Mild Traumatic Brain Injury

The risk of developing an addiction to alcohol, tobacco, or drugs increases in the period immediately following mild traumatic brain injury (mTBI) but decreases over time, new research shows. The historical prospective study showed that in the short-term, individuals with mTBI had a significantly increased risk for alcohol dependence, nicotine dependence, and nondependent abuse of drugs or alcohol compared with a similarly injured non-mTBI comparison group. "Our findings suggest an increased risk for incidence of alcohol dependence, nondependent abuse of drugs or alcohol, and nicotine dependence during the first 30 days following mild TBI and a risk thereafter for alcohol dependence for at least 6 months after injury," the authors, led by Shannon C. Miller, MD, from the Veterans Affairs Medical Center, Cincinnati, Ohio, write.

According to the investigators, addiction-related disorders have been linked to an increased risk for TBI caused by motor vehicle accidents and falls. However, they note, little research has assessed the reverse pattern. The investigators sought to assess possible associations between mTBI, commonly known as a concussion, and addiction-related disorders in active-duty US military personnel. The researchers used electronically recorded demographic, medical, and military data for more than one half million active-duty US Air Force service members. mTBI was identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes listed by the Centers for Disease Control and Prevention in 2003. According to these codes, mTBI is defined as transient confusion or disorientation, memory loss, or brief loss of consciousness. The researchers selected 5065 incident cases among airmen who were on active duty for at least 180 days between October 1, 2001, and September 30, 2008. The comparison group included 44,733 airmen who were diagnosed with an outpatient injury to the torso, spinal cord, abdomen, pelvis, digestive tract, or genitourinary tract and were designated as the "other-injured group" for the purposes of the study. Time after mTBI was divided into 3 periods: 1 to 30 days, 31 to 179 days, and longer than 180 days. The researchers found that the hazard for alcohol dependence was significantly elevated for all 3 periods in the mTBI group compared with the other-injured group. The hazard for alcohol dependence was highest in the first 30 days following a diagnosis of mTBI (hazard ratio [HR], 3.48; 95% confidence interval [CI], 1.86 - 6.51). The likelihood of alcohol dependence decreased consistently with time. At 31 to 179 days post mTBI, the HR was 2.66 (95% CI, 1.86 - 3.81), and at 180 days or longer post mTBI, the HR was 1.70 (95% CI, 1.31 - 2.21). The pattern for nicotine dependence and nondependent abuse of drugs or alcohol was similar, with the highest HR for nicotine (HR, 2.03; 95% CI, 1.56 - 2.66) and for drugs or alcohol (HR, 2.11; 95% CI, 1.65 - 2.70) occurring within the first 30 days of mTBI. The study also showed a greater risk for opioid dependence or abuse in the 1- to 30-day period (HR, 6.14; 95% CI, 1.20 - 31.31) and also in the 31- to 179-day period (HR, 3.98; 95% CI, 1.14 - 13.93). However, these 2 HRs were based on only 3 and 4 diagnoses, respectively.Previous research has indicated that the effects of mTBI resolve quickly, but the results of the current study suggest that alcohol dependence "may be a long-lasting adverse health outcome following mild TBI," the investigators write.

"Given the increasing emphasis and awareness of mild TBI in both military and civilian populations, these findings may have far-reaching clinical and military readiness implications," the authors suggest. They add that their study has limitations, including the use of multiple ICD-9-CM codes to identify mTBI. They also suggest that the codes may not have been assigned accurately in all cases, but that the strategy of using the other-injured comparison group and the use of 3 different periods could mitigate these limitations. Dr. Miller and colleagues also caution against any cause-and-effect interpretations of the study results. "Although a causal mechanism seems biopsychosocially plausible, it is not clinically intuitive that hazard ratios would be elevated so soon after the incident mild TBI (within 30 days)," they write. They conclude that any alcohol or drug use after TBI is concerning because of the potential for reduced healing, risk for seizures and repeat TBI, and exacerbation of residual cognitive, emotional, and behavioral impairments. Further, the authors call for routine screening for addiction-related disorders after mTBI and for alcohol dependence screening to continue for at least 6 months following the injury.

US Cancer Screening

In the last decade, the general US population did not meet Healthy People 2010 (HP2010) goals for cancer screening except for colorectal cancer, according to results from a US survey published online December 27 in Frontiers in Cancer Epidemiology and Prevention. However, cancer survivors met goals for all cancer types except cervical cancer.  "There is a great need for increased cancer prevention efforts in the U.S., especially for screening as it is considered one of the most important preventive behaviors and helps decrease the burden of this disease on society in terms of quality of life, the number of lives lost and insurance costs," lead author Tainya C. Clarke, MPH, a research associate in the Department of Epidemiology and Public Health at the University of Miami, Miller School of Medicine, Florida, said in a news release.  "But despite this, our research has shown that adherence rates for cancer screenings have generally declined with severe implications for the health outlook of our society," Dr. Clarke said. Despite earlier diagnoses and more effective treatments prolonging survival, cancer is still a leading cause of death and a highly prevalent chronic disease. In 2011, cancer-related deaths in the United States exceeded 570,000.  The objective of this study was to analyze 10-year trends in adherence to screening for site-specific cancers as recommended by the American Cancer Society, using the HP2010 goals as an adherence measure. Participants were 174,393 adults at least 18 years of age who completed the National Health Interview Survey between 1997 and 2010 for whom detailed cancer screening information was available. The investigators also analyzed data from 7528 working cancer survivors representing 3.8 million US workers, as well as data from 119,374 adults representing more than 100 million working Americans with no history of cancer.  The US population slightly exceeded the HP2010 goal for colorectal screening, with 54.6% of the general public having colorectal screening compared with the HP2010 goal of 50%. However, the general US population surveyed failed to meet HP2010 goals for recommended breast, cervical, and prostate cancer screening.  Cervical cancer screening rate was higher in women aged 21 years and older than in those aged 18 years and older, suggesting that increasing human papillomavirus vaccination may contribute to decreasing Papanicolaou tests. The proportion of men older than 50 years receiving prostate-specific antigen (PSA) screening decreased by nearly 20% from 1999 to 2010, which the investigators suggest might reflect questions being raised about the effectiveness of PSA screening.  In contrast to the overall population, cancer survivors met and maintained the HP2010 goal for cancer screening at all sites with the exception of screening for cervical cancer, which decreased to 78% during the last decade. Compared with the general population, cancer survivors had higher screening rates, but there was a decline among cancer survivors who took part in cancer screenings during the last 3 years. Screening rates among cancer survivors were higher for those employed in white-collar and service occupations than for those employed in blue-collar occupations. Cancer survivors report "higher screening rates than the general population," the study authors write. "Nevertheless, national screening rates are lower than desired, and disparities exist by cancer history and occupation. Understanding existing disparities, and the impact of cancer screening on survivors is crucial as the number of working survivors increases."  Limitations of this study include a reliance on self-report for the main outcome variables, that the sample size of cancer survivors employed in the farming sector was too small for analysis, and a lack of data on what type of Papanicolaou test (liquid-based or glass smear) was performed on women screened for cervical cancer.  "This declining trend foreshadows a future negative impact on mortality from cancers of the breast, and cervix as well as increased morbidity associated with a later diagnosis of prostate cancer," the study authors conclude. "Disagreements among the [US Preventive Services Task Force], the [American Cancer Society] and other recommending bodies over cancer screening guidelines may have contributed to the decline in screening throughout the decade. A decline in worker insurance rates over the decade under study could also be a contributing factor."

Carotid Artery Stenting

According to the authors, treatment options for patients with significant carotid atherosclerosis include carotid endarterectomy (CEA), carotid artery stenting (CAS), and medical therapy. This is an analysis of results from the Stenting and Angioplasty with Protection in Patients at High-Risk for Endarterectomy (SAPPHIRE) randomized trial, which examined patients at higher surgical risk to determine factors predictive of death or stroke within 30 days of CAS. A new study gives guidance on patient features that identify patients at high and low risk for stroke or death after  carotid artery stenting - CAS. Using a population of patients at high surgical risk undergoing stenting (the SAPPHIRE worldwide study), researchers identified variables that were independently associated with higher risk, including demographic, clinical history, and lesion anatomy features, with the aim of developing a bedside tool for risk prediction. "We developed and validated a predictive model and integer-based tool to predict the occurrence of death or stroke within 30 days of CAS," Neil J. Wimmer, MD, from the Division of Cardiovascular Medicine, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts, and colleagues conclude. The tool was validated internally by statistical methods, but the investigators are also in the process of validating it externally in a new dataset, told senior author Laura Mauri, MD, also from the Division of Cardiovascular Medicine, Brigham and Women’s Hospital, and Harvard Medical School. "That being said, it's pretty robust," she said of the tool. "It's been constructed in over 10,000 patients and is already in a form that's easy to use, so we hope it will be able to be used right away by clinicians to estimate risk in individual patients." Their report was published online November 5 in Stroke to coincide with its presentation at the American Heart Association Scientific Sessions 2012 in Los Angeles, California.  The  SAPPHIRE  trial was a randomized comparison of CEA (carotid endarterectomy) vs carotid angioplasty and stenting in patients deemed at high surgical risk. However, with only 334 patients, it was not large enough to determine the features strongly associated with periprocedural risk, the authors write. For this analysis, they used data from SAPPHIRE, a single-group prospective study of higher-risk patients undergoing CAS using distal protection. The goal was to develop and internally validate a model and bedside tool to predict death or stroke within 30 days of stenting in patients at higher surgical risk by using variables that could be collected easily during clinical practice, the authors write. "The prediction model generated here can be used to support decision-making." Only patients with at least a single anatomic or comorbid factor associated with elevated surgical risk were included; in all, 10,186 patients were included in the analysis. The overall rate of stroke or death was 3.6% at 30 days after carotid stenting, which, Dr. Mauri said, is "interesting, because the patients who were included in the study were selected for having a high risk for undergoing carotid endarterectomy. And there are certain consensus opinion variables that surgeons feel increase the risk of carotid endarterectomy. Well, those variables are different from the ones that pertain to carotid artery stenting." They found that elevated age, history of stroke, history of transient ischemic attack (TIA), recent myocardial infarction (MI), the need for both cardiac surgery and carotid revascularization, dialysis treatment, the presence of a type 2 or 3 aortic arch, a right-sided carotid stenosis, a longer carotid plaque, and a severely tortuous carotid arterial system were all important risk factors for the development of stroke or death within 30 days of CAS.

·         Increased age

·         History of stroke

·         History of TIA presentation

·         Recent (<4 weeks) MI

·         Dialysis treatment

·         Need for cardiac surgery as well as carotid revascularization

·         Right-sided carotid stenosis

·         Longer carotid plaque

·         Type 2 or 3 aortic arch

·         Tortuous carotid arterial system

Using these factors, the researchers developed a model and integer-based risk score for predicting stroke or death within 30 days. The model was calibrated and internally validated, using bootstrap resampling. The risk score, included in the article, assigns points for each risk factor. The sum of the points relates to the level of risk, ranging from a less than 3% risk with 8 or fewer points to a greater than 10% risk with 16 or more points. "If you just look at the table for the risk score, the most powerful predictors obviously are the ones that give you the most points, and patients who needed to have carotid surgery together with coronary revascularization were at very high risk; patients with a recent MI, patients undergoing dialysis, those were really strong predictors, in addition to patients with advanced age, particularly those who were over 70 years of age," Dr. Mauri said.

Beautiful people

Despite the widely accepted ‘What is beautiful is good’ stereotype, our findings suggest that the beautiful strive for conformity rather than independence, and for self-promotion rather than tolerance,” writes a research team led by Lihi Segal-Caspi of the Open University of Israel.

In other words, the positive traits we attribute to good-looking people are simply a matter of stereotyping. But this study, published in the journal Psychological Science, suggests the unusually attractive have a distinct set of values—and they’re not, well, pretty.

The experiment featured 236 university students (mean age 29), all of whom completed detailed questionnaires designed to uncover their personality traits and deeply held values. Half the participants—118 women—were then videotaped for roughly one minute apiece as they walked around a table and read a weather forecast while looking into the camera.
The other 118 (a mixed group, 59 percent female and 41 percent male) subsequently watched the tapes. They rated each woman for attractiveness (passing judgment on her body, voice, degree of refinement and stylishness of dress), and offered their perception of her traits and values.
In line with prior research, “perceiving a target as physically attractive was associated with perceiving her as agreeable, open to experience, extroverted, conscientious and emotionally stable,” the researchers write. In contrast, on their self-assessment forms, attractive and less-attractive women did not significantly differ on these traits.
However, attractive and less-attractive women did differ on their self-reported values. “Attractiveness correlated with values that express the motivation to conform and submit to social expectations,” the researchers write, “and with values that express a focus on self-promotion rather than on concern for others.”
This is, of course, one small sample from one small country, but the results make intuitive sense. If beautiful people get doted on from a young age, they surely get the sense that society values them highly; it follows that they’d be more likely to be conformists than rebels.
Similarly, a focus on self-promotion as opposed to empathy may suggest narcissism—but isn’t being treated as special the perfect incubator for such an attitude?

Vision and Hearing Loss in Older Adults

Among 446 older adults (mean age, 79.9 years) screened, 3 measures of low-contrast visual acuity were significantly associated with moderate bilateral hearing loss in analyses controlling for age and comorbid conditions, report Marilyn E. Schneck, PhD, and colleagues at the Smith-Kettlewell Eye Research Institute in San Francisco, California. "It is suggested that audiologists consider including a brief test of low contrast vision, such as low contrast acuity. Likewise, eye care practitioners should consider performing a screening test of hearing on their patients. Depending on the severity of the dual sensory loss, referral for rehabilitation may be called for," they write. Although most people can adapt well to moderate loss of either vision or hearing, dual sensory impairment can lead to significant decline in quality of life, said Dr. Schneck, a scientist at Smith-Kettlewell and a research scientist at the University of California at Berkeley School of Optometry. "If someone has a vision impairment and is more likely to have a hearing impairment, it has implications for things like speech reading, which we all do to some extent, but people with hearing impairment come to rely on more and more. 

If they're compromised in their low-contrast visual acuity, that could pose a problem to them when they try to make up with vision the information lost to hearing. The investigators cite evidence that dual sensory loss can have greater effects on depression, cognitive function, and quality of life compared with sensory hearing or vision loss alone. Although the study has substantial design flaws, it draws attention to the fact that older adults frequently have sensory deficits that may get overlooked, commented William J. Hall, MD, Fine Professor of Medicine at the Center for Healthy Aging at the University of Rochester School of Medicine in New York. "All healthcare providers who deal with older people need to be aware of the potential for multiple morbidities at the same time. Frankly, what I find is that we commonly miss hearing loss in older people," said Dr. Hall . However, he questioned the investigators' choice to control for age by 5- to 8-year groups rather than as a continuum, and he noted that it would be a mistake to infer from the data that a single mechanism might be responsible for both hearing and vision loss. Johanna M. Seddo, MD, ScM, director of the Ophthalmic Epidemiology and Genetics Service at the New England Eye Center at Tufts Medical Center in Boston, Massachusetts, agrees with Dr. Hall that the authors should have looked at age as a continuous variable. She also noted that the study sample was small, with only 57 of the 446 participants having moderate hearing loss. "It might also have been helpful if the authors had looked at cardiovascular risk factors [other than stroke]. For example, smoking has been shown to be a risk factor for hearing loss in some studies, and we know that it's related to diseases that cause visual loss, both macular degeneration and cataract," she said. Dr. Schneck and colleagues looked at a cohort of older adults enrolled in a longitudinal study of vision and function in Marin County, California. The participants were screened for visual function with both high-contrast and low-contrast visual acuity tests. Moderate visual impairment was defined as binocular high-contrast visual acuity worse than 0.54 logarithm of the minimum angle of resolution, equivalent to 6/21 or 20/70 or worse on a Snellen chart. The authors defined moderate hearing impairment as the inability to hear pure tones presented twice to each ear by an audioscope set to deliver 500-, 2000-, and 4000-Hz frequencies at 40 decibels. As might be expected, the investigators found that prevalence of hearing loss, visual impairment, and dual sensory deficits increased with age. For example, only 1.6% of 67- to 74-year-olds had moderate hearing impairment, compared with 32.7% of those aged 85 years and older. Similarly, although no participants in the 67- to 74-year-old age range met the vision impairment criteria, 19.1% of those aged 85 and up had at least moderate vision loss. No participants younger than age 75 had dual hearing and vision loss, compared with less than 1% of those aged 75 to 79 and 11.8% of those aged 85 and older. In multivariate logistic regression analysis controlling for age, hearing impairment was significantly positively associated with a history of cataract surgery (odds ratio [OR], 1.97; 95% confidence interval [CI], 1.01 - 3.85; P < .05) and self-reported stroke (OR, 2.69; 95% CI, 1.18 - 6.15; P < .05) and was negatively associated with a history of glaucoma (OR, 0.37; 95% CI, 0.15 - 0.88; P < .05). The overall rate of moderate visual impairment was 5.4%, and the rate of moderate, bilateral hearing impairment was 12.8%, suggesting that the conditions are linked in at least some participants, the investigators say. "If vision and hearing impairments were independent, the probability of having both would be the product of the separate impairment probabilities. In this case, we would expect dual sensory loss in 0.7% of people. In fact, the prevalence of dual sensory loss was over four times higher (3.1%), indicating that the two kinds of impairment are associated," they write. The vision measures that were significantly associated with hearing loss were overall low contrast (10%) acuity (OR, 1.50; 95% CI, 1.02 - 2.22; P < .05), low contrast acuity at low luminance (OR, 1.46; 95% CI, 1.07 - 1.98; P < .05), and low contrast and acuity in glare (OR, 1.40; 95% CI, 1.02 - 1.91; P < .05). "For any of these three measures, those who perform poorly were 40-50% more likely to have moderate bilateral hearing loss than those who scored well on that measure," the investigators write. Normal or high-contrast acuity measures were not significantly associated with hearing loss, however.

alcohol

Does moderate, prudent drinking protect the heart and arteries? Two analyses say, actually that the answer is yes. But they raise a bigger issue: What should we do with this information? The answer to that question may come as a surprise. Let's look at the findings first. Researchers from the University of Calgary, University of Texas Health Science Center, and Harvard Medical School scoured the medical literature for long-term studies that compared drinking habits with the development of cardiovascular disease. Of the 4,235 studies they identified, 84 met the researchers' strict criteria. When combined, these studies included more than two million men and women who were followed for an average of 11 years. Using a technique called meta-analysis, the researchers pooled results from the 84 publications and analyzed the data as if they were from one gigantic study. Compared with no alcohol use, moderate alcohol use over the average study duration

• reduced the risk of a new diagnosis of coronary artery disease by 29%
• reduced the risk of dying from any cardiovascular disease by 25%
• reduced the risk of dying from a heart attack or coronary artery disease by 25%
• reduced the risk of dying from any cause by 13%
• reduced the risk of having an ischemic (clot-caused) stroke by 8%
• increased the risk of dying from a stroke by 6%
• increased the risk of having a hemorrhagic (bleeding) stroke by 14%.
The amount of alcohol consumed influenced the effect. For coronary artery disease and death from it, any amount of alcohol, from just under one-half drink per day on up , reduced heart disease risk by about 25%. But this was offset by stroke risk: at four drinks per day, the risk of having a stroke was 62% higher than it was with no alcohol use, and the risk of dying from a stroke was 44% higher. The lowest risk for any cause of death was at one drink per day (BMJ, Feb. 26, 2011). A companion article by the same authors summarized the strong evidence for how alcohol might influence cardiovascular disease, by boosting protective HDL and adiponectin (a hormone that has beneficial effects on blood sugar, the breakdown of fats in the bloodstream, and the inner lining of arteries), and reducing levels of fibrinogen (a protein that helps form blood clots). Wine, beer, and spirits appeared to have similar effects.
In the United States, a standard drink contains about 0.6 fluid ounces of alcohol. The drinks shown above contain roughly that amount of alcohol. Moderate drinking is generally defined as no more than two drinks a day for men and no more than one drink a day for women. The National Institute on Alcohol Abuse and Alcoholism defines drinking as low risk, increased risk, and highest risk.
You might expect the authors of this work to conclude that drinking alcohol is good for the heart and arteries and might be recommended to some people. Instead, they concluded that "our findings lend further support for limits on alcohol consumption." The researchers based this conclusion on the complexity of alcohol's effects on health. Moderate drinking offers some protection against coronary artery disease, but it does just the opposite for hemorrhagic stroke, while heavier drinking significantly increases the risk of having or dying from a stroke. And then there's the rest of the body to consider. Alcohol affects every system in the body, from the brain on down. For people who aren't addicted to alcohol, a little bit has no long-lasting ill effects and may, in some instances, be beneficial, as with the heart and arteries. For example, a small amount of alcohol taken with a meal improves tissues' sensitivity to insulin, which may decrease the chances of developing type 2 diabetes. Excessive consumption of alcohol is only harmful. It is a major cause of preventable deaths and contributes to liver disease, a variety of cancers, and other health problems. Too much alcohol can dissolve the best intentions and the closest relationships. "Few people know what so-called safe drinking is, and many have no idea of the harm alcohol can cause," says Dr. Kenneth J. Mukamal, an author of the two BMJ papers and an internist at Harvard-affiliated Beth Israel Deaconess Medical Center.
When it comes to health, alcohol is a sharp, double-edged sword. A little bit of alcohol, in the neighborhood of a drink a day, may be beneficial for the heart and arteries. With excessive drinking, which differs from person to person, the risks or hazards outweigh the benefits. The CDC estimates that excessive alcohol use contributes to almost 80,000 deaths a year in the United States. These come from motor vehicle accidents and violence, liver disease and hemorrhagic stroke, and 50 other causes.
Immediate health risks
• motor vehicle accidents, falls, drownings, burns
• violence, including intimate partner violence and child maltreatment
• risky sexual behaviors that can result in unintended pregnancy, sexually transmitted diseases, or intimate partner violence
• miscarriage, stillbirth, physical and mental birth defects
• alcohol poisoning
Long-term health risks
• dementia and stroke
• heart attack, cardiomyopathy, atrial fibrillation, hypertension
• depression, anxiety, suicide
• family problems, unemployment
• cancer of the mouth, throat, esophagus, liver, colon, breast
• cirrhosis of the liver, alcoholic hepatitis
• pancreatitis, gastritis
For some people, having a glass of wine, a beer, or a cocktail is a pleasurable social or relaxing activity. For others, drinking alcohol leads to nothing but problems. There are more people in the latter category than we'd like to think. A nationwide survey of 43,000 adults conducted by the National Institutes of Health tells a cautionary tale. Among those who said they drink alcohol, four in 10 were heavy drinkers or at risk for becoming one. To look at it another way, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) estimates that nearly 19 million Americans have a problem with alcohol. The terms "moderate" and "excessive" have long been used to describe drinking habits. The NIAAA now uses more descriptive terms — low risk, increased risk, and highest risk. In this case, risk refers to the chances of developing alcohol-related health problems, alcoholism, or both.
Low-risk drinking. For men, this is no more than four drinks in a single day and no more than 14 drinks in a week; for women, no more than three drinks in a single day and no more than seven drinks in a week. (About 57% of Americans who drink alcohol fall into this category.) Increased-risk drinking is drinking more than either the single-day limit or the weekly limit (29% of drinkers). Highest-risk drinking is drinking more than the single-day limit and the weekly limit (14% of drinkers).
No prescription for alcohol: Studies supporting the cardiovascular benefits of drinking alcohol have often raised the question of whether some older people should start drinking, or if doctors should sometimes recommend it. "From a health perspective, there are few, if any, situations in which it makes sense for someone to begin drinking alcohol," says Dr. Mukamal. The potential benefit is limited (more exercise would be a better choice). It would take more time than most doctors can give to have a nuanced conversation about the risks and benefits of alcohol. And encouraging nondrinkers to begin drinking "doesn't make good medical sense, since there's no proof they can do it safely," Dr. Mukamal cautions. If alcohol affected only the coronary arteries, drinking it might be good medicine. But it affects almost every other part of the body, and the amount consumed determines the ultimate outcome. That means a more careful approach to this two-faced beverage is in order.