The secret trigger

-“Doctor…After so many years, my husband still doesn’t open up to me.”

One of the commonest concerns of ladies in steady relationships is the one expressed by Jane X. in my office a while ago. Their partners do not show the same willingness to share their innermost feelings as they are with their bodies in the bedroom’s intimacy. And they have emotional frustration.

It is far more difficult for men, especially of mature age, to confide their most intimate secrets, fears, desires as they had been often reared with the silly motto that “men don’t cry” or that “men must toughen up at all times.” Well, we all know that men do cry and it has nothing to do with our sense of manhood as there are many circumstances in life that alter our equilibrium.

For many years I’ve been pondering whether the fabled “secret trigger” that makes males forfeit their usual defensiveness and open their hearts to a particular person exist as a constitutional feature. I know I have one. But do men of all stripes and backgrounds possess such a hidden emotional lever?

Wandering the magical streets of Venice I had the sudden inspiration to write a scene of my novel where two characters inebriated with love find it. If science cannot yet confirm our assumption of its existence, the women’s sentimentality and writers’ imagination can start to shape it in our minds.

“Chiara and Saul arrived at the ‘Ponte della Donna Onesta’, a small bridge that spans the ‘Rio della Frescada’, uniting Dorsoduro with San Polo. A legend affirms that a cutler lived with his beautiful wife nearby; a young patrician ordered a knife so he could get close to her. When the artisan was absent, he raped her. Full of shame, she took her own life with the same tool.

As they were crossing it, Chiara suddenly stopped and turned around.

-“Tell me…Can a woman love a man so much as to die for him?”

-“Hu-huh…Don’t really know…It could have been more plausible in other times when women were less empowered—much more dependent on men.“

-“What do finances have to do with a woman’s feelings?”

-“ C’mon, Chiara…. I’m not the right one to answer that—”

-“What? Can’t you appreciate the devotion of a woman in love?”

Saul averted his eyes, watching the slowly moving brackish watercourse.

-“Forget it,” Chiara said, tearing a piece of krapfen. “Open your mouth—“

Caressing his face, she gently placed the morsel inside. He closed his eyes.

A Swann moment paralyzed the neural networks of his sensory grid.

Saul is tightly holding his mother Rebecca’s hand, shopping together for groceries in the Venetian quarter, right after the Sabbath ended. After they left the bakery, she pauses. “Wait, dear… Have a bite.”

She takes a crisp pastry out of the bag and gives it to her eager son. No futile words or judgements. Only categorical motherly affection. Opening his eyes, Saul grabs Chiara by her waist and kisses her.

Chiara, the bookish spinster with little life experience, finds what his late wife did not in their twenty years of marriage: his secret trigger.

Nature’s sentimental ruse that forever attaches a man to a woman.”

What do you think? Please tell us.

Don’t leave me alone.

Cannabis in PTSD – Part I

We can still remember that great scene in Oliver Stone’s “Platoon” movie where the stressed-out grunts dance in their tent while passing around a bamboo pipe. The association of marijuana with the U.S. military dates back to the Vietnam War where it was a good, ready solace for the terrified and tired soldiers in the field.

The diagnostic term “Post-Traumatic Stress Disorder” (PTSD) refers to a series of psychiatric symptoms secondary to an unusually stressful/traumatic emotional event, a common occurrence in the military. The fifth edition of the “Diagnostic and Statistical Manual” (DSM) has these criteria categories:

  • Criteria A: the person was exposed to death, threatened death of threatened serious injury or sexual violence by direct or indirect ways.
  • Criteria B: the traumatic event is consistently experienced.
  • Criteria C: avoidance of trauma-related stimulation after the trauma.
  • Criteria D: frequent thoughts or feelings that began or worsened after the trauma.
  • Criteria E: trauma related arousal and activity that began or worsened after the trauma.
  • Criteria F: symptoms last greater than one month.
  • Criteria G: creates distress or functional impairment.
  • Criteria H: symptoms are not due to medications, drug abuse or medical illness.

The PTSD complex can include the syndromes of Depersonalization (observers consider that the individual is dreaming) and Derealization (the individual feels things that do not have an external stimuli) Exposure to high explosive blasts account for a considerable number of PTSD cases, for which physicians must always suspect and rule out structural brain changes before using the PTSD label as a primary psychiatric – not physical disorder.

In PTSD there is an endocannabinoid deficiency, as the body does not produce enough to fill all the brain receptor sites; by replenishing them, the CB-1 signals deactivate the traumatic memories, avoiding the impaired fear extinction, aversive memory consolidation and chronic anxiety of PTSD. Cannabis can produce acute anxiety reactions and panic attacks, especially in individuals not used to THC. Is it an adjuvant cause or a needed relief?

A paper by the “National Center for PTSD” said that the effects of cannabis use vary according to the concentration and potency of the cannabinoids. “The concentration of THC in the marijuana plant can range in strength from less than 1% to 30% based upon strain  and cultivation methods…Cannabis extract products, such as waxes and oils, have been produced and sold in which the concentration of THC can be as high as 90%.” Even though the prolonged use of Cannabis may reduce the worst symptoms of PTSD, it can produce a steady physiological tolerance and eventually drug addiction.

We will continue this discussion in an upcoming second part of this article.

What do you think? Please tell us.

Don’t leave me alone.

The hopeless struggle

-“Doctor…How could I not discover it before? My husband is gay!”

Kathryn X. is a nice and attractive middle-aged lady that has devoted her life to take care of her husband and two children for the past fifteen years. When her husband decided to go to the gym three times per week after work, she accepted it as a necessary lifestyle compromise to lose excess weight.  However when he returned late at night, she started to have her suspicions. She didn’t know that the cause of his tardiness was not a “she” but a “he.”

In 1929 Marguerite Yourcenar published “Alexis or the treaty of the useless combat” which basically consists of a long detailed letter from a famous musician to his wife in order to tell her that he is gay and is leaving her. The sexual desire is hardly ever a single conscious decision but a series of subjective experiences that mould our loving and erotic needs in our lives. Usually the choice of mate is aligned with the sexual desire but when there is a mismatch between the two, the individual has an emotional frustration.

Dr. Walter Ghedin said: “when the homosexual desire surfaces and settles in the emotional staple, thousands of images appear in the mind.” They are:

  1. What do I do?
  2. How do I satisfy it?
  3. Do I share it with someone?
  4. Am I homosexual or bisexual?
  5. How do I live with this burden?

In most young men there is an occasional brief imagery of homosexual affinity that quickly fades away without ever being put into real practice. In other men the homosexual desire appears during the adolescence and they can conceal it with an occasional transgression that does not bother them. But in a minority of them the homosexual desire becomes stronger as they age with a firm determination to share their lives with a “special someone.”

Dr. Guedin says “when the desire and the homosexual orientation appear without a comeback in a man ‘apparently’ heterosexual, the coming out of the closet is the most healthy attitude as you cannot live in the middle pulled apart by two opposing desires…The stronger sexual desire will prevail.”

The “coming out of the closet’ will provoke a disconcerting situation for the family members, especially the concerned spouse. She will ask herself:

  1. How could I not notice it?
  2. How could I live in the middle of a lie?
  3. Why didn’t he tell me before?
  4. How am I going to tell the kids?
  5. What will my family members say?
  6. Should I have done more to retain him?
  7. Was I too careless and distracted with the kids?
  8. Should I have gone to the gym with him?

Dr. Ghedin says that “men and women that go thorough the experience of trying to understand the camouflaged sexual desire of their loved ones are in fact meshing their psyches with dilemmas and assumptions that do not help. That need to understand should be replaced by a capacity to empathise.”

What do you think? Please tell us.

Don’t leave me alone.

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.

What do you think? Please tell us.

Don’t leave me alone.

Born a rebel

-“Don’t look at anyone during the ceremony,” my grandmother Yolanda said to Gladys, my mother, right before they were ready to leave their home in Colón to attend the wedding of one of her nieces in downtown Montevideo.

Gladys was a young, beautiful and red-haired teenager that was already turning heads but  whose conservative Italian parents were raising her in an outer borough near their winery. Gifted with a good ear, my mother wanted to become a teacher of Music but my grandmother adamantly refused to buy her a piano because she might have disturbed my grandfather’s naps during her practice runs.

Rebelling against her staid upbringing, she did look at someone. My father Mario, the brother of the groom and a dashing tall young man, caught her eye; a few months later it was their turn to tie the knot. One year later yours truly was born, right in the middle of her act of disobedience.

My mother dedicated herself to take care of her children while my father pursued a career in a commercial bank, which meant long hours at his desk. My mother was always in a sunny mood and never let her two children know about her underlying frustration of not being able to pursue a teaching career and her passion for piano; only later in life did she confess that to us. But her rebellious streak simmered on and would occasionally re-surface.

One day, when I was a first-grader in the Lycée Français, I came back from school in a distraught mood. My mother noticed it when she was serving me the cafe-au-lait.

-“What’s wrong son?” she asked me.

-“Er…My teacher suddenly changed me to another room today, down the hallway…When we were practicing the alphabet, a boy next to me asked how to do the letter a…Mom, how could he not know it by now?”

-“Mmm…sounds strange. I’ll go talk to the teacher tomorrow. Don’t worry.”

In a typically authoritarian move of the rigid French educational system, my teacher (I remember her name and face very well but I will not identify her) had been upset by my hyperactive way of socializing in class and decided unilaterally, without consulting her superior or even calling my parents, to demote me to a room full of laggards of the tough learning system. And then you wonder why the Vietnamese kicked the French out in Dien-Bien-Phu…

I remember that I was promptly installed back in my room and seat the next day after my mother paid an unannounced visit and spoke with the director.

Unfazed by the incident, I unabashedly went back to my routine of turning front and back to chat in earnest. My mother was standing in the left side of the doorway feigning to be listening to two teachers on the right side of it. Over the years I learned her quaint way of dealing with stubborn contenders; she closed her eyes, slightly nodded her head and muttered the word “yes.”

Her seemingly passive attitude was the expression of camouflaged rebellion.

-“See! See!” my teacher said pointing at me. “He’s still talking around—”

-“Yes, yes” my mother said, calmly assenting. “ But he’s staying here…”

Those professionals, in spite of their training in Uruguay and an educational stint in Paris, could not handle my mother, a woman that only completed primary school.

That day I decided to conserve the great attributes of the French culture (my father’s heritage) but to develop the disarming wits and bold determination of the resilient Italian peasantry that had to learn how to neutralize many seemingly superior invaders over the centuries in order to survive. And that critical choice has served us very well.

Gracias Mamá

What do you think? Please tell us.

Don’t leave me alone.

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.

What do you think? Please tell us.

Don’t leave me alone.

The sleepwalker

-“Doctor…I sleep with only one eye closed—my son sleepwalks.”

Brenda X. is a pleasant lady in her thirties that has been babysitting her son aged seven years since he was three years old because he is a sleepwalker. She is always on the watch because he has frequent bouts of somnambulism and she guards him against any possible harm during his nightly forays.

When I was a little child I often sat up suddenly in bed and walked to the living room of our apartment in Montevideo to sit down and chat, sporting a glazed over look, with my dear father Mario who often escorted me around. He told me that after peaking at 3- 4 years old, this activity started to wane and then suddenly stopped; I never had any recollections of these events.

The sleep walking episodes occur during the initial or Non-REM phase of sleep in the initial third phase of the cycle when slow activity predominates. Sleepwalking is more common in children and its prevalence can reach up to 10% of the population; it can be inherited as an autosomal dominant trait. Patients with sleepwalking have a rise of brief arousals in the EEG tracing.

Sigmund Freud said that the unconscious sexual desires of the “Id” are usually repressed by the “Super Ego” during the waking period but when the conscience dims down, they surface to take control of the person’s volition. Those impulses metamorphose into dreams and in certain cases into motor impulses that can prodd the individual to walk and talk. Sleepwalking has been adduced to be an attenuating factor in many crimes.

Long, long time ago (before I became a monk of Medicine) I went to a New Year’s Eve party in an East Upper side townhouse in New York City… I do remember going to bed in the wee hours with a gorgeous mature brunette…I woke up the next morning in the arms of a red-haired girl in a Brooklyn flat.

What do you want me to say? Mmm…How did I manage to cross the East River in the middle of the night? Still can’t remember…

What do you think? Please tell us.

Don’t leave me alone.