The need for sex

We can certainly agree that good and frequent sex is a healthy human habit. However when people are asked if having a lot of sex is important for the couple’s sense of well being they will say that it is not the determining factor to consider. A recent study explains the disconnect between these attitudes.

Dr. Lindsey Hicks, a psychological researcher at Florida State University, found that the frequency of sex is not directly related with people’s reporting of their satisfaction in their steady relationships but it does influence their more spontaneous and automatic responses when they are asked about it. As those automatic responses don’t require a conscious vetting, Hicks et al. believed that they might uncover some implicit perceptions and associations.

Initially they studied 216 newlywed-couples with a comprehensive survey that measured the satisfaction in their relationships. The participants rated different qualities of the marriages, their agreement or lack of it with certain statements and their satisfaction with their partners in a marriage setting. After completing the survey, they were tasked with a computer classification of responses to certain words after their partners’ pictures appeared briefly. The response time indicates how firmly two items are linked automatically; the faster the response time, the stronger the association between the two, If, after seeing the picture of their partner, the person responded more slowly to negative words than positive ones, it signified positive implicit attitudes.

Dr. Hicks did not find any direct association between the participants’ frequency of sex and their satisfaction levels, as happened in other studies. But the sexual frequency was directly related to their automatic responses; the more sex they had, the more positive attitudes towards the partners were.

This finding happened in both men and women. Another longitudinal study (extended in time) that studied 112 newlyweds confirmed that sex frequency was related with the participants’ automatic responses to the visual stimuli.

Some people are so profoundly unhappy that they can’t even admit it to themselves.

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Prevention of diabetic neuropathy

Primary care physicians, physiatrists and neurologists deal almost daily with one of the most dangerous complications of diabetes mellitus: chronic neuropathies. Its unchecked progression will eventually produce crippling foot ulcers and a neurogenic arthropathy that may lead to amputations and inability to walk.

A new position statement by the American Diabetes Association written by professionals in North America and Europe updated a consensus statement from the American Diabetes Association published in 2004. As there is an increase in diabetic cases in modern societies and too few specialists to deal with them, the preventive measures take a new Public Health significance.

The clinical exam—outlined in a step-by-step algorithm— performed by primary physicians in the office is the critical step in order to diagnose it and to defer the costly referrals to specialists for electrophysiological studies. The distal symmetric polyneuropathy (DSPN) and autonomic neuropathy are the most common clinical variants seen in the primary care practices.

People in the early stages of the disease process—called pre-diabetes—can develop a neuropathy.  The statement emphasizes that both small and large fiber neuropathy are present in patients with pre-diabetes and new onset of the disease. Close regulation of the blood glucose level can slow the progression of DSPN (distal symmetric polyneuropathy) to a certain degree.

The examination should include a good history and “either temperature or pinprick sensation (small fiber function) and vibration sensation using a 128-Hz tuning fork (large-fiber function) Patients should have a 10-g monofilament test to assess for feet at risk for ulceration and amputation.” Testing for DSPN should start 5 years after diagnosis of type I and patients with type II. Patients where motor involvement is greater than the sensory one, whose symptoms start abruptly or are asymmetric should be referred.

Diabetes is one of the few causes of neuropathy that has treatment options.

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Is endovascular therapy useful in stroke?

Five clinical trials have been designed to establish which is the treatment window and the best method to select patients for the endovascular therapy.There is a consensus that it is effective if it is started within six hours of the episode and the baseline collateral flow predicts the final treatment outcome.But there are still several unanswered questions that have been recently reviewed in a seminal paper that discusses the ongoing clinical trials.

Is thrombectomy useful if it’s implemented at more than 6 hours from onset?

The DEFUSE 3 clinical trial was designed to study the premise that this intervention might be able to salvage the brain tissue 6 hours after the event; the goal is to identify potential candidates by imaging techniques in order to use treatment protocols approved by the Federal Drug Administration (FDA)

The eligible candidates have an occlusion of the Internal Carotid artery or an MI occlusion and a target mismatch profile; those with contraindications for CT or MRI scans and a baseline NIH Stroke Scale (NIHSS) were excluded form the trial. The patients are triaged either for the thrombectomy plus the traditional therapy or that medical therapy alone. The treatment is delivered within 16 hours with a Solitaire device or a Penumbra aspiration system.

Is the Trevo thrombectomy plus medical management better after 90 days?

The DAWN trial will study the outcomes of the endovascular therapy when it is administered 6 to 24 hours after the onset of the event; the participants, randomized in a 1:1 ratio in 50 sites, will be studied at 90 days. Unlike the DEFUSE 3 study some patients will have a clinical-imaging mismatch.

Do stroke patients ineligible for t-PA benefit from the endovascular therapy?

The POSITIVE trial will study those patients that undergo a thrombectomy compared to medical therapy alone at 6 to 12 hours after the event. Patients that do not have in the imaging studies an associated large penumbra—an area that might be functionally compromised—will be excluded from it.

Is thrombectomy better for patients with moderate to good collateral flow?

The MR CLEAN LATE trial will study those eligible patients that undergo the procedure after 6 to 12 hours after the event and will enrol 500 patients. The RACECAT trial in Catalonia will determine which triage method is more effective; after the emergency responders contact the neurologists, the patients will be quickly referred to either a stroke or a thrombectomy unit.

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Is rest necessary after a sports concussion? 

 

At the “Fourth International conference on Concussion in Sport” held in Zurich in November 2012 there was a consensus among the experts that cognitive and physical rest were the pillars of the treatment of concussion. In 2013 the American Academy of Neurology released a report that concurred; those patients are at an increased risk of re-injury in the event’s aftermath.

The prevalent opinion was that people with a sports concussion should have a period of cognitive and physical rest until the post-concussive symptoms like dizziness, fatigue, headache and irritability have disappeared. Once they go back to the sports practice, they must stop it if their symptoms re-appear. However there is a budding dissenting view, which states that long periods of inactivity may lead to loss of physical fitness, anxiety and depression.

In a secondary analysis of the prospective, multicenter “Predicting Persistent postconcussive Problems in Pediatrics” study, Canadian researchers of the “Pediatric Emergency Concussion Team” enrolled 3,063 participants ranging form 5 to 17 year old who had been admitted to the Emergency Department for an acute concussion between August 2013 and June 2015. At the time of admission, data on their medical history, the characteristics of their injury and their physical and cognitive symptomatology were recorded.

At day 7 and also at day 28 the participants were contacted by telephone or email in order to question them (or their parents) based on the questionnaire of the “Zurich Consensus Statement on Concussion” return-to-play steps. Based on those responses, four levels of early physical activity were defined:

  1. No physical activity
  2. Light activity (exercise like walking, swimming, stationary cycling)
  3. Moderate activity (non-contact sports activities)
  4. Full exercise (competitive sports and/or contact sports)

The main measurement for the outcome was the presence of “persistent post-concussive symptoms” (PPCS), which was arbitrarily defined as three new or worsening symptoms on the “Post-Concussion Symptom Injury” scale at day 28 compared with the participants’ status before the concussion event.The clinical signs of PPCS happened in 24% of the participants in the group with early physical activity compared to 43.5% in the no activity-group.

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Are antipsychotics safe for the elderly?

Getting old and marching towards our inevitable passing away have never been easy for humans across the ages, except in some cultures where there is a fatalistic conception of life or a more mature assumption of natural events.In our modern societies the drama is compounded by the radical breakdown of family ties that confine the elderly people to hospitals and nursing homes.

The medical and nursing personnel of assisted living facilities seem all too ready to use antipsychotic drugs to treat the delirium of elderly patients, instead of using preventive measures like the company of someone that provides some attention and comfort to them. Nurses must limit the evening-hour disruptions in sleep, noise and lights while doctors should refrain from prescribing drugs with anticholinergic effects, treat pain and hydrate them.

MR Agar et al. studied the efficacy of risperidone and haloperidol in the treatment of delirium of elderly patients by enrolling 247 patients at 11 inpatient hospice or hospital palliative care in Australia from August 2008 to April 2014. Eighty two patients received risperidone, eighty one received haloperidol and eighty four received a placebo; age-adjusted oral doses were administered every 12 hours for 3 days based on their symptomatology.

After 72 hours the patients receiving antipsychotic drugs had significantly higher symptoms of delirium than those taking the placebo; they also had extrapyramidal effects like acute dyskinesias, dystonic reactions, tardive dyskinesia and Parkinsonism. Patients receiving haloperidol had much more sedation on the “Richmond Agitation Sedation scale” than the placebo. Patients in the haloperidol group had much better survival than the placebo.

Experts in Geriatrics have long criticized the quick fix of administering an antipsychotic drug to the usually frail elderly patients and have advocated the proper training and assignment of critical resources to physicians in the provision of environmental and biopsychosocial interventions to treat them.  Dying is a messy, oftentimes chaotic, process tainted with numerous cultural overtones, which must be understood by caregivers for the elderly patients.

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An in vivo biomarker for brain injury

 

Many research teams have been looking for a reliable tool to determine the possibility of serious neuropsychological damage after repeated brain injury. Not only are sports professionals interested in finding it for the benefit of players in contact sports but also the parents of young people practicing it.

A new study published online in JAMA Neurology describes such a tool to measure the inflammation of in the brains of football players, before the clinical deficiencies become evident. Dr. Coughlin et al. radio-tagged the protein 18 kDa (TSPO), which might be related with the activation of the microglia—the immune cells that herald the repair of injured brain tissue.

The study compared four active and 10 recently retired NFL players with 16 participants that were matched for age, sex, education and body mass index. The mean age of the players and the control participants was 31.3 years. Using TSPO radio-imaging techniques, they found that the NFL players showed significantly higher levels in 8 of the 12 brain regions examined.; there was also limited changes in the brain white matter in 13 NFL players. The neuropsychological evaluation did not yield any significant differences.

The experts disagree about the utility of this study as it involved a small number of participants and it could not be a reliable indicator of the long-tem changes in brain health over a course of a lifetime. However they all agree that it could pave the way for new clinical studies to measure the inflammation of contact sports players before crippling lesions are evident.

There is increased media attention about the brain injury of professional and amateur players of contact sports; even Hollywood has joined the frenzy with movies like “Concussion.” For parents with small children, there is a perception that they are not safe and demand alternatives like “flag football.”

As long as the civic society claims for more transparency in sports medicine that not only protects the interests of business franchises and sponsors but also the participants there will be new studies to identify biomarkers to detect early injuries to the brain.

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The risk of stroke in TAVI

Open-heart surgery is still the procedure of choice to replace an aortic valve. But in the past few years the technical improvements in catheter-based devices and the corresponding medical procedures have added to the appeal of the Transcatheter Aortic Valve replacement (TAVI) as a good alternative.Moreover the procedure is preferred for patients considered risky candidates for open-heart surgery with its sequel of complications and long recovery.

A new study from Australia found that every 10 intermediate-risk patients who underwent TAVI for severe aortic stenosis had clinical and radiological evidence of subtle neurologic injury. The study had three major flaws:

  1. Ten of the forty participants did not have the MRI studies.
  2. The implantation methods of the catheter varied.
  3. There was not a control group of patients with open-heart surgery.

TAVI is less invasive—allowing a speedier recovery of most patients—but it has the potential risk of dislodging a plaque or a clot that can travel by the bloodstream to the brain and produce a life-threatening stroke. More often there might be some subclinical neurologic injuries that produce limitations. Investigators do not know if those brain injuries produced by the TAVY are associated with a greater future risk of stroke, dementia and even death.

The choice of TAVI is not without its risks, for which patients must be fully informed of their extent before wilfully signing up for that procedure. No matter how small the strokes are they constitute a higher risk for dementia. In order to prevent these subclinical neurologic injuries during the catheter replacement, devices are being designed in order to capture the small debris.

The SENTINEL study compared the neurological outcomes of intermediate-risk patients who had TAVI with a filtering device to patients who had it without the filtering device. The filter did collect the debris but there was not a significant difference in the cognitive decline between those two groups. Researchers are now planning a bigger study to find a statistical difference.

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