The acute, systemic effects of aerobic exercise in recently concussed adolescent student-athletes: preliminary findings.

OBJECTIVES: Examine the acute effects (pre-, during, post-intervention) of two different intensities of aerobic exercise or rest on autonomic, oculomotor, and vestibular function and symptom burden in patients with a recent sport-related concussion (SRC) and compare their responses to sex-matched, age-stratified, non-concussed (HEALTHY) student-athletes. METHODS: Student-athletes between the ages of 13 and 18 that presented to the sports medicine clinic within Day 3-7 post-SRC and from local schools were recruited for a randomized controlled trial (RCT). The participants were administered the Vestibular/Ocular Motor Screening (VOMS), King-Devick (K-D), and Post-Concussion Symptom Scale (PCSS) before and after the intervention. Heart rate variability (HRV) and mean arterial pressure (MAP) were collected before, during, and after the intervention. The intervention was either a single, 20-min session of treadmill walking at 40% (40HR) or 60% of age-predicted max heart rate (60HR), or seated, rest (NOEX). RESULTS: 30 participants completed the intervention with the SRC group treated 4.5 ± 1.3 days post-injury. Pre-exercise HRV and MAP were significantly different (p's < 0.001) during treatment but returned to pre-exercise values within 5 min of recovery in both the SRC and HEALTHY groups. Both the SRC and HEALTHY groups exhibited similar reductions pre- to post-intervention for symptom severity and count (p's < 0.05), three VOMS items (p's < 0.05) but not K-D time. CONCLUSIONS: To date, this is the first adolescent RCT to report the acute, systemic effects of aerobic exercise on recently concussed adolescent athletes. The interventions appeared safe in SRC participants, were well-tolerated, and provided brief therapeutic benefit. TRIAL REGISTRATION: Clinicaltrials.gov Identifier NCT03575455.

Simultaneous robotic assisted laparoscopic prostatectomy (RALP) and inguinal herniorrhaphy (IHR): proof-of-concept analysis from a high-volume center.

PURPOSE: Inguinal hernia (IH) is detected in approximately 33% of RALP's either pre or intraoperatively wherein all are repaired during RALP to circumvent future herniorrhaphy (Fukuta et al., Urology 68(2):267-271, 2006; Nielsen, Urology 66(5):1034-1037, 2005). Some debate this policy by quoting the potential risk of mesh lying close to the vesicourethral anastomosis leading to infections and adhesions. The current study was initiated to elucidate the feasibility and outcomes of simultaneous inguinal herniorrhaphy (IHR) during RALP. METHODS: Historic analysis of prospectively maintained data of 1224 RALP patients, as per inclusion criteria, between 2012 and 2017 was done, among whom 143 patients had a concurrent IHR using 3DmaxTM polypropylene monofilament mesh. Patients were then compared for demographics, peri-operative features, and outcomes. RESULTS: The mean age and AUA score were significantly different (p < 0.002, p < 0.01 respectively) between patients undergoing only RALP and RALP with IHR. BMI was not significantly different. One hundred forty-three patients (11.6%) underwent IHR at 155 hernial sites, 12 sites being bilateral. One hundred and one sites (65.2%) were diagnosed intraoperatively. The mean console time was 67.4 ± 11.5 min for RALP which increased by 6.9 ± 10.7 min in unilateral and by 10.7 ± 8.6 min in bilateral IHR. There were no mesh-associated or Clavien Dindo class II-V complications. Mean follow-up was 36 ± 1.4 months with no recurrences. CONCLUSION: This study reiterates the feasibility and advisability of repairing most inguinal hernias encountered during RALP as it is without any significant alteration of peri-operative morbidity, is associated with excellent post-operative outcomes, and obviates the need for a future surgical procedure.

Trait anxiety mimics age-related cardiovascular autonomic modulation in young adults.

Anxiety produces maladaptive cardiovascular changes and accelerates biological aging. We evaluated cardiovascular reactivity in young and middle-aged individuals with varying anxiety scores to test the hypothesis that anxiety mimics cardiovascular aging by influencing cardiovascular autonomic modulation. The State-Trait Anxiety Inventory was used to classify healthy young individuals (20-29 years) into high (YHA, n=22;10 men) and low (YLA, n=21;10 men) anxiety, and to identify middle-aged individuals (50-60 years) with low anxiety (MLA, n=22;11 men). Heart rate, blood pressure (BP) and their variability (HRV and BPV, respectively) and baroreflex function were analyzed from beat-to-beat finger BP and electrocardiogram recordings collected during 5-min baseline, 6-min speech task (ST) and 3-min post ST recovery. Analyses of covariance showed significant differences (P<0.05) at baseline for HRV, BPV and barorelfex, and low-frequency power of systolic BP variability (LFSBP) was lower, whereas baroreflex and high frequency (HF) normalized units were higher in the YLA compared with YHA and MLA groups. Compared with YLA, YHA and MLA displayed attenuated vagal withdraw response (HF) to ST. BP and LFSBP responses to ST in YHA and MLA were higher compared with the YLA group. These findings suggest that anxiety could be linked to cardiovascular aging as it attenuates cardiac reactivity and exaggerates vascular responses to stress.

Impact of psychological distress on cardiovagal reactivation after a speech task.

Cardiovascular disease (CVD) is more prevalent in individuals with Type-D personality(distressed) who tend to avoid confrontation in social situations (social inhibition) and have a greater tendency to experience negative emotions (negative affectivity). Although psychological distress is associated with increased risk of adverse cardiovascular outcomes and impaired heart rate (HR) modulation, studies examining cardiac autonomic modulation in distressed individuals through heart rate variability (HRV) and baroreflex functioning during, and more importantly, after stress are scarce. Accordingly, we investigated blood pressure (BP), baroreflex sensitivity (BRS) and HRV responses before, during and after an interpersonal speech task (ST) in individuals with high distress scores (HD) and low distress scores (LD).

The nigrostriatal system in the presymptomatic and symptomatic stages in the MPTP monkey model: a PET, histological and biochemical study.

Parkinson's disease (PD) is diagnosed when striatal dopamine (DA) loss exceeds a certain threshold and the cardinal motor features become apparent. The presymptomatic compensatory mechanisms underlying the lack of motor manifestations despite progressive striatal depletion are not well understood. Most animal models of PD involve the induction of a severe dopaminergic deficit in an acute manner, which departs from the typical, chronic evolution of PD in humans. We have used 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) administered to monkeys via a slow intoxication protocol to produce a more gradual development of nigral lesion. Twelve control and 38 MPTP-intoxicated monkeys were divided into four groups. The latter included monkeys who were always asymptomatic, monkeys who recovered after showing mild parkinsonian signs, and monkeys with stable, moderate and severe parkinsonism. We found a close correlation between cell loss in the substantia nigra pars compacta (SNc) and striatal dopaminergic depletion and the four motor states. There was an overall negative correlation between the degree of parkinsonism (Kurlan scale) and in vivo PET ((18)F-DOPA K(i) and (11)C-DTBZ binding potential), as well as with TH-immunoreactive cell counts in SNc, striatal dopaminergic markers (TH, DAT and VMAT2) and striatal DA concentration. This intoxication protocol permits to establish a critical threshold of SNc cell loss and dopaminergic innervation distinguishing between the asymptomatic and symptomatic parkinsonian stages. Compensatory changes in nigrostriatal dopaminergic activity occurred in the recovered and parkinsonian monkeys when DA depletion was at least 88% of control, and accordingly may be considered too late to explain compensatory mechanisms in the early asymptomatic period. Our findings suggest the need for further exploration of the role of non-striatal mechanisms in PD prior to the development of motor features.

Impact of passive vibration on pressure pulse wave characteristics.

The augmentation index (AIx), a marker of wave reflection, decreases following acute leg exercise. Passive vibration (PV) causes local vasodilation that may reduce AIx. This study investigated the effects of acute PV on wave reflection and aortic hemodynamics. In a crossover fashion 20 (M=9, F=11) healthy young (22±3 year) participants were randomized to 10 min PV or no vibration control (CON) trials. Subjects rested in the supine position with their legs over a vibration platform for the entire session. Radial waveforms were obtained by applanation tonometry before and after 3 min (Post-3) and 30 min (Post-30) of PV (∼5.37 G) or CON. No change in parameters was found at Post-3. We found significant time-by-trial interactions (P<0.01) at Post-30 for augmented pressure, AIx and second systolic peak pressure (P2), such that these parameters significantly (P<0.05) decreased (-2.3±3.0 mm Hg, -7.2±6.9% and -1.5±3.5 mm Hg, respectively) after PV but not after CON. These findings suggest that acute PV applied to the legs decreases AIx owing to a decrease in wave reflection magnitude (P2). Further research is warranted to evaluate the potential clinical application of PV in populations at an increased cardiovascular risk who are unable to perform conventional exercise.

Advance directives outside the USA: are they the best solution everywhere?

This article evaluates the potential role of advance directives outside of their original North American context. In order to do this, the article first analyses the historical process which has promoted advance directives in recent years. Next, it brings to light certain presuppositions which have given them force: atomistic individualism, contractualism, consumerism and entrepreneurialism, pluralism, proceduralism, and "American moralism." The article next studies certain European cultural peculiarities which could affect advance directives: the importance of virtue versus rights, stoicism versus consumerist utilitarianism, rationalism verus empiricism, statism versus citizens' initiative, and justice versus autonomy. The article concludes by recognising that autonomy has a transcultural value, although it must be balanced with other principles. Advance Directives can have a function in certain cases. But it does not seem adequate to delegate to advance directives more and more medical decisions, and to make them more binding everyday. It is indispensable to develop other decision-making criteria.

Medicine in John Locke's philosophy.

John Locke's philosophy was deeply affected by medicine of his times. It was specially influenced by the medical thought and practice of Thomas Sydenham. Locke was a personal friend of Sydenham, expressed an avid interest in his work and shared his views and methods. The influence of Sydenham's medicine can be seen in the following areas of Locke's philosophy: his "plain historical method"; the emphasis on observation and sensory experience instead of seeking the essence of things; the rejection of hypotheses and principles; the refusal of research into final causes and inner mechanisms; the ideal of irrefutable evidence and skepticism on the possibilities of certainty in science. The science which for Locke held the highest paradigmatic value in his theory of knowledge was precisely medicine. To a great extent, Locke's Essay on Human Understanding can be understood as an attempt to justify, substantiate, and promote Sydenham's medical method. This method, generalized, was then proposed as an instrument for the elaboration of all natural sciences.

The illusion of futility in clinical practice.

The claim that a treatment is futile is often used to justify a shift in the physician's ethical obligations to patients. In clinical situations in which non-futile treatments are available, the physician has an obligation to discuss therapeutic alternatives with the patient. By contrast, a physician is under no obligation to offer, or even to discuss, futile therapies. This shift is supported by moral reasoning in ancient and modern medical ethics, by public policy, and by case law. Given this shift in ethical obligations, one might expect that physicians would have unambiguous criteria for determining when a therapy is futile. This is not the case. Rather than being a discrete and definable entity, futile therapy is merely the end of the spectrum of therapies with very low efficacy. Ambiguity in determining futility, arising from linguistic errors, from statistical misinterpretations, and from disagreements about the goals of therapy, undermines the force of futility claims. Decisions to withhold therapy that is deemed futile, like all treatment choices, must follow both clinical judgments about the chance of success of a therapy and an explicit consideration of the patient's goals for therapy. Futility claims rarely should be used to justify a radical shift in ethical obligations.