January 31, 2014
By Mary Pickett M.D.
Harvard Medical School
What's the latest news in the medical journals this month? Find out what your doctor is reading.
Giving Your Brain a Rest after Concussion Leads to Faster Recovery
When a person suffers a concussion, a good coach or doctor will tell the patient to take a break from high-impact sports until symptoms have resolved. But in addition to avoiding impact trauma, is it important for the brain to rest in other ways? Maybe so. A study that was published online January 6 by the journal Pediatricsshowed faster recovery for concussion patients who temporarily cut back on time spent in academic activities and other cognitive (mental) activities.
Researchers tracked the recovery of 335 young patients (ages 8 years to 23 years) who suffered concussions. The patients reported the amount of cognitive activity they participated in during the initial weeks after their injury. The categories were "complete cognitive rest" (no reading, no computer time or videos), "minimal cognitive activity" (no reading or homework, and less than 20 minutes per day of online activity and video games), "moderate cognitive activity" (reading less than 10 pages per day, and less than 1 hour total of homework, online activity and video games), "significant cognitive activity" (reading less and doing less homework than usual), or "full cognitive activity" (no change in activities).
The self-ratings occurred several times during the course of the study. Researchers used the ratings to rank patients from most to least rested. The speed of recovery was interesting. People who ranked in the busiest 25% for cognitive activity after their accident took an average of about 100 days to recover from their symptoms. But patients in the other groups said they felt fully recovered in fewer than 50 days. Moderate and minimal cognitive activity got the same recovery times as did complete cognitive rest. The researchers found that complete rest offered no measurable advantage (and is unnecessary).
This study does not prove that cognitive rest helps recovery, because it relied on patient reports. It is possible that people who were the most active in cognitive activities were also most aware of subtle symptoms. Still, the study is important and provides us with new ideas about brain injury and recovery. It may be helpful for schools and workplaces to limit participation to fewer hours in the initial weeks after a concussion to speed up recovery.
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Drinking in Middle Age Predicts Memory Loss Later
A long-term study connects years of heavy drinking in middle-aged men to faster mental decline later in life. The journal Neurology published the study January 15. The study included 5,054 men. They were asked about their drinking habits 3 times in 10 years. Then, in their mid-50s, they took a mental skills test. It assessed memory and executive function, which includes reasoning and planning abilities. They repeated the test twice in the next 10 years. Mental decline occurred and became measurable as much as 6 years earlier in men who had at least 2½ drinks a day (36 grams of alcohol), compared with men who drank less.
The study also included 2,099 women. There were not enough heavy drinkers among them for the study to adequately explore a connection between drinking and memory loss. With smaller numbers to study, the study could only report a "trend" for women, without having statistical certainty about the connection.
The current advice about reasonable alcohol use will remain the same: An average of no more than one drink per day for women and two per day for men.
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More News in Brief
- Surveillance Tests May Detect Return of Colon Cancer.Colon cancer that is detected by screening tests, such as colonoscopy, can usually be treated with surgery. For most people this cures the cancer. Sometimes, however, traces of the cancer are missed in the original surgery and the cancer can come back. So, what is the best way to check people with a history of colon cancer to catch any recurrence early? The Journal of the American Medical Association published a study January 15 that explored this question.
The study included 1,200 people who had been through colon cancer surgery. They were randomly divided into 4 groups. One group received regular computed tomography (CT) scans. Another group got regular tests for a blood protein, called CEA. At abnormal levels, this protein can be a sign of cancer. A third group got both tests. The fourth group had no special follow up. Researchers kept track of people for an average of 4.4 years. In that time, only 2.3% of those in the group that got no special follow up had a second surgery, because their colon cancer returned. (It was still at a curable stage.) Similar surgeries were done in 6.7% of the CEA group and 8% of the CT group. Using CT and CEA tests to monitor for cancer recurrence both seem to be helpful strategies to find a return of cancer when it is still at a curable stage.
- Doubts Remain, but Vitamin E Might Help People with Alzheimer's. Vitamin E is an antioxidant. Many people have hoped that it might have anti-aging effects, or might slow the progression of dementia. Previous vitamin E studies have shown a small benefit for people with severe dementia, but there has also been concern about risks from vitamin E. (High doses of vitamin E can increase the risk of blood thinning medicines, and one study connected vitamin E an to earlier age of death). A new study looked at the effect of vitamin E on people with mild to moderate Alzheimer's — the earlier stage of dementia. The study randomly divided 613 people with mild to moderate Alzheimer's into 4 groups. One group received 2,000 international units (IU) daily of alpha tocopherol, a form of vitamin E. This is a very large prescription dose. Another group received the Alzheimer's medicine memantine (Namenda) along with the same dose of vitamin E. A third and fourth group got memantine alone or placebo (fake) pills.
The rate of memory decline was similar for groups that got vitamin E as for groups that did not. But over each of the next 2 years, researchers saw that compared with the placebo group, people who took vitamin E alone had a roughly 19% lower rate of functional decline (meaning they required less assistance with activities of daily living). By the end of 2 years, they seemed to require 2 fewer hours of care, compared with the other groups. Curiously, no such benefit was seen in the group that got vitamin E in combination with memantine. And people who took the drug were more likely to get infections. The new study isn't large enough to eliminate previous concerns about risks from vitamin E, but it might re-ignite some interest in the vitamin as a possible help for Alzheimer's. Because of side effects, discuss this vitamin with your doctors before considering its use. The study was published in the January 1 issue of The Journal of the American Medical Association (JAMA).
- Implanted Stimulator May Improve Sleep Apnea. A small but exciting study may pave the way for a new treatment for people with sleep apnea. Obstructive sleep apnea causes a person to stop breathing or causes breathing to become very shallow for brief periods. The airway collapses during sleep. This causes a low blood oxygen level and leads to fatigue and a higher risk of heart disease. Sleep apnea is traditionally treated with a tightly fitting mask worn at night that generates constant air pressure. This mask is called continuous positive airway pressure or CPAP. Many people find it difficult to tolerate.
A new treatment using a surgically implanted stimulator was tested in 124 volunteers. The device has an electrical box much like a pacemaker that is implanted in the chest wall. An implanted wire carries the signal up beneath the skin of the neck to the back of the airway. The device electrically stimulates a nerve that controls the tongue and muscles in the upper airway. The pulses are timed to the breathing cycle. They cause the tongue to move slightly forward, and cause the upper airway to open. The stimulator was tested after implantation and again after a year of use. The benefits seem to be lasting. Episodes of apnea and drops in blood oxygen were reduced about 70%. This may make it an acceptable new treatment for sleep apnea, if additional studies can confirm the device's safety. The New England Journal of Medicine published the study January 9.
- Low Vitamin D Level Predicts More Active Multiple Sclerosis. Multiple sclerosis (MS) causes neurologic symptoms and commonly leads to disability. Low vitamin D levels may be a risk factor for progression of multiple sclerosis. This remarkable finding is suggested by a study of 465 patients who were newly diagnosed with the disease. The study was published online by JAMA Neurology on January 20. All of the patients were receiving interferon 1-b, a medication that is commonly used to treat MS. During the first year after diagnosis, each participant got a blood test to measure vitamin D levels. They were rechecked a year later. Participants' symptoms and MRI changes were documented for a total of five years. Higher vitamin D levels predicted fewer MS symptoms. People who started with vitamin D levels greater than or equal to 20 ng/mL during their first year of symptoms had less disability over the subsequent 4 years, compared with people who started out with vitamin D deficiency (a level less than 20 nannograms per milliliter). Correcting vitamin D deficiency seemed to help. People with low vitamin D at the time of diagnosis who boosted their vitamin D level by at least 20 ng/mL in the first year had a 57% lower relapse rate and fewer changes on MRI, compared with people who started with low vitamin D levels and did not increase them. Vitamin D testing and supplementation may become an important part of MS treatment, if this pattern is confirmed in larger studies. This was not a randomized trial, so it does not prove that supplementing vitamin D can help MS.
- FDA Recommends Lower Dose Acetaminophen in Combination Pill. Health care providers should discontinue prescribing pain medicines and cold medicines that contain more than 325 milligrams of acetaminophen (Tylenol) per tablet or capsule. This recommendation came from the U.S. Food and Drug Administration (FDA) on January 14. It affects a variety of pain medicines, such as Vicodin, Lortab and Percocet. The FDA chose this dose because it is common practice for patients to take a "two-tablet" dose. This would keep the maximum dose of acetaminophen to 650 milligrams, which is acceptably safe. According to the FDA, higher doses do not have proven additional benefits. Higher doses of acetaminophen carry a risk for liver injury. Many people have taken unsafe amounts of acetaminophen by combining products, by taking multiple doses in a day, or by drinking alcohol while taking products that contain acetaminophen.
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Mary Pickett, M.D., is an associate professor at Oregon Health Science University where she is a primary care doctor for adults. She supervises and educates residents in the field of Internal Medicine, for outpatient and hospital care. She is a Lecturer for Harvard Medical School and a Senior Medical Editor for Harvard Health Publications.