A review of methamphetamine use and stroke in the young.

Methamphetamine (meth) is a potent and addictive central nervous system stimulant with increasing use. Stroke is one severe possible complication of meth use. Due to high levels of manufacturing in Mexico, the western United States has experienced greater consequences of meth use. The literature reviewed herein is comprised of case studies and series, and it suggests that hemorrhagic stroke (including hypertensive-like intracerebral hemorrhage and aneurysmal subarachnoid hemorrhage), as opposed to ischemic stroke, is the more common type of neurovascular complication of meth use. Meth-related strokes are a particular concern for younger patients with stroke and may be a partial explanation for increasing stroke rates in this age group. We describe two cases (one intraparenchymal hemorrhage and one ischemic stroke) in young patients (<50 years old) with recent meth use to illustrate clinical characteristics and therapeutic considerations. There are several proposed pathophysiological explanations for meth-associated hemorrhagic stroke including an induced hypertensive surge, vasospasm, blood brain barrier breakdown, chronic hypertension, aneurysm development and rupture, and very rarely associated vasculitis. The increased risk of ischemic stroke related to meth use is less well supported in the literature, but this may, in part, be related to a lack of appropriately designed and powered research studies. Proposed mechanisms for ischemic stroke complications of meth use include those affecting blood vessels such as accelerated atherosclerosis, chronic hypertension, vasospasm, and vasculitis, plus mechanisms that affect the heart including cardiomyopathy, arrhythmias, and infective endocarditis (especially with injection drug use). Standard therapeutic interventions for acute stroke and approaches to secondary stroke prevention seem appropriate for meth-associated strokes, with the addition of abstinence from continued meth use. There is no evidence for any meth-specific stroke treatments. Finally, the prolonged duration of meth withdrawal is described. Larger, prospective studies of meth-related strokes are needed to allow for a better understanding and improved care for this often-devastating consequence of an increasingly prevalent cause of strokes in young patients.

Alternate Graft Options for Staged Flexor Tendon Reconstruction: A Cadaveric Study of Hamstring Autografts Compared to Conventional Autografts.

PURPOSE: To compare the semitendinosus and gracilis tendon lengths and diameters to the palmaris longus, plantaris, flexor digitorum profundus, and flexor pollicis longus (FPL) tendons in a cadaveric model to evaluate the feasibility of hamstring autograft use for staged flexor tendon reconstruction. METHODS: Fifteen fresh cadavers were evaluated for surgical incisions about the knee, forearm, and hand. All flexor digitorum profundus (FDP), FPL, palmaris longus, plantaris, semitendinosus, and gracilis tendons were harvested from each specimen. Diameter and length were recorded and means with SDs were calculated. The mean diameters of the gracilis and semitendinosus were compared to the mean diameters of the FDP and FPL tendons. The hamstring tendon lengths were then compared in terms of percentage of the palmaris longus and plantaris tendon lengths. RESULTS: The gracilis (18.0 cm) and semitendinosus (19.9 cm) means were notably longer than the palmaris longus (16.0 cm) and shorter than the plantaris (30.0 cm). The average gracilis tendon diameter (3.8 mm) was smaller than the flexor tendon diameters except for the little finger FDP (3.8 mm). The semitendinosus tendon diameter (4.8 mm) was larger than all flexor tendons with the exception of the middle finger FDP (4.6 mm). Average gracilis and semitendinosus tendon diameters were 3.7 mm and 4.5 mm in males, and 3.8 mm and 4.8 mm in females. CONCLUSIONS: This study showed the gracilis tendon to have adequate length and diameter for potential autograft use in staged flexor tendon reconstruction in all digits but the little finger. The semitendinosus is larger in diameter than the native flexor tendons, making it a poor autograft option in cases with an intact pulley system. CLINICAL RELEVANCE: Common tendon autograft options for flexor tendon reconstruction are variably present, and the use of gracilis and semitendinosus autograft present potential graft options.

Intraductal Papillomas.

The most common manifestation of papillary breast disease is intraductal papilloma (IDP). As breast disease management becomes more refined, increasing attention has been directed at determining which IDPs require excision, and which can be monitored. This article will discuss the most common factors currently impacting personalized decision-making.

Surgical resection for bulky or recurrent axillary metastatic melanoma.

INTRODUCTION: Metastatic melanoma has few FDA approved treatments, and aggressive surgical resection has to be considered for management of bulky axillary metastases. We hypothesized that axillary resection in this setting is well tolerated and improves symptoms in the majority of patients. METHODS: We reviewed a prospectively collected database and identified 47 stage IIIC and IV patients with axillary nodal disease greater than 5 cm (68%), recurrent disease (36%), or disease adherent to axillary neurovascular structures (45%). Paresthesias, pain, and bleeding were present in 40% of patients, and were stable or improved after surgery in 75%. Most patients were asymptomatic prior to resection, and underwent resection for prevention of potential symptoms. RESULTS: Most patients underwent outpatient surgery. Postoperative complications included lymphedema (34%), range of motion limitation (23%), wound infection (17%), and neuropathic pain (17%). Among symptomatic patients, average time to progression was 3 months, compared to 9.5 months in asymptomatic patients (P = 0.08). Five-year survival was lower (16%) in symptomatic patients than in asymptomatic patients (35%, P = 0.001). DISCUSSION: Surgery for bulky axillary melanoma metastases is well tolerated, and should be considered in the management of Stage III or IV melanoma. Resection prior to symptoms may improve quality of life and is associated with longer survival.

Randomized clinical trials in breast cancer.

Breast cancer remains the most common cancer diagnosed in women and the second leading cause of cancer-related deaths in this group. Significant advances in the treatment of breast cancer and in the ability to screen for the disease mean that it is also one of the most curable forms of cancer. Long-term updates of the trials reviewed in the previous edition of this article have demonstrated that breast-conserving therapy remains a viable option for most patients, and that local control is related to overall survival. New chemotherapeutic options and endocrine therapies are available to select subsets of patients, and the use of endocrine therapy in breast cancer prevention has been shown to be of clear benefit. The sheer number of breast cancer-related randomized, controlled trials makes it impossible to review all level Ia evidence in this article but, where possible, extensive referencing and tabular review of related trials are used to provide the reader with a clear outline of the central data dictating current standard of care.