic and clinical findings observed in sixteen subjects examined at our Cardiological Service in the period from January 1987 to April 1988. Mean age of these subjects is 40 +/- 27.04. Of these subjects, six are affected by other cardiac pathologies and ten are unaffected (Group A). First, we describe in all the patients M-mode and two dimensional patterns of persistence of the right venous sinus valve known as the Chiari network. This structure can present as a highly mobile, highly reflective echo target, which can be seen especially by means of the bi-dimensional technique. The Chiari network could be seen with all four standard approaches. The two most diagnostic views are, in our experience, the short axis parasternal view (62.5%), and the subcostal view (87.5%). In a great number of subjects (75%) the Chiari network could be seen in at least two approaches. Second, in Group A we make a clinical examination. Nine subjects in this group show the presence of a cardiac systolic murmur with vibratory characters from grade 1/6 to grade 3/6. 50% of the same patients presented supraventricular arrhythmias (particularly, two presented reciprocating paroxysmal supraventricular tachycardia and one paroxysmal atrial fibrillation). The significance of these findings is not clear yet. We, at least, emphasise that the Chiari network could be confused with other curvilinear highly mobile, echo targets such as right-heart vegetations, flail tricuspid leaflets, a small right-heart thrombus or even a pedunculated right heart tumor (especially right atrial myxoma). On the contrary, this structure might be considered a "normal anatomic variant".

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A case of a 60-year-old woman suffering from hypertension, who presented an episode of acute myocardial ischemia with an elevation of the ST segment in the anterior ECG lead, is reported. On examination, a transient loud systolic murmur was present; it completely disappeared soon after the cessation of acute myocardial ischemia. Doppler echocardiography was performed a few times, during and after the acute ischemia: it was able to show a sort of "hour-glass" deformation of the left ventricle due to the akinesia of the anterior and apical segments. This functional anatomic deformation hampers the outflow from the left ventricle thus creating a dynamic left intraventricular gradient, which is clearly shown by pulsed wave and continuous Doppler echocardiography.

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The clinical case of an elderly patient hospitalised for acute abdomen type syndrome is reported. Investigation, particularly echography, pointed to a diagnosis of partially ruptured giant biliary cyst of the liver. The clinical pictures and the unusual features of this rare condition are discussed. Differential diagnosis with respect to echinococcosis and polycystic liver is examined.

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90 hospitalized drug addicts observed in 1979-83 were examined. The investigation of the main anamnestic, clinical and instrumental parameters made it possible to construct a profile of the main physical handicaps affecting drug addicts and the main pathologies they encounter. In conclusion it is emphasised that it is probably not the drug in itself but rather their unhealthy life style that is the primary cause of drug addicts' poor health.

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Ninety drug addicts observed in 1973-83 were examined in a study of the main anamnestic and behavioural parameters, the reasons for hospitalisation, the presence of withdrawal symptoms during treatment and any prospects of long-term cure. In conclusion, it is emphasised that the low frequency of real withdrawal pathology often renders "scaled" treatment with methadone superfluous. Finally it is pointed out that in itself, the hospitalisation period can do almost nothing to break the addiction spiral unless it forms part of a wider prospect of global treatment.

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