Neuromodulation for Migraines

For several years we have been using the TENS machines to stimulate the Peripheral Nervous System in order to get needed relief for chronic neuro-muscular problems. The same physiological principle is being used to stimulate the Central Nervous System. One of the stealthiest developments in the treatment of Migraines has been the technological development of devices that will control the episodes. Various regulatory issues have delayed their introduction in the commercial market but they will soon become an option if insurers start to cover them. Here is a review of the three devices that have been approved by the FDA.

Transcutaneous Supraorbital Neurostimulation. It is the first device that was approved by the FDA and its commercial name is “Cefaly.” It is applied on a set of electrodes on the forehead to stimulate both supraorbital nerves. According to a scientific study the device must be used for 20 minutes per day for at least three months in order to noticed a significant reduction of headache days. It has both a high-intensity and low-intensity settings in the USA; in the EU and Canada it has a preventive, acute and chronic settings. With an approximate cost of U$ 400, it is not yet covered by the Payors.

Single-Pulse Transcranial Magnetic Stimulation. The second approved device is a single-pulse transcranial magnetic stimulator that is commercially available under the name “Spring TMS”; it is applied in the back of the skull and sends pulses forward up to the frontal area. It blocks the slow activation of cortical neurons dubbed as “cortical spreading depression” (CSD) that forms the basis of the auras patients experiment before an attack. A study found it effective at the beginning to wipe out the aura and the expected fit; the FDA has approved the deployment of two pulses right before an attack. In a preventive mode, 4 pulses are applied in both the morning and at night.It is only available to rent for 3 months with a price of U$ 150 per month.

Non-invasive Vagal Nerve Stimulation. The third device is a stimulator of the vagus nerve placed on the neck that is used for cluster headaches and set at two cycles in the treatment and prevention protocols. Two studies have shown that it can end an acute episode of cluster headache but it was not effective in the treatment of chronic cluster attacks. Also not effective in chronic migraines after 2 months, it might be effective at longer time points. It can block the CSD and down-regulate the thalamo-cortical pathways.

What do you think? Please tell us.

Don’t leave me alone.

75th Anniversary of “Casablanca”

For Ingrid Bergman and Humphrey Bogart time has come to a standstill. We always view and remember them in that final, excruciatingly romantic adieu. The film “Casablanca”, shot entirely in a backlot of Warner Brothers and that made its debut in the middle of World War II, turns 75 years old now. It was released on November 26th 1942 in the Hollywood Theatre and later won three Academy Oscars: best picture, best director and best screenplay.The sudden success of this melodrama surprised its producers and continues up to this day, as younger generations are bedazzled by its romanticism.

In “Everybody’s comes to Rick’s”, the theatre play that inspired the movie, Rick Blaine was a successful lawyer with a wife and children that decided to give everything up to open a gaming operation in Casablanca. Ilsa Lund, his lover, follows him to that city in order to continue their hot affair. Initially the producers wanted Ronald Reagan to play the central character. The character of Sam was supposed to be played by Ella Fitzgerald or Lena Horne, not a man who did not even know how to play the famous piano.

Ingrid Bergman complained several times to Michael Curtiz, the director, that Humphrey Bogart was not putting enough passion in the love scenes; the actor had a good reason to hold off, as his wife Mayo Methot was jealous. Well into the filming process the producers and director did not know how to end the movie. Will Ilsa and Rick come together? Will they separate? They re-wrote that scene many times until they found a credible way; the actors received the final script just a few hours before the shooting.

The famous line at the end of the movie—“I believe that this is the beginning of a great friendship”—was added in the post-production stage and Humphrey Bogart was expressly summoned to register it with his voice. There was a scandal in the Oscar awards ceremony when Jack Warner, the harsh head of the studio, sprinted out of his seat to receive the statue while Hal Wallis, the producer and rightful recipient of it, was blocked in his seat. When Humphrey Bogart stepped out of the car with his wife at the ceremony the crowd surged forward and was contained by a phalanx of police officers, The admirers clapped wildly and shouted: “here’s looking at you, kid.”

In this “modern” age of unbridled input of visual and auditory stimuli that literally overwhelm our capacity to process so much information in a hurry, a little slowing down to properly appreciate this masterpiece, affectionately cuddling with some good company and the drink of our choice, is a welcome alternative for a rainy weekend afternoon. A little romanticism can soothe our hearts and recharge our spirits for the long term survival.

What do you think? Please tell us.

Don’t leave me alone.

The “shameful” menstruation

-“Doctor…We would never allow her to use that contraption—a devilish invention.”

Those harsh words—reminiscent of a tirade from Savonarola in a Firenze public square during the Inquisition—were uttered when I questioned a lady why she had not instructed her daughter how to use a tampon during her menstrual period. Due to uncontrolled bleeding she had brought her to the Emergency room where I used to moonlight for long week-ends in an isolated, quaint small town in the northern hills of Georgia. Fortunately the local gynecologist was making rounds in the hospital and he took care of the situation immediately, including a long talk with the mother.

Women menstruate and have always needed ways to contain the bleeding. There are numerous accounts sine Antiquity of several types of material used to insert in the vaginal cavity and limit the blood flow, which were also used to avoid pregnancy. Egyptian women used papyrus, Greek women used gauze, Roman women used wool—materials that were highly absorbent. In our age a tampon has of a core made of cotton covered with polyethylene. The patriarchal institutions were always leery of that necessary practice as it was solely carried out by women without any manly supervision or control.

In the beginning of the 20th century, Earle Cleveland Haas designed the first commercial tampon to help his wife, a ballerina, to control her bleeding. In 1931 Gertrude Tendrich bought his patent to create the Tampax brand; the inclusion of millions of American women in the World War II factories prodded the use of the device, in spite of the silly puritanical resistance to it. A few years later Judith Esser-Mittag, a German gynecologist, designed one that did not require an applicator, which she dubbed as “o.b.”(ohne binde)

Paradoxically, in our age of women’s liberation from the social prejudices, we can still see the resilient stigmatization of menstruation in the media. TV or radio ads about tampons tend to emphasize their “hygienic” and “aesthetic value” as if that natural biological process were a shameful disease to cure.The feminine care industry has exploited that irrational “sense of dirtiness” to relegate the use of tampons to the sphere of intimacy, not to be discussed.

Menstruation is an integral part of the uniquely marvellous biological cycle of mammals that enable us to create new life and perpetuate our species. The mendacious demeaning of women’s functions must stop in the public sphere.

What do you think? Please tell us.

Don’t leave me alone.



Fatigue in Multiple Sclerosis

Fatigue is the worst debilitating symptom of patients with MS (multiple sclerosis) as it severely limits their participation in the public sphere and the workforce, besides alienating their interpersonal relationships. It has a subjective component, i.e. how patients feel, and an objective one, i.e. the diminished performance in physical and intellectual tasks. Kluger et al. created a unified taxonomy to guide its treatment in the medical settings.

Perceived fatigue is what the patient actually feels at any given time; it can be defined as a lack of purpose in daily activities that hampers performance.

Fatigability (also called performance fatigability) is what can be objectively measured by an examiner; it is defined by the measure of change in the performance of a physical or a cognitive task over a certain period of time.

Perceived fatigue is measured by the “Neurological Fatigue Index” (NFI-MS), which was approved by the FDA. It is made of 23 standard questions that cover three domains of fatigue; physical, cognitive and sleep quality. It also has a summary scale that covers the physical and cognitive domains. Fatigability can be measured with a 6-Minute Walk Test (6MWT), a grip strength test and the response speed to different cognitive tests. The third measurement of fatigability is carried out with the “Continuous Performance Test” (CPT) that checks the timely attention in front of a computer screen.

Mayis Aldughmi et al. studied the perceived fatigability and fatigability in 52 patients with mild forms of MS with a mean age of 46 years. The percent change score of the 6MWT was not statistically associated with the physical domain, the cognitive domain or the summary scale. The grip strength test change scores were not statistically associated with physical domain, the cognitive domain or the summary scale. But the performance fatigability was statistically associated with the three parameters of the NFI-MS. The data illustrates that performance fatigability during an attention-based test is associated with increased physical and cognitive perceived fatigue and the overall perceived fatigue. However those assessments of performance fatigability during a physical task did not yield some significant results. This study showed that the presence of depression was associated with fatigue.

In this study MS patients had fatigue after 3 performance fatigability tests: walking, handgrip and attention. Only attention had a statistically significant association with perceived fatigue, unlike the other 2 performance measures.

What do you think? Please tell us.


Don’t leave me alone.

Dating a younger man

-“Doctor…Only with him I can be my true self—with my imperfections included.”

Kimberly X. is a divorced, attractive, middle-aged mother of two children who is steadily dating a younger lad who seems to push all her right buttons. While she enjoys his furious stamina in bed and his obsequious attention, there is much more at play than mere physical attraction according to her. She feels totally different in his presence, much more at ease and relaxed. More confident, less defensive, definitely happier.

Before she started that relationship she used to show up in my office with a clean but slightly negligée look that included a way too frumpy long skirt; she spoke in short sentences, mostly avoiding my gaze and even stuttering. Sensing that she needed a change of lifestyle I did encourage her to go out with friends or even on her own. She met her beau in a casual visit to a bar.

After the event, she became a completely different woman with great looks and the relaxed confidence of someone who was in charge of her destiny. Her long years as a serious spouse had seared the need to spin all her stories, becoming predictably polished and protective of the image she provided. Spontaneous showing of emotions was frowned upon in her social circle and she chose not make waves for his staid accountant-husband. When he finally dumped her for his young secretary, she felt an immense sense of relief. She confessed to me that for the first time in her life she was experimenting new poses for making love with her beau and that she was enjoying it to the hilt.

Her exhilarating experience of “feeling free to express herself” reminded me of an event that had occurred to me in Italy years ago and that I never shared with anyone, except with the readers of my novel. Maurizio, one of the three main characters, is visiting the city of Torino with his grandfather and before leaving town he goes out to buy souvenirs, including a very special one to Renata, his clandestine sexy lover. It goes like this:

“They went back to the hotel to fix their belongings for the trip back.While Antonio packed the suitcase, Maurizio went out to buy the souvenirs. He found a rounded kiosk, staffed by an old woman who was sitting inside. He walked around it, gazing at the big display, trying to make up his mind. He breathed deeply and approached the old lady that was ignoring him.

-“Can you get me something that’s on the other side?” Maurizio said.

She stared at him for a second; she grabbed a bunch of keys and stood up. Going around, he pointed at a glossy German magazine titled “Anal Love” showing some young women in trance with an irrepressible carnal pleasure.

-“You’re too young to peruse this—”

-“Oh, no…It’s for my Uncle Pasquale—he’s Neapolitan.”

-“Those ‘terrones’ should better learn to work!” she said, opening the rack. “They only sit on their butts, sipping Fernet and bad-mouthing girls…”

She took the magazine out and handed it to him. He paid her and ran away.

In the next rendez-vous, he gave the present to Renata; she perused it.  After her first orgasm, she turned around. “My ass is yours—take it.”

Like a condor perched atop an Andean peak, she is ready to deploy her wings, soaring across the azure sky, to reach yet another summit.

She raises her arms. “Vaffanculo a tutti politici di Roma ladrona.”

What do you think? Please tell us.

Don’t leave me alone.


Tuberculosis and HIV

Tuberculosis is one of the leading causes of chronic disability and death in the developing world and is the first one killer of people infected with HIV. The risk of contracting TB increases with HIV, especially after the CD4 counts start to fall and even after the institution of anti-retroviral therapy. Preventive therapy with isoniazid—a cheap and well-tolerated drug—has been instituted for more than five decades with good, measurable results.

Several clinical trials have confirmed the usefulness of the preventive use of isoniazid in people already infected with the HIV virus, even without the availability of proper anti-retroviral therapy for all those patients. A large cohort study in Brazil showed that the use of isoniazid had a synergy effect in patients treated with ART, with a 76% reduction in the TB incidence. However only a million of the approximately eligible people to receive this drug, have been duly treated due to several operational handicaps, including the erroneous perception that it might interfere with the ART efficacy.

Anani Badje et al. published the results of the TEMPRANO study—a randomised clinical trial that focused on the effects of the use of isonaizid in HIV patients with CD4 counts of less than 800 cells per ul but above the threshold for starting the anti-retroviral therapy. The initial results showed that both the use of isoniazid and anti-retroviral therapy reduced the grave clinical consequences of HIV infection and the use of both had the greatest benefits. After 6 months of the use of isoniazid in HIV patients, there was a 37% reduction in the mortality rate that was independent of the ART use.

The results of the TEMPRANO study are encouraging for HIV patients because:

  1. People with high CD4 counts had good survival rates over 5 years
  2. Benefits were noted for people with and without positive tests for TB
  3. Adjustment of baseline covariates did not change the final results
  4. Benefits of the use of isoniazid were independent of the ART

There should be a more forceful design and implementation of isoniazid delivery for the HIV patients who are at high risk of contracting TB and who would benefit the most.

What do you think? Please tell us.


Don’t leave me alone.

The swinging couple

-“Doctor…My husband likes to watch me making love with another man.”

Lucy X. is a nice looking middle aged professional who had consulted me a few years ago for the treatment of an anodyne lower urinary tract infection. She spontaneously told me that her unusually active sexual lifestyle as a member of a local Swingers’ club had probably produced the “wear” effect. Her husband, another successful professional, had prodded her to join the daring experience as he was getting bored of their couple’s sexual routine. His prolonged lassitude was a source of emotional frustration for her.

One of the commonest sexual fantasies of adults is that “our significant other” has sex with another person but it usually stays in our dreamworld. In order to execute that fantasy there must be audacity and an unequivocal understanding of the pre-arranged parameters of such an encounter. Those that participate in the swinging lifestyle usually have had extensive chats with each other where the ruleS of interaction are clearly defined in advance.

According to the prevalent “swinger’s credo” the traditionally assumed fidelity of the monogamous couple prods the bored members to “try a tryst” with the inevitable emotional frustration when the truth inevitably surfaces.  Swingers claim to maintain their emotional allegiance to one particular partner but expressly allow the sexual experimentation with other people. Their sexual arousal often depends on the double role of actor and spectator in the sexual act, i.e. the “voyeur”, which is essential for their satisfaction. Their occasional partner becomes a true “object of pleasure” in their minds; in French swinging is called “échangisme”, which typifies an objectification.

The use of adequate protection like condoms to avoid mishaps is mandatory as well as the tacit understanding that a partner can say “no” anytime. The practice with non-vetted partners is discouraged. Except on a few occasions.

Long, long time ago (before I became a monk of Medicine) one of my dates suddenly looked at me in the eye in the middle of dinner at a resto. She said:

-“Hey, my married twin sister is arriving in town later tonight.”

-“Really?” I casually replied. “Should pick her up at the airport—”

-“Thanks darling,” she said caressing my face.” Mmm…do you mind if she stays with us for the week-end? She freaks out if she has to sleep alone..Don’t deny me!”

What do you want me to say? In the arduous slogging of that insomniacs’ night my generous predisposition to be a Good Samaritan got the very best out of me…

What do you think? Please tell us.

Don’t leave me alone.