Aortic dissection in young adults who abuse amphetamines

The cardiovascular pathologist in the aortic team

Aortic diseases require a multidisciplinary management for diagnosis, treatment and follow-up with better outcomes in referral centers using a team-based approach. The setting up of a multi-disciplinary aortic team for the discussion of complex cases has been already proposed; it is also supported by the ACC/AHA. Surgeons and radiologists, more or less other physicians such as cardiologists, geneticists, rheumatologists/internal medicine specialists and pathologists are involved into such a team. The role of the cardiovascular pathologist is to examine the aortic specimens, to diagnose and classify the aortic lesions. Herein, the role of the pathologist in the aortic team is discussed and the pathobiology of aortic diseases is reviewed for reference by pathologists. The aortic specimens are mainly obtained from emergency or elective surgical procedures on the thoracic aorta, less frequently from organ/tissue (including cardiac or heart valve) donors, post-mortem procedures or abdominal aortic surgery. In the last decade, together with the progress of medical sciences, the histological definitions and classifications of the aortic pathology are undergoing thorough revisions that are addressed to an etiopathogenetic approach because of possible clinico-pathological correlations, therapeutic and prognostic impact. Pathologists may also have an important role in research and teaching. Therefore, histological analyses of the aortic specimens require adequate sample processing and pathologist expertise because histology contributes to definite diagnosis, correct management of patients and even (in genetic diseases) families, but also to research in the challenging field of aortopathies.

[Recreative drug use and cardiovascular disease]

Widely spread, and continuously increasing, recreational drug use in general population has been associated with cardiovascular events, as illustrated by clinical studies and supported by a pathophysiological rationale. Understanding the cardiovascular effects of drugs, screening, and secondary prevention are crucial components in the management of those patients in cardiology.

An Uncommon Presentation of Acute Thoracic Aortic Dissection

We present a case of a 40-year-old Caucasian male with past medical history of polysubstance abuse (cocaine and methamphetamine), who presented to the emergency department (ED) complaining of intermittent cough with associated chest discomfort and shortness of breath for 2 weeks. Initial vital signs demonstrated borderline tachycardia (98 beats per minute), tachypnea (37 times per minutes), and hypoxia (oxygen saturation 89% on room air), and his physical exam was grossly unremarkable. A preliminary workup including a computed tomography angiography (CTA) revealed a type A aortic dissection with both thoracic and abdominal involvement for which the patient was admitted. This patient had resection of the ascending aorta with graft placement, cardiopulmonary bypass, aortic root replacement using composite prosthesis and left and right coronary reconstruction and reimplantation and survived a complicated hospital course. This case demonstrates the classic association known to exist between recreational drug use, specifically stimulants such as cocaine and amphetamines, and acute aortic dissection (AAD). However, such a presentation of borderline subacute, painless dissection in the setting of polysubstance use raises further questions, since uncommon AAD is typically found in higher-risk populations such as those with connective tissue disorders (Marfan syndrome, Ehlers-Danlos syndrome, Loeys-Dietz syndrome), bicuspid aortic valve, chronic hypertension, or previous aortic pathology. We therefore suggest clinicians strongly consider uncommon AAD as part of their differential diagnosis in patients with known or highly suspected polysubstance abuse.

Acute aortic dissection

Although substantial progress has been made in the prevention, diagnosis, and treatment of acute aortic dissection, it remains a complex cardiovascular event, with a high immediate mortality and substantial morbidity in individuals surviving the acute period. The past decade has allowed a leap forward in understanding the pathophysiology of this disease; the existing classifications have been challenged, and the scientific community moves towards a nomenclature that is likely to unify the current definitions according to morphology and function. The most important pathophysiological pathway, namely the location and extension of the initial intimal tear, which causes a disruption of the media layer of the aortic wall, together with the size of the affected aortic segments, determines whether the patient should undergo emergency surgery, an endovascular intervention, or receive optimal medical treatment. The scientific evidence for the management and follow-up of acute aortic dissection continues to evolve. This Seminar provides a clinically relevant overview of potential prevention, diagnosis, and management of acute aortic dissection, which is the most severe acute aortic syndrome.

Intranasal Use of Prescription Stimulants Among Adults Aged 18 to 30: Results From A Crowdsourcing Platform

OBJECTIVE

Few studies of prescription stimulant non-oral, non-medical use (NMU) (defined by use not as prescribed) have been conducted in adults beyond the college population. The purpose of this study was to characterize prescription stimulant non-oral use, specifically intranasal (IN) use (snorting) in young adults.

METHOD

Amazon's MTurk platform was used to recruit participants for an online survey. Data were collected from March to April 2020.

RESULTS

Thirty-two percent (n = 157) of survey respondents (N = 975), aged 18 to 30, reported IN prescription stimulant use (average of 32.1 episodes of lifetime IN use). Adderall was the most-reported prescription stimulant used intranasally (89.2%). Most IN users (82%; n = 68) reported spending no more than 5 minutes tampering with prescription stimulants. Intranasal users said they would take the medication orally if unable to tamper or manipulate medication for IN use.

CONCLUSION

These data help quantify a complex public health issue of ongoing IN use of prescription stimulants and suggest a potential role for manipulation-deterrent medications.

The effects of methamphetamine on electrocardiographic parameters in male patients

OBJECTIVE

We aimed to compare the electrocardiographic parameters in patients with methamphetamine use to healthy controls.

METHODS

The study is a cross-sectional case-control study. Sixty-eight patients diagnosed with methamphetamine use disorder (MUD) according to DSM-5 criteria and 65 subjects in healthy control group who can match the patient group with demographic data were included in the study. Heart rate, P wave dispersion, QT dispersion, QTc and Tp-e/QTc ratios were calculated in the ECGs of all participants.

RESULTS

The mean age of the patients was 25.60 ± 5.70 and of the control group was 27.43 ± 6.10 (p = 0.076). There was no statistically significant difference between the blood pressure, body mass index, HDL-LDL-total cholesterol and triglyceride values of the participants (p > 0.05). Although QT dispersion was 13.68 ± 9.12 in patients with methamphetamine use disorder, it was calculated as 9.08 ± 7.85 in the control group (p = 0.002). Finally, the Tp-e/QTc ratio of the patients was higher than the healthy controls (p = 0.014).

CONCLUSION

In our study, we found a significant deterioration in QT dispersion and Tp-e/QTc ratio in the MUD group. Therefore, it should be kept in mind that there is a risk of malignant arrhythmia in this patient group and care should be taken in terms of arrhythmic events during follow-up in this patient group.Key pointsPatients with methamphetamine use showed significant deterioration in QTd and Tp-e/QTcMethamphetamine users have prolonged Tp-e/QTc ratio and QTdCaution should be exercised in terms of arrhythmic events in methamphetamine users.

Methamphetamine induces thoracic aortic aneurysm/dissection through C/EBPβ

AIMS

Thoracic aortic aneurysm/dissection (TAAD) is a life-threatening disease with diverse clinical manifestations. Although the association between methamphetamine (METH) and TAAD is frequently observed, the causal relationship between METH abuse and aortic aneurysm/dissection has not been established. This study was designed to determine if METH causes aortic aneurysm/dissection and delineate the underlying mechanism.

METHODS AND RESULTS

A new TAAD model was developed by exposing METH to SD rats pre-treated with lysyl oxidase inhibitor β-aminopropionitrile (BAPN). Combination of METH and BAPN caused thoracic aortic aneurysm/dissection in 60% of rats. BAPN+METH significantly increased the expression and activities of both matrix metalloproteinase MMP2 and MMP9, consistent with the severe elastin breakage and dissection. Mechanistically, METH increased CCAAT-enhancer binding protein β (C/EBPβ) expression by enhancing mothers against decapentaplegic homolog 3 (Smad3) and extracellular regulated protein kinase (ERK1/2) signaling. METH also promoted C/EBPβ binding to MMP2 and MMP9 promoters. Blocking C/EBPβ significantly attenuated METH+BAPN-induced TAAD and MMP2/MMP9 expression. Moreover, BAPN+METH promoted aortic medial smooth muscle cell (SMC) apoptosis through C/EBPβ-mediated IGFBP5/p53/PUMA signaling pathways. More importantly, the expression of C/EBPβ, MMP2/MMP9, and apoptosis-promoting proteins was increased in the aorta of human patients with thoracic aortic dissection, suggesting that the mechanisms identified in animal study could be relevant to human disease.

CONCLUSIONS

Our study demonstrated that METH exposure has a casual effect on TAAD. C/EBPβ mediates METH-introduced TAAD formation by causing elastin breakage, medial cell loss and degeneration. Therefore, C/EBPβ may be a potential factor for TAAD clinical diagnosis or treatment.

Characterizing prescription stimulant nonmedical use (NMU) among adults recruited from Reddit

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Adults reporting past 5-year non-oral prescription stimulant NMU were studied.

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Non-oral NMU preferences were snorting (59%) injecting (4%) or smoking (1%).

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Polysubstance use was reported by 79.1% of the sample.

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Route of administration and motivation for prescription stimulant NMU were related.

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Prescription stimulant oral and intranasal NMU was to enhance performance.

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Prescription stimulant intravenous and smoking NMU was to get high.

Objective

Increased prescription stimulant nonmedical use (NMU) is part of a growing polysubstance use landscape. The purpose of the present study was to characterize prescription stimulant NMU among adults reporting past 5-year non-oral prescription stimulant NMU.

Methods

Adults who reported non-oral prescription stimulant NMU within the last 5 years were recruited by banner ads placed on the Reddit website between February and September 2019. Types of prescription stimulants used, routes of administration, preferred routes of administration, motivations for prescription stimulant NMU, concurrent substances used simultaneously during prescription stimulant NMU, illicit substances used and factors impacting prescription stimulant NMU were queried.

Results

Respondents (n = 225) were male (86.2%), non-Hispanic (92.4%), white (78.2%), between 18 and 24 (48.0%) or 25–34 (43.1%) years with some amount of college education (81.3%). Most reported lifetime intranasal (93.8%) or oral use (85.2%). Prescription stimulants were diverted: 64.5% reported the prescription stimulants were given to them by a family or a friend and 10.5% reported that they had stolen these medications from a family or friend. Preferred route of administration was oral use (70.2%). Motivations to use were stratified by route of administration: intranasal (55.6%) or oral (63.0%) use was primarily endorsed as an attempt to enhance performance at work or at school; use by injection (57.1%) or smoking (62.5%) was primarily endorsed to get high. Most of the sample reported concurrent drug use (79.1%) including tobacco (57.3%), marijuana (52.0%), caffeine (47.6%) or alcohol (41.8%), among others. When excluding licit substances, 30.7% reported using 1 illicit substance concurrently with prescription stimulants and 25.3% reported using 2 or more illicit substances concurrently with prescription stimulants. Whether participants would undertake prescription stimulant NMU was determined by their work/school schedules or the location of the NMU (48.9%) whereas the route of administration employed was primarily influenced by the desired feeling or effect (56.9%).

Conclusions

Adults reporting lifetime non-oral prescription stimulant NMU engage in substantial risky behaviors that in addition to alternate routes of administration include polysubstance use, diversion and concurrent substance use.

Internal carotid artery and bilateral vertebral arteries dissections associated with amphetamine abuse: Case report

Arterial dissection is an important cause of stroke in young patients. Various factors influencing arterial dissection included amphetamine abuse and anterior circulation is the majority of stroke locations. We reported the Case of a 40-year-old male patient with chronic amphetamine used since childhood. He had increased the consumption from once a month to every other day in the last year. The patient suffered from acute left-side hemiparesis and neglect. Computed tomography angiography of the brain and neck vessels demonstrated non-atheromatous vasculopathy with a suspected dissection process of the right internal carotid artery and bilateral vertebral arteries. A review of recent data is also provided to clarify the possible mechanism.

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Arterial dissection is one of the most common causes of stroke in young-adults.

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Dissection of both anterior and posterior cerebral circulations is extremely rare.

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Amphetamine abuse has been described as a potential cause of arterial dissection.

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Drug abuse screening should be performed in stroke in the young presuming dissection.

Sexual orientation, gender identity, and gender expression: From current state to solutions for the support of lesbian, gay, bisexual, transgender, and queer/questioning patients and colleagues

Many of the systemic practices in medicine that have alienated lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) individuals persist today, undermining the optimal care for these patients and isolating LGBTQ medical providers from their colleagues. The 2020 Task Force on Diversity, Equity, and Inclusion Report recently published by the Society for Vascular Surgery marked the first publication advocating for the inclusion of sexual orientation and sexual identity in the development of initiatives promoting and protecting diversity across vascular surgery. Vascular providers should be aware that it is crucial to cultivate an environment that is inclusive for LGBTQ patients because a large proportion of these patients have reported not self-disclosing their status to medical providers, either out of concern over potential personal repercussions or failing to recognize the potential relevance of LGBTQ status to their medical care. Safe Zone training has provided a standard resource for providers and staff that can be integrated into onboarding and routine training. Clarifying the current terminology for sexual orientation and identity will ensure that vascular providers will recognize patients who could benefit from screening for additional vascular risk factors relevant to this population related to sexual health, social behavior, physical health, and medical therapies. The adoption of gender neutral language on intake forms and general correspondence with colleagues is key to reducing the unintended exclusion of those with LGBTQ identities in both inpatient and outpatient environments. In many locales across the United States, the professional and personal repercussions for openly reporting LGBTQ status persist, complicating efforts toward quantifying, recognizing, and supporting these patients, practitioners, and trainees. Contributing to an inclusive environment for patients and peers and acting as a professional ally are congruent with the ethos in vascular surgery to treat all patients and colleagues with respect and optimize the healthcare of every vascular patient.

Spontaneous dissection of bilateral internal carotid and vertebral arteries

Spontaneous dissection of the major arteries of the neck is known to increase the risk of stroke or transient ischaemic attack in young and middle-aged adults. Most of the reported cases of arterial dissections in the neck involve one or both paired extracranial carotid or vertebral arteries. Spontaneous dissection of the bilateral internal carotid and vertebral arteries is extremely rare. We report a case of spontaneous bilateral internal carotid artery and vertebral artery dissection while using a prescribed pill for weight loss which contained amphetamine derivative. A review of literature is also provided.

Vertebral Artery Dissection Related to Amphetamine Abuse - A Case Report

We report the case of a 37-year-old male patient with chronic amphetamine abuse who presented with vertebral artery dissection. Prior to presentation, he had increased the consumption of amphetamine from 5 times a year to once every week and had used amphetamine on the day of presentation. He attended with neck pain, vertigo and coordinating difficulties of his left arm. Computed tomography angiogram of the neck vessels showed a left vertebral stenosis and cerebral magnetic resonance imaging showed a left vertebral pseudolumen and a medullary stroke. Cervical artery dissection is a major cause of stroke in the young. To the authors’ knowledge, this is the second reported case of vertebral artery dissection in a patient with amphetamine abuse. Amphetamine might contribute to an increased risk of vertebral artery dissection through its vasculopathic properties although more data are needed to establish a causal relationship.

Causal Attributions in an Australian Aboriginal Family With Marfan Syndrome: A Qualitative Study

Causal attributions are important determinants of how health threats are processed and affect health-related behaviors. To date, there has been no research on causal attributions in genetic conditions in Aboriginal Australians. Forty members of a large Aboriginal Australian family with Marfan syndrome (MFS) were invited to participate in an ethically approved study exploring causal attributions, including perceived causes of phenotypic variability within the family. Eighteen individuals consented to conduct semi-structured qualitative interviews, which were recorded, transcribed verbatim and analyzed thematically. Most participants knew that MFS was genetic, but there were diverse theories about inheritance, including beliefs that it skipped generations, was affected by birth order and/or gender, and that it co-occurred with inheritance of blue eyes within this family. The mutation was thought to have been inherited from British settlers and initially triggered by disease or diet. Factors believed to modify disease severity included other genes and lifestyle factors, particularly alcohol and substance abuse and stress. Generally, this family did not endorse “blaming” chance or a higher power for phenotypic variability, though some felt that the spirits or a deity may have played a role. In conclusion, although participants knew MFS was a genetic condition, many speculated about the role of non-genetic causes in initiating the original mutation; and the gene-environment interaction was thought to affect severity. This study demonstrates a successful approach for exploring causal attributions in other genetic conditions in First Australians.

High-Risk Chief Complaints I: Chest Pain-The Big Three (an Update)

Nontraumatic chest pain is a frequent concern of emergency department patients, with causes that range from benign to immediately life threatening. Identifying those patients who require immediate/urgent intervention remains challenging and is a high-risk area for emergency medicine physicians where incorrect or delayed diagnosis may lead to significant morbidity and mortality. This article focuses on the 3 most prevalent diagnoses associated with adverse outcomes in patients presenting with nontraumatic chest pain, acute coronary syndrome, thoracic aortic dissection, and pulmonary embolism. Important aspects of clinical evaluation, diagnostic testing, treatment, and disposition and other less common causes of lethal chest pain are also discussed.

Characterizing Pathways of Non-oral Prescription Stimulant Non-medical Use Among Adults Recruited From Reddit

Objective: Prescription stimulant non-medical use (NMU) is a national predicament. While the risks of prescription stimulant NMU have been considered, less is known about non-oral use. To focus on this gap, a sample of adults with non-oral prescription stimulant NMU within the last 5-years was recruited. The purpose of the present study was to characterize the pathways and substance transitions associated with prescription stimulant NMU and non-oral prescription stimulant NMU in this unique sample of adults. Methods: Adults (n = 225) reporting non-oral prescription stimulant NMU within the last 5 years were recruited to complete an online survey by banner ads placed on the Reddit website between February and September 2019. After completion of the survey, a second study consisting of an in-depth telephone interview was conducted with 23 participants: interviews took place between July and September 2019. Data reported here include substance, route of administration and class transitions, as well as qualitative data from the interviews. Results: Approximately 1 in 5 began their substance use trajectory with prescription stimulants (19.1%). Other than marijuana, most exposures to illicit substances occurred after both initial prescription stimulant NMU and initial non-oral prescription stimulant NMU. The most frequently reported route of administration transition was from oral use to snorting (n = 158, 70.2%), however, other route of administration transitions included oral use to injection drug use (n = 14, 6%). In-depth interviews elaborated upon these transitions and indicated that prescription stimulant NMU was consequential to substance use pathways. Conclusions: Oral prescription stimulant NMU was a precursor to non-oral prescription stimulant NMU. Non-oral prescription stimulant NMU was a precursor to illicit substance use, suggesting that prescription stimulant NMU impacts substance use pathways and revealing opportunities for intervention.

Endovascular management of iatrogenic dissection into the petrous segment of the internal carotid artery during mechanical thrombectomy for acute stroke

Iatrogenic dissection of the internal carotid artery is a well-known complication that can occur during mechanical thrombectomy for acute stroke. The vast majority of these injuries are limited to the cervical segment, and only in exceptional circumstances do they require surgical intervention. In the present case, extension of the lesion into the petrous segment of the carotid artery resulted in an acute neurologic decline necessitating emergent endovascular repair. We discuss the nuances of managing an exceptionally rare presentation of this complication.

Cerebrovascular and cardiovascular diseases caused by drugs of abuse

Drugs such as stimulants, sedatives, sleeping pills, and narcotics are associated with drug abuse and are therefore regulated by law. Physical dependence on these drugs is sometimes difficult to control despite an awareness of the problems they cause in daily life and the harm they can cause to the body. Drug dependence is a social problem worldwide, and the physical implications are serious. Many of these drugs cause cerebrovascular and cardiovascular diseases, which often require emergency medical treatment. Differential diagnosis is essential because of the likelihood of life-threatening events, especially among young people who exhibit cerebrovascular and cardiovascular diseases without any of the typical risk factors. Drugs of abuse, especially stimulants, induce a hyperadrenergic state that evokes vasoconstriction and tachycardia, as well as subsequent ischemic and hemorrhagic stroke, acute coronary syndrome, arrhythmias, and aortic dissection. Chronic drug abuse can also cause cardiac hypertrophy and left ventricular dysfunction. As a treatment for these conditions, sedative drugs can be effective but the use of vasodilators may also be required. There are concerns that the use of both alpha- and beta-adrenergic receptor blockers may cause tachycardia and increased blood pressure. Therefore, careful differential diagnosis and selection of therapeutic agents is required.

Methamphetamine use association with pulmonary diseases: a retrospective investigation of hospital discharges in California from 2005 to 2011

BACKGROUND

Methamphetamine can have acute and long-term adverse health consequences. Our objective was to determine whether methamphetamine use is associated with more hospitalisation codes for asthma exacerbation, chronic obstructive pulmonary disease (COPD) exacerbation, pneumonia and acute respiratory failure (ARF).

METHODS

The Health Care Utilization Project (HCUP) database includes retrospective inpatient discharge abstracts from 2005 through 2011 from the California state inpatient databases (SIDs). ICD-9 codes were used to identify hospitalisations for asthma exacerbation, COPD exacerbation, acute pneumonia, ARF and methamphetamine use from discharges with complete demographic data and ages 18 to 75 years. Adjusted rate ratios comparing methamphetamine users with nonusers were estimated separately for each pulmonary disease diagnosis by sex using negative binomial regression models.

RESULTS

We included 21 125 249 inpatient discharges from 2005 through 2011 in California in our analysis; 182 766 (0.87%) had methamphetamine use. The rate ratio comparing pneumonia in discharges with methamphetamine use versus those without were 1.40 (95% CI 1.18, 1.67) for women and 1.18 (95% CI 1.04, 1.35) for men; comparing ARF 1.77 (95% CI 1.59, 1.98) for women and 1.24 (95% CI 1.12, 1.37) for men; and comparing COPD exacerbation 1.40 (95% CI 1.18, 1.67) for women and 0.90 (95% CI 0.79, 1.02) for men.

CONCLUSIONS

A positive association was found when comparing inpatient hospital discharge diagnoses for methamphetamine use and those for pneumonia and ARF in both sexes. This association was not seen when comparing discharge diagnoses for methamphetamine and those for asthma exacerbation in both sexes or COPD exacerbation in men. While future investigation for is warranted, this finding may help to further characterise the pulmonary toxicity of methamphetamine.

Age-related presentation of acute type A aortic dissection

BACKGROUND

We evaluated the clinical and anatomic presentations of acute type A aortic dissection according to patient age.

METHODS

We retrospectively reviewed 235 consecutive patients who underwent acute type A dissection repair between January 2000 and December 2014. The influence of age on anatomical and clinical presentation, surgical management in the entire cohort and also after exclusion of patients with known connective tissue disorders was assessed using logistic regression.

RESULTS

Males presented with type A acute aortic dissection at a younger age than females. Acute onset with signs of myocardial ischemia, connective tissue disorders, or bicuspid aortic valve characterized the younger population. Extension to the coronary sinus(es) ( p = 0.0003), descending thoracic aorta ( p = 0.016), and abdominal aorta ( p = 0.029), and an intimal tear at the level of the aortic root ( p = 0.0017) correlated inversely with patient age. Similar findings were obtained after exclusion of patients with connective tissue disorders or a bicuspid aortic valve.

CONCLUSIONS

More frequent proximal and distal progression of the dissection flap occurs in younger patients with acute type A aortic dissection. Older age is associated with a lower probability of an intimal tear at the level of the sinus of Valsalva. These findings, associated with prognostic implications, account for the choice of more radical proximal procedures for repair of aortic dissection in younger patients.

Genetic diagnostics of inherited aortic diseases : Medical strategy analysis

Genetic aortic syndromes (GAS) include Marfan, Loeys-Dietz, vascular Ehlers-Danlos, and Turner syndrome as well as congenital bicuspid aortic valve. The clinical management of these diseases has certain similarities and differences. We employed medical strategy analysis to test the utility of genetic diagnostics in the management of GAS. We chose the standpoint of the cardiologist for our analysis. In the first step, the medical goals in the management of GAS are specified. In the second step, the accuracy of genetic diagnostics for GAS is examined. Finally, conclusions can be drawn about the utility of genetic diagnostics in managing GAS. We found that genetic diagnostics is necessary to exclude GAS, to diagnose GAS, and to specify disease types. Second, combining phenotype with genotype information maximizes the predictability of the course of disease. Third, with genetic diagnostics it is possible to predict the birth of children with causative mutations for GAS and to initiate drug therapy to prevent the onset of aortic dilatation or to slow down its progression to aortic aneurysm. Finally, genetic diagnostics improves prognostic predictions and thereby contributes to a better timing of elective surgery and to a better choice of procedures. The findings of our medical strategy analysis indicate the high utility of genetic diagnostics for managing GAS.

Acute aortic emergencies--part 2: aortic dissections

Patients with aortic disease are some of the highest acuity patients that emergency clinicians encounter. Dissection is the most common aortic catastrophe and involves separation of the aortic layers in a longitudinal fashion leading to diminished perfusion and systemic ischemia. Characteristics of pain, branch vessel involvement, and incidence lead to an understanding of patient presentation, morbidity, and mortality. Diagnosis, selection of diagnostic studies, the degree of preoperative ischemia, and risk of operative mortality can be accomplished using validated clinical decision tools. Emergency interventions are guided by the type of dissection according to the Stanford classification system. Medical management includes pain control and anti-impulse, antihypertensive therapy through vasodilatation and blockage of the sympathetic β-response. The patient may then be evaluated for open surgical intervention, aortic fenestration, endovascularly placed stent grafts, or a combination possibly in a staged approach. Morbidity includes rupture, stroke, paraplegia, acute renal failure, bowel ischemia, and peripheral ischemia.

Genes in Thoracic Aortic Aneurysms and Dissections - Do they Matter?: Translation and Integration of Research and Modern Genetic Techniques into Daily Clinical Practice

Since the identification of the fibrillin-1 gene as the causal gene for Marfan syndrome, our knowledge of molecular genetics and the applicability of genetic testing in clinical practice have expanded dramatically. Several new syndromes related to thoracic aortic aneurysms and dissections (TAAD) have been described and the list of underlying genes in syndromal and nonsyndromal TAAD already includes more than 10 different genes and is rapidly expanding. Based on this knowledge, our insights into the underlying pathophysiology of TAAD have improved significantly, and new opportunities for targeted treatment have emerged. Clinicians involved in the care of TAAD patients require a basic knowledge of the disease entities and need to be informed on the applicability of genetic testing in their patients and families. Gene-tailored treatment and management is indeed no science fiction anymore and should now be considered as part of good clinical practice. We provide a systematic overview of genetic TAAD entities and practical recommendations for genetic testing and patient management.

[The medical treatment of attention deficit hyperactivity disorder (ADHD) with amphetamines in children and adolescents]

INTRODUCTION

Psychostimulants (methylphenidate and amphetamines) are the drugs of first choice in the pharmacological treatment of children and adolescents with attention deficit hyperactivity disorder (ADHD).

OBJECTIVE

We summarize the pharmacological characteristics of amphetamines and compare them with methylphenidate, special emphasis being given to a comparison of effects and side effects of the two substances. Finally, we analyze the abuse and addiction risks.

METHODS

Publications were chosen based on a Medline analysis for controlled studies and meta-analyses published between 1980 and 2011; keywords were amphetamine, amphetamine salts, lisdexamphetamine, controlled studies, and metaanalyses.

RESULTS AND DISCUSSION

Amphetamines generally exhibit some pharmacologic similarities with methylphenidate. However, besides inhibiting dopamine reuptake amphetamines also cause the release of monoamines. Moreover, plasma half-life is significantly prolonged. The clinical efficacy and tolerability of amphetamines is comparable to methylphenidate. Amphetamines can therefore be used if the individual response to methylphenidate or tolerability is insufficient before switching to a nonstimulant substance, thus improving the total response rate to psychostimulant treatment. Because of the high abuse potential of amphetamines, especially in adults, the prodrug lisdexamphetamine (Vyvanse) could become an effective treatment alternative. Available study data suggest a combination of high clinical effect size with a beneficial pharmacokinetic profile and a reduced abuse risk.

CONCLUSIONS

In addition to methylphenidate, amphetamines serve as important complements in the psychostimulant treatment of ADHD. Future studies should focus on a differential comparison of the two substances with regard to their effects on different core symptom constellations and the presence of various comorbidities.

Diabetes and reduced risk for thoracic aortic aneurysms and dissections: a nationwide case-control study

BACKGROUND

Vascular diseases are the principal causes of death and disability in people with diabetes. At the same time, studies suggest a protective role of diabetes in the development of abdominal aortic aneurysms. We sought to determine whether diabetes is associated with decreased hospitalization due to thoracic aortic aneurysms and dissections (TAAD).

METHODS AND RESULTS

We used the 2006 and 2007 Nationwide Inpatient Sample (NIS) to determine TAAD discharge rates. Control subjects were randomly selected to achieve three controls per case. Predictor variables in multilevel logistic regression included age, race, median income, diabetes, and hypertension. We estimated that the average rate of hospital discharge for TAAD among individuals diagnosed with diabetes was 9.7 per 10 000, compared to 15.6 per 10 000 among all discharges. The prevalence of diabetes was substantially lower in TAAD (13%) than in control (22%) records. After adjustment for demographic characteristics, the negative association between diabetes and TAAD remained highly significant in both NIS datasets. Compared to discharges without diabetes, those with chronic complications of diabetes were least likely to be diagnosed with TAAD (OR [odds ratio] 0.17, 95% CI, 0.12-0.23). A significant association remained between uncomplicated diabetes and TAAD. We replicated these findings in an independent group of patients who were hospitalized with acute thoracic aortic dissections.

CONCLUSIONS

The principal implication of our findings is that diabetes is independently associated with a decreased rate of hospitalization due to TAAD in proportion to the severity of diabetic complications. Future studies should consider diabetes in predictive models of aneurysm expansion or dissection. (J Am Heart Assoc. 2012;1:jah3-e000323 doi: 10.1161/JAHA.111.000323.).